To investigate whether proton density fat fraction (PDFF) measurements using a six-echo modified Dixon sequence can help to differentiate between benign and malignant vertebral bone marrow lesions.
Sixty-six patients were prospectively enrolled in our study. In addition to conventional MRI at 3.0-Tesla including at least sagittal T2-weighted/spectral attenuated inversion recovery and T1-weighted sequences, all patients underwent a sagittal six-echo modified Dixon sequence of the spine. The mean PDFF was calculated using regions of interest and compared between vertebral lesions. A cut-off value of 6.40% in PDFF was determined by receiver operating characteristic curves and used to differentiate between malignant (< 6.40%) and benign (≥ 6.40%) vertebral lesions.
There were 77 benign and 44 malignant lesions. The PDFF of malignant lesions was statistically significant lower in comparison with benign lesions (p < 0.001) and normal vertebral bone marrow (p < 0.001). The areas under the curves (AUC) were 0.97 for differentiating benign from malignant lesions (p < 0.001) and 0.95 for differentiating acute vertebral fractures from malignant lesions (p < 0.001). This yielded a diagnostic accuracy of 96% in the differentiation of both benign lesions and acute vertebral fractures from malignancy.
PDFF derived from six-echo modified Dixon allows for differentiation between benign and malignant vertebral lesions with a high diagnostic accuracy.
• Establishing a diagnosis of indeterminate vertebral lesions is a common clinical problem
• Benign bone marrow processes may mimic the signal alterations observed in malignancy
• PDFF differentiates between benign and malignant lesions with a high diagnostic accuracy
• PDFF of non-neoplastic vertebral lesions is significantly higher than that of malignancy
• PDFF from six-echo modified Dixon may help avoid potentially harmful bone biopsy
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Area Under the Curve
Six-Echo Modified Dixon
Negative Predictive Value
Proton Density Fat Fraction
Positron Emission Tomography/Computed Tomography
Positive Predictive Value
Receiver Operating Characteristic
Region Of Interest
Spectral Attenuated Inversion Recovery
Short-Tau Inversion Recovery
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The authors state that this work has not received any funding.
The scientific guarantor of this publication is Priv.-Doz. Dr. med. Guido Matthias Kukuk at Bonn University Hospital.
Conflict of interest
The authors of this manuscript declare relationships with the following companies: Dr. Jürgen Gieseke is an employee of Philips Healthcare (Best, The Netherlands) but had no control of inclusion of any data or data analysis. The other authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.
Statistics and biometry
No complex statistical methods were necessary for this paper.
Written informed consent was obtained from all patients in this study.
Institutional review board approval was obtained.
• diagnostic or prognostic study
• performed at one institution
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Schmeel, F.C., Luetkens, J.A., Wagenhäuser, P.J. et al. Proton density fat fraction (PDFF) MRI for differentiation of benign and malignant vertebral lesions. Eur Radiol 28, 2397–2405 (2018). https://doi.org/10.1007/s00330-017-5241-x