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Does the presence of macroscopic intralesional fat exclude malignancy? An analysis of 613 histologically proven malignant bone lesions

  • Musculoskeletal
  • Published:
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Abstract

Objective

To determine if macroscopic intralesional fat detected in bone lesions on CT by Hounsfield unit (HU) measurement and on MRI by macroscopic assessment excludes malignancy.

Materials and methods

All consecutive CT-guided core needle biopsies (CNB) of non-spinal bone lesions performed at a tertiary center between December 2005 and September 2021 were reviewed. Demographic and histopathology data were recorded. All cases with malignant histopathology were selected, and imaging studies were reviewed. Two independent readers performed CT HU measurements on all bone lesions using a circular region of interest (ROI) to quantitate intralesional fat density (mean HU < −30). MRI images were reviewed to qualitatively assess for macroscopic intralesional fat signal in a subset of patients. Inter-reader agreement was assessed with Cronbach’s alpha and intraclass correlation coefficient.

Results

In 613 patients (mean age 62.9 years (range 19–95 years), 47.6% female), CT scans from the CNB of 613 malignant bone lesions were reviewed, and 212 cases had additional MRI images. Only 3 cases (0.5%) demonstrated macroscopic intralesional fat on either CT or MRI. One case demonstrated macroscopic intralesional fat density on CT in a case of metastatic prostate cancer. Two cases demonstrated macroscopic intralesional fat signal on MRI in cases of chondrosarcoma and osteosarcoma. Inter-reader agreement was excellent (Cronbach’s alpha, 0.95–0.98; intraclass correlation coefficient, 0.90–0.97).

Conclusion

Malignant lesions rarely contain macroscopic intralesional fat on CT or MRI. While CT is effective in detecting macroscopic intralesional fat in primarily lytic lesions, MRI may be better for the assessment of heterogenous and infiltrative lesions with mixed lytic and sclerotic components.

Clinical relevance statement

Macroscopic intralesional fat is rarely seen in malignant bone tumors and its presence can help to guide the diagnostic workup of bone lesions.

Key Points

• Presence of macroscopic intralesional fat in bone lesions has been widely theorized as a sign of benignity, but there is limited supporting evidence in the literature.

• CT and MRI are effective in evaluating for macroscopic intralesional fat in malignant bone lesions with excellent inter-reader agreement.

• Macroscopic intralesional fat is rarely seen in malignant bone lesions.

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Abbreviations

CNB:

Core needle biopsies

HU:

Hounsfield unit

MSK:

Musculoskeletal

PACS:

Picture archiving and communication system

ROI:

Region of interest

References

  1. Schweitzer ME, Levine C, Mitchell DG et al (1993) Bull’s-eyes and halos: useful MR discriminators of osseous metastases. Radiology 188:249–252

    Article  CAS  PubMed  Google Scholar 

  2. Simpfendorfer CS, Ilaslan H, Davies AM et al (2008) Does the presence of focal normal marrow fat signal within a tumor on MRI exclude malignancy? An analysis of 184 histologically proven tumors of the pelvic and appendicular skeleton. Skeletal Radiol 37:797–804

    Article  CAS  PubMed  Google Scholar 

  3. Chung CB, Murphey M, Cho G et al (2005) Osseous lesions of the pelvis and long tubular bones containing both fat and fluid-like signal intensity: an analysis of 28 patients. Eur J Radio 53:103–109

    Article  Google Scholar 

  4. Kenneally BE, Gutowski CJ, Reynolds AW et al (2015) Utility of opposed-phase magnetic resonance imaging in differentiating sarcoma from benign bone lesions. J Bone Oncology 4:110–114

    Article  Google Scholar 

  5. Omoumi P (2022) The Dixon method in musculoskeletal MRI: from fat-sensitive to fat-specific imaging. Skeletal Radiol 51:1365–1369

    Article  PubMed  Google Scholar 

  6. Park S, Do Huh J (2022) Differentiation of bone metastases from benign red marrow depositions of the spine: the role of fat-suppressed T2-weighted imaging compared to fat fraction map. Eur Radiol 32:6730–6738

    Article  CAS  PubMed  Google Scholar 

  7. Kim YP, Kannengiesser S, Paek MY et al (2014) Differentiation between focal malignant marrow-replacing lesions and benign red marrow deposition of the spine with T2*-corrected fat-signal fraction map using a three-echo volume interpolated breath-hold gradient echo Dixon sequence. Korean J Radiol 15:781

    Article  PubMed  PubMed Central  Google Scholar 

  8. Douis H, Davies AM, Jeys L, Sian P (2016) Chemical shift MRI can aid in the diagnosis of indeterminate skeletal lesions of the spine. Eur Radiol 26(4):932–40

    Article  CAS  PubMed  Google Scholar 

  9. Zampa V, Cosottini M, Michelassi M et al (2002) Value of opposed-phase gradient-echo technique in distinguishing between benign and malignant vertebral lesions. Eur Radiol 12:1811–1818

    Article  PubMed  Google Scholar 

  10. Dreizin D, Ahlawat S, Del Grande F, Fayad LM (2014) Gradient-echo in-phase and opposed-phase chemical shift imaging: role in evaluating bone marrow. Clin Radiol 69:648–657

    Article  CAS  PubMed  Google Scholar 

  11. Douis H, Davies AM, Jeys L, Sian P (2016) Chemical shift MRI can aid in the diagnosis of indeterminate skeletal lesions of the spine. Eur Radiol 26:932–940

    Article  CAS  PubMed  Google Scholar 

  12. Ladd LM, Roth TD (2017) Computed tomography and magnetic resonance imaging of bone tumors. Semin Roentgenol 52:209–226

    Article  PubMed  Google Scholar 

  13. Nascimento D, Suchard G, Hatem M, De Abreu A (2014) The role of magnetic resonance imaging in the evaluation of bone tumours and tumour-like lesions. Insights Imaging 5:419–440

    Article  PubMed  PubMed Central  Google Scholar 

  14. Kim WH, Kim CG, Kim DW (2012) Optimal CT number range for adipose tissue when determining lean body mass in whole-body F-18 FDG PET/CT studies. Nucl Med Mol Imaging 46:294–299

    Article  PubMed  PubMed Central  Google Scholar 

  15. Jang S, Graffy PM, Ziemlewicz TJ et al (2019) Opportunistic osteoporosis screening at routine abdominal and thoracic CT: normative L1 trabecular attenuation values in more than 20,000 adults. Radiology 291:360–367

    Article  PubMed  Google Scholar 

  16. George D, Mallery P (2003) SPSS for Windows step by step: a simple guide and reference. 11.0 update, 4th ed. Boston: Allyn & Bacon. 231

  17. Koo TK, Li MY (2016) A guideline of selecting and reporting intraclass correlation coefficients for reliability research. J Chiropractic Med 15:155–163

    Article  Google Scholar 

  18. Stacy GS, Lo R, Montag A (2015) Infarct-associated bone sarcomas: multimodality imaging findings. AJR Am J Roentgenol 205:W432–W441

    Article  PubMed  Google Scholar 

  19. Hansford BG, Hanrahan CJ, Girard N et al (2020) Untreated plasmacytoma of bone containing macroscopic intralesional fat and mimicking intraosseous lipoma: a case report and review of the literature. Clin Imaging 64:18–23

    Article  PubMed  Google Scholar 

  20. Tiemeier GL, Brown JM, Pratap SE et al (2018) Pleomorphic liposarcoma of bone: a rare primary malignant bone tumour. Clin Sarcoma Res 8:2

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Downey EF, Worsham GF, Brower AC (1982) Liposarcoma of bone with osteosarcomatous foci: case report and review of the literature. Skeletal Radiol 8:47–50

    Article  PubMed  Google Scholar 

  22. Torigoe T, Matsumoto T, Terakado A et al (2006) Primary pleomorphic liposarcoma of bone: MRI findings and review of the literature. Skeletal Radiol 35:536–538

    Article  PubMed  Google Scholar 

  23. Palczewski P, Swiątkowski J, Gołębiowski M, Błasińska-Przerwa K (2011) Intraosseous lipomas: a report of six cases and a review of literature. Pol J Radiol 76:52–59

    PubMed  PubMed Central  Google Scholar 

  24. Milgram James W (1990) Malignant transformation in bone lipomas. Skeletal Radiol 19(5):347–52

    Google Scholar 

  25. McMenamin DS, Stuckey SL, Potgieter GJ (2007) T1 Hyperintense vertebral column melanoma metastases. AJNR Am J Neuroradiol 28:1817–1818

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  26. Daldrup-Link HE, Henning T, Link TM (2007) MR imaging of therapy-induced changes of bone marrow. Eur Radiol 17:743–761

    Article  PubMed  Google Scholar 

  27. Park S, Huh JD (2023) Bone metastases with post-treatment intralesional fatty content of the spine: imaging features from T1-weighted imaging with CT finding correlations. Acta Radiol 64:153–163

    Article  PubMed  Google Scholar 

  28. Lecouvet FE, Larbi A, Pasoglou V et al (2013) MRI for response assessment in metastatic bone disease. Eur Radiol 23:1986–1997

    Article  CAS  PubMed  Google Scholar 

  29. Swartz PG, Roberts CC (2009) Radiological reasoning: bone marrow changes on MRI. AJR Am J Roentgenol 193:S1–S4

    Article  PubMed  Google Scholar 

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Funding

The authors state that this work has not received any funding.

Author information

Authors and Affiliations

  1. Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Sherman 231, Boston, MA, 02215, USA

    Eddy D. Zandee van Rilland, Se-Young Yoon & Jim S. Wu

  2. Department of Radiology, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL, 32224, USA

    Hillary W. Garner

  3. Department of Radiology, University of Limerick, St. Nessan’s Rd, Limerick, V94F898, Ireland

    Jennifer Ni Mhuircheartaigh

Authors
  1. Eddy D. Zandee van Rilland
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  2. Se-Young Yoon
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  3. Hillary W. Garner
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  4. Jennifer Ni Mhuircheartaigh
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  5. Jim S. Wu
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Corresponding author

Correspondence to Eddy D. Zandee van Rilland.

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Guarantor

The scientific guarantor of this publication is Jim S. Wu, MD.

Conflict of Interest

Hillary W. Garner has a Know-How Agreement with Immersive Touch®.

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.

Jennifer Ni Mhuircheartaigh is a member of the European Radiology Editorial Board. She has not taken part in the review or selection process of this article.

Statistics and Biometry

No complex statistical methods were necessary for this paper.

Informed Consent

Written informed consent was waived by the institutional review board.

Ethical Approval

The institutional review board approval from the Beth Israel Deaconess Medical Center Committee on Clinical Investigations was obtained.

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None.

Methodology

• Retrospective

• Observational

• Performed at one institution

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Zandee van Rilland, E.D., Yoon, SY., Garner, H.W. et al. Does the presence of macroscopic intralesional fat exclude malignancy? An analysis of 613 histologically proven malignant bone lesions. Eur Radiol (2024). https://doi.org/10.1007/s00330-024-10687-7

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  • DOI: https://doi.org/10.1007/s00330-024-10687-7

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