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MRI of a newborn boy scanned for lipomeningocele (not shown). Sagittal T1-weighted MRI (TR/TE: 500/11 ms). Note signal similarity between cellular red bone marrow (*), paraspinal muscles (m) and intervertebral discs (arrow)
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Polyostotic bone and bone marrow lesions in children may be due to various disorders. Radiographically, lytic lesions may become apparent after loss of more than 50% of the bone mineral content. Scintigraphy requires osteoblastic activity and is not specific. MRI may significantly contribute to the correct diagnosis and management. Accurate interpr...
Citations
... Leukaemia and lymphoma can present with diffuse, patchy, or focal patterns of infiltration (Fig. 5). Thirty percent of children with acute lymphoblastic leukaemia have marrow infiltration and bone pain at presentation (Fig. 6) [21]. Langerhans cell histiocytosis, a disorder of abnormal myeloid cell proliferation, is an important differential diagnosis to consider. ...
... The 'halo' sign has high sensitivity and specificity for metastases and is described as a peripheral zone of high signal on fluidsensitive sequences which surrounds a lesion [2]. Of note, lytic lesions only become apparent on radiographs after loss of more than 50% bone mineral content [21]. Of course, in clinical settings, MRI is used to assess bone marrow rather than mineral content. ...
The paediatric metaphysis is afflicted by a wide range of pathological processes as it is the most metabolically active and well-vascularised part of the developing skeleton. This review focuses on metaphyseal marrow signal change detected with magnetic resonance imaging, which is most often occult on radiographs. When bilateral, these imaging appearances frequently present a diagnostic quandary. This review assists the radiologist to confidently dismiss physiological signal change and confidently work through the differential diagnosis. This is achieved by illustrating a practical method of classifying signal change into four categories: physiological red marrow, red marrow reconversion, marrow infiltration, and oedema-like marrow signal intensity. In doing so, various pathological entities are reviewed along with imaging pearls and next-step investigations.
Graphical abstract
... PET-MR, when available, is preferred over PET-CT, mostly for the better evaluation of soft tissue and BM involvement. In addition, at diagnosis or during response assessment, PET-MR could highlight bone alterations which were not necessarily related to HL and were consistent with ischemic damages, including BILs-a condition that results from a reduction in or complete loss of blood supply to a bone region [8]. Available data about the real incidence and prognosis of BILs are scarce because prospective WB-MR studies are lacking in CAYAs with cancer, in contrast with the numerous published data on ischemic lesions [9,10]. ...
... On PET images the BILs showed low uptake due to having low metabolic activity, and on MR images they appeared as serpiginous areas with a low signal on T1W and a hyperintense signal on T2W images due to granulation tissue, surrounded by areas of hypointense sclerosis on all sequences [20]. In our case series, the 30 observed BILs presented the particular combined features that are common in the manifestation of ON [8]. In our study, it is of note that 66.7% of the BILs were detected in the meta-diaphysis of long bones, unlikely according to the literature which reported the majority of ON in epiphysis and rarely in metaphysis [8,10,20]. ...
... In our case series, the 30 observed BILs presented the particular combined features that are common in the manifestation of ON [8]. In our study, it is of note that 66.7% of the BILs were detected in the meta-diaphysis of long bones, unlikely according to the literature which reported the majority of ON in epiphysis and rarely in metaphysis [8,10,20]. In addition, the literature described ischemic-necrotic lesions of bones frequently accompanied by symptoms such as pain and reduced joint mobility, with debilitating degenerative patterns that can evolve into joint collapse and the need for prosthetic replacement [21]. ...
Hodgkin’s lymphoma (HL) is one of the neoplasms with the best prognosis in children, adolescents and young adults, but sufferers are burdened by the possibility of developing adverse effects such as Bone Ischemic Lesions (BILs) which are lesions of the bone caused by the loss of/reduction in blood flow. The main goal of this retrospective study was to evaluate the role of [18F]FDG-PET-MR in the early detection of BILs in a single-center cohort of uniformly treated pediatric HL patients. BILs were assessed through PET-MR images as the appearance of medullary lesion surrounded by a serpiginous, tortuous border. From 2017 to 2022, 10/53 (18.9%) HL patients developed BILs which were mostly (8/10 patients) multifocal. Overall, 30 lesions were identified in the 10 asymptomatic patients, all with the above-mentioned features at MR and with very low [18F]FDG uptake. BILs were incidentally detected during HL therapy (n = 6) and follow-up (n = 4), especially in the long bones (66.7%). No factors correlated with the occurrence of BIL were identified. No patients developed complications. PET-MR is a sensitive combined-imaging technique for detecting BILs that are asymptomatic and self-limiting micro-ischemic lesions. BILs can be monitored by clinical follow-up alone both during and after therapy.
... Due to the morphology of the growing skeleton, MRI often allows a more in-depth look: Permanent and transient cartilaginous structures such as articular cartilage, growth plates, epiphyses, and apophyses can be directly visualized [11]. Bone marrow properties and changes including age-dependent conversion from red to yellow marrow or its reconversion in chronic hematopoetic conditions can be well assessed on MR images [12]. Torsional analysis of the lower limbs have shifted from CT to (hip-knee-ankle) MRI [13]. ...
Children and adolescents with bone and growth disorders require interdisciplinary care from various specialists including pediatric radiologists with a focus on musculoskeletal disorders. This article covers routine topics, differential diagnoses, and selected research imaging in children with osteogenesis imperfecta (OI), X‑linked hypophosphatemic rickets (XLH), achondroplasia, and other bone and growth disorders from the standpoint of a tertiary referral center.
... MRI is the method of choice in human medicine to diagnose spinal and bone marrow pathology because of its excellent tissue contrast. 4,11,12 Precise discrimination of benign from aggressive vertebral lesions is difficult with conventional MRI because of the similar imaging manifestations of different pathologies. In this study, spinal pain, vertebral cortical interruption, signal intensity changes in the paravertebral musculature, spinal cord compression and lymphadenomegaly were significantly more common in aggressive polyostotic vertebral diseases. ...
... The combination of T1W and STIR sequences have been shown in the human literature to be the most useful sequences for detection of bone marrow abnormalities and to discriminate benign from malignant bone marrow changes. 11,12,23 In this study, the same sequences were proven useful. Indeed, T1W signal intensity changes were particularly helpful to characterise malignant vertebral changes and STIR signal intensity changes to differentiate aggressive from benign lesions, the latter frequently suppressing on this sequence due to increased fat infiltration. ...
Background:
There is a lack of information regarding magnetic resonance imaging (MRI) features of polyostotic vertebral lesions in dogs. The aim of this retrospective study was to identify and differenciate low-field MRI features of aggressive versus benign multifocal vertebral diseases in dogs.
Methods:
MRI examinations from 49 dogs with polyostotic vertebral lesions were reviewed. Images were evaluated for vertebral intensity changes, expansile lesions, new bone formation, cortical bone interruption, paravertebral musculature changes, lymphadenomegaly, spinal cord compression and spinal cord signal changes.
Results:
Twenty-nine dogs with non-aggressive bone lesions and 20 dogs with aggressive vertebral lesions were included. Non-aggressive lesions had variable T2-weighted fast spin-echo (T2W) signal intensity and the majority displayed low signal intensity on short tau inversion recovery (STIR). Aggressive lesions predominantly had high T2W and STIR signal intensity, with variable signal intensity on T1-weighted spin-echo and contrast enhancement. Aggressive lesions were associated with spinal pain (p < 0.01), new bone formation (p = 0.02), spinal cord compression (p < 0.01) and lymphadenomegaly (p < 0.01). Cortical interruption (p < 0.01) and paravertebral musculature changes (p < 0.01) were the strongest indicative imaging features for aggressive lesions.
Conclusion:
Spinal pain, spinal cord compression, new bone formation, lymphadenomegaly and especially cortical interruption and paravertebral musculature signal intensity changes were the best discriminators for differentiating malignant from benign vertebral lesions.
... However, to keep the examination time in an acceptable range, particularly regarding patient comfort and safety, intelligent and dedicated sequence protocols are recommended. Moreover, the high sensitivity of MRI regarding bone marrow changes has to be considered to avoid overinterpretation of normal findings in children [24]. Therefore, for specific applications and diagnostic confidence, an optimized agreement of sequence numbers, spatial resolution and acquisition time must be realized. ...
The purpose of this recommendation of the Oncology Task Force of the European Society of Paediatric Radiology (ESPR) is to indicate reasonable applications of whole-body MRI in children with cancer and to address useful protocols to optimize workflow and diagnostic performance. Whole-body MRI as a radiation-free modality has been increasingly performed over the last two decades, and newer applications, as in screening of children with germ-line mutation cancer-related gene defects, are now widely accepted. We aim to provide a comprehensive outline of the diagnostic value for use in daily practice. Based on the results of our task force session in 2018 and the revision in 2019 during the ESPR meeting, we summarized our group’s experiences in whole-body MRI. The lack of large evidence by clinical studies is challenging when focusing on a balanced view regarding the impact of whole-body MRI in pediatric oncology. Therefore, the final version of this recommendation was supported by the members of Oncology Task Force.
... Many respondents also indicated a preference for coronal T1-weighted imaging, most often performed without fat saturation. A discussion of the merits of fat saturation, or a lack thereof, are beyond the scope of this investigation, though unenhanced T1-weighted images without fat saturation will allow a sensitive assessment of bone marrow [15]. Many pediatric radiologists also indicate they use axial imaging in their whole-body MRI to gain the benefits of multiplanar evaluation and fulfill requirements of Children's Oncology Group protocols. ...
Background:
Whole-body magnetic resonance imaging (MRI) is an evolving and increasingly powerful imaging tool with a variety of applications in the pediatric patient population. Variability exists among radiology practices in how this MRI tool is used and how it performed.
Objective:
Our objective was to gain an improved understanding of technical and utilization practices in pediatric whole-body MRI across North America by exploring indications for exam performance, determining referral patterns, and assessing technical protocols and procedures.
Materials and methods:
A 19-question survey was generated in Survey Monkey and distributed in 2016 to the Society for Pediatric Radiology membership. The survey asked questions that included practice type, imaging modality preferences for diseases commonly evaluated with whole-body MRI, MRI field strength and sequence selection, and billing practices.
Results:
Data were obtained from 62 unique responses to the survey, representing 471 physicians. The majority (93%) practice in an academic institution or private practice with academic affiliation and most practices have utilized whole-body MRI for less than 6 years. Whole-body MRI is performed in pediatric patients 0 to 18 years of age, and was the preferred imaging modality for diagnosis/staging/follow-up in neurofibromatosis, type 1 (75%), chronic recurrent multifocal osteomyelitis (CRMO) (74%), cancer predisposition syndromes (75%), vasculopathies (50%) and disseminated/multifocal infection (49%). The most commonly utilized sequences are coronal short tau inversion recovery (STIR) (90%), coronal T1 with or without fat saturation (65%), and axial diffusion-weighted imaging (DWI) (48%). No preference was shown for either 1.5-T or 3-T systems. Wide variability was seen in preference for billing code utilization, though the majority use chest/abdomen/pelvis (57%) or unlisted MRI (37%) codes.
Conclusion:
Radiology practitioners - represented by the Society for Pediatric Radiology pediatric radiologists - are using whole-body MRI in the imaging care of pediatric patients for a variety of indications. Survey results reveal some variability in exam utilization and technical performance practices among those pediatric radiologists who perform whole-body MRI.
... Conventional radiography, computed tomography (CT), and various scintigraphic techniques (bone scan, 123I metaiodobenzylguanidine scintigraphy [MIBG], 18Ffluorodeoxyglucose positron emission tomography [FDG-PET]), are currently used for staging, yet all these techniques expose the patient to ionizing radiation and have a variable sensitivity for detecting osteomedullary metastases in different types of tumors [8][9][10][11][12][13]. Consequently, there is an increasing interest in alternative, preferably radiation-free, techniques with a track record in osteomedullary pathology, such as whole-body magnetic resonance imaging (WB-MRI) [14]. ...
Background:
Many solid neoplasms have a propensity for osteomedullary metastases of which detection is important for staging and subsequent treatment. Whole-body magnetic resonance imaging (WB-MRI) has been shown to accurately detect osteomedullary metastases in adults, but these findings cannot be unconditionally extrapolated to staging of children with malignant solid tumors.
Objective:
To conduct a literature review on the sensitivity of WB-MRI for detecting skeletal metastases in children with solid tumors.
Materials and methods:
Searches in MEDLINE and EMBASE databases up to 15 May 2017 were performed to identify studies on the diagnostic value of WB-MRI. Inclusion criteria were children and adolescents (age <21 years) with a primary solid tumor who were evaluated for skeletal metastases by WB-MRI and compared to any type of reference standard. The number of included patients had to be at least five and data on true positives, true negatives, false-positives and false-negatives had to be extractable.
Results:
Five studies including 132 patients (96 patients with solid tumors) were eligible. Patient groups and used reference tests were heterogeneous, producing unclear or high risk of bias. Sensitivity of WB-MRI ranged between 82% and 100%. The positive predictive value of WB-MRI was variable among the studies and influenced by the used reference standard.
Conclusion:
Although WB-MRI may seem a promising radiation-free technique for the detection of skeletal metastases in children with solid tumors, published studies are small and too heterogeneous to provide conclusive evidence that WB-MRI can be an alternative to currently used imaging techniques.
... Finally, we limited our evaluation to adult patients because of the higher prevalence of bone metastases in this population. As a result of agerelated changes in spinal marrow, the values reported for adults might be different from those for children, although these changes probably affect the aspect of metastases for both T1-weighted and Dixon fat-only images equally (40). ...
Purpose To test the potential of Dixon T2-weighted fat-only sequences to replace T1-weighted sequences for the detection of bone metastases, with the hypothesis that diagnostic performance with an alternative magnetic resonance (MR) imaging protocol (sagittal spin-echo Dixon T2-weighted fat-only and water-only imaging) would not be inferior to that with the standard protocol (sagittal spin-echo T1-weighted and spin-echo Dixon T2-weighted water-only imaging). Materials and Methods A total of 121 consecutive whole-spine MR imaging examinations (63 men; mean age ± standard deviation, 61.4 years ± 11.8) performed for suspected vertebral bone metastases were included in this retrospective, institutional review board-approved study. Quantitative image analysis was performed for 30 randomly selected spine levels. Qualitative analysis was performed separately by two musculoskeletal radiologists, who registered the number of metastases for each spine level. Areas under the curve with the protocols were compared on the basis of nonparametric receiver operating characteristic curve estimations by using a noninferiority test on paired data, with a best valuable comparator as a reference. Interobserver and interprotocol agreement was assessed by using κ statistics. Results Contrast-to-noise ratio was significantly higher on the alternative protocol images than on the standard protocol images (181.1 [95% confidence interval: 140.4, 221.7] vs 84.7 [95% confidence interval: 66.3, 103.1] respectively; P < .001). Diagnostic performance was not significantly inferior with the alternative protocol than with the standard protocol for both readers in a per-patient analysis (sensitivity, 97.9%-98.9% vs 93.6%-97.9%; specificity, 85.2%-92.6% vs 92.6%-96.3%; area under the curve, 0.92-0.96 vs 0.95, respectively; all P ≤ .02) and a per-spine level analysis (all P < .01). Interobserver and interprotocol agreement was good to very good (κ = 0.70-0.81). Conclusion Dixon T2-weighted fat-only and water-only imaging provide, in one sequence, diagnostic performance similar to that of the standard combination of morphologic sequences for the detection of probable spinal bone metastases, thereby providing an opportunity to reduce imaging time by eliminating the need to perform T1 sequences. (©) RSNA, 2017.
A young boy presented with increasing lower limb pain and swelling for a month. At the time of his hospitalisation, he was unable to walk. We report the patient’s clinical journey with clinical commentary throughout, highlighting the importance that uncommon diseases may be diagnosed with a high index of suspicion and thorough history taking.
Purpose
The purpose of this retrospective study was to determine the prevalence of artifacts on whole-body (WB) magnetic resonance imaging (MRI) examination in pediatric patients and identify their causes.
Materials and methods
A total of 107 pediatric patients who underwent a total of 107 WB-MRI examinations, including short-tau inversion recovery (STIR) and T1-weighted sequences, were included. There were 62 girls and 45 boys with a mean age of 11 ± 3 (SD) years (age range: 2–16 years). WB-MRI examinations were analyzed for the presence of artifacts on STIR and T1-weighted sequences. Artifacts were further assigned to one of eight categories (motion, partial volume, cross-talk, phase sampling, susceptibility, equipment, noise, and “other”) and 19 anatomical sites by a 4-year resident. Prevalence of artifacts were analyzed especially according to hands position during the examination for the upper limbs and patients’ age. Age was expressed as a binary variable using median age (10 years) as the cut-off value. All qualitative variables were compared using chi-square test.
Results
A total of 3436 artifacts were found. The STIR sequences showed more “noise” artifacts (93/1038; 8.96%) and more “cross-talk” (102/1038; 9.83%) artifacts than T1-weighted sequences (12/1038 [1.16%] and 7/1038 [0.67%], respectively) (P < 0.001 for both). T1-weighted sequences showed more “equipment” (84/1038; 8.09%) and “stair-step” (a subset of “other”) (41/1038; 3.95%) artifacts than the STIR sequences (39/1038 [3.76%] and 21/1038 [2.02%], respectively) (P < 0.001 and P = 0.01, respectively). T1-weighted sequences showed fewer artifacts on the wrists when the hands were under the bottom (P = 0.001). T1-weighted sequences showed less “equipment” artifacts when the hands were alongside the body (22/296; 7%) than on the abdomen (48/432; 11%) or under the bottom (14/128; 11%) (P < 0.001). STIR sequences showed more “motion” artifacts when the hands were on the abdomen (54/432; 13%) than alongside the body (30/296; 10%) or under the bottom (15/128; 12%) (P < 0.001). WB-MRI examinations had more “susceptibility” artifacts (38/960; 4%) and more “equipment” artifacts (81/960; 8.4%) in patients older than 10 years than in those under 10 years (23/752 [3.1%] and 42/752 [5.6%]) (P = 0.01 and P < 0.001, respectively).
Conclusion
Artifacts on WB-MRI do not affect coronal STIR and T1-weighted sequences equally, so the use of both sequence types appears useful. Hands position should be considered with respect to both diagnostic benefit and safety.
