MR IMAGING OF TUMOR AND TUMORLIKE

LESIONS OF BONE AND SOFT TISSUE

Journal Reading Oncology

Abdurrahman, dr
• MR imaging is the examination of choice for
– local staging of tumors of bone and
– evaluating clinically indeterminate soft-tissue
masses.
• Bone and soft-tissue tumors should be
diagnosed and staged before biopsy.
• Two institutions in the application of MR
imaging for 1865 tumors or tumorlike lesions
of bone and soft tissue.
• Abnormal MR image in symptomatic patients
with normal radiographs
• Value of MR imaging in evaluating sarcomas
after chemo- or radiotherapy
• Patient histories and clinical examinations
determine the need for further evaluation of a
soft tissue mass by MR imaging.
Indications for MR Imaging in Patients
with Solitary Tumors of Bone
• Plain film radiograph is
– not only the least expensive, but also
– the most reliable predictor of the histologic nature of a
given lesion
• Accurate evaluation of the radiographs in
conjunction with knowledge of the
– patient’s age,
– sex, and
– clinical presentation
cannot be overemphasized because it determines the
next step in the evaluation of the abnormality.
Patient management follows one of four paths:
• (1) no future observation or treatment required
(for example, metaphyseal fibrous defect);
• (2) observation with periodic plain film
examination (e.g., enchondroma);
• (3) biopsy and excision (e.g., benign
intracompartmental lesions, simple bone cyst); or
• (4) further imaging for staging before surgery
(e.g., aggressive benign lesions, indeterminate
and malignant tumors).
• CT or MR imaging of a solitary bone tumor
should be performed before biopsy
• Biopsy before staging negates the value of
imaging to direct the site of and approach to
biopsy.
• Immediate period after biopsy, difficulty in
distinguishing from edema, hemorrhage, and
reactive fibrosis may result in overestimation
of tumor extent
• The choice of imaging technique is influenced by
– location of the tumor and
– the ability of the radiologist to identify the
morphologic features of the tumor on plain films
arrive at a differential diagnosis.
• The optimal staging examination for tumors of
the peripheral skeleton is MR imaging
• Staging achieved by using two pulsing
sequences:
– coronal or sagittal Ti -weighted pulsing sequence
for intramedullary extent of disease and
– multiecho T2-weighted axial sequence for
demonstration of extraosseous disease and the
relationship to neurovascular structures
• The accuracy of MR for recognizing intramedullary
and extraosseous disease and the relationship of
the tumor to adjacent neurovascular structures is
superior than CT.
• CT is better for the demonstration of
– tumor mineralization,
– fine periosteal reactions, and
– cortical integrity,
but in most cases, these features are shown adoquately
on plain film
• CT is preferred over MR imaging in the
peripheral skeleton when osteoid osteoma is
strongly suspected.
• In these cases, CT is the preferred examination
because it is extremely sensitive for detection
and precise delineation of the nidus
• MR imaging is a useful problem-solving
technique in those patients with pain in the
appendicular skeleton and normal or subtly
abnormal findings on radiographs.
• Neoplasms that may present in this manner
are the round-cell tumors (Ewing sarcoma,
lymphoma, myeloma) and metastasis
• Lesions in flat bones such as the pelvis, scapulae, ribs,
and vertebrae cannot be characterized on plain films as
completely as can tumors of long bones
• The lesion may be difficult to see in its entirety, and
uncertainty may exist about its extent and relationship
to the bone or origin.
• The characterof the tumor also may be difficult to
appreciate.
• When a lesion cannot be characterized on the
radiographs, CT is preferred to MR imaging because it
permits analysis of the internal features of a lesion, and
it will depict the lesion’s morphology accurately
• In vertebral lesions, MR imaging provides an
accurate depiction of the relationship of
tumor to the spinal canal
• Rarely are both CT and MR imaging required,
and they should not be routinely considered
as complementary.
MR Imaging in the Diagnosis of Tumor
and Tumorlike Lesions of Bone
• Because most tumor and tumorlike lesions of
bone have long T1 and long T2 relaxation
times and because benign and malignant
tumors are so demarcated, MR is unreliable in
predicting the histology of the tumor
• For tumors of bone that have a soft-tissue
component, MR imaging cannot distinguish
edema and reactive changes at the tumor
periphery from actual tumor invasion
• during limb-salvage procedures every effort is
made to obtain a wide margin by removing
tumor, surrounding edema and reaction, and
a layer of uninvolved tissue
Indications for MR Imaging in Patients
with Soft-Tissue Masses
• MR imaging is the examination of choice for
soft-tissue masses
• The patient’s history and clinical examination
determine the need for MR imaging
• When MR imaging of soft-tissue masses is
indicated it should always be done in the axial
plane and complemented with either the
sagittal or the coronal plane
 MR Imaging in the Diagnosis of
Soft-Tissue Masses
• Most tumors, both benign and malignant, have
long T1 and long T2 relaxation times. Therefore,
in most cases, signal intensity alone provides little
information about the histologic nature of a given
mass
• Exceptions include lipoma, subacute hematoma,
hemangioma, intralesional hemorrhage, and
welldifferentiated lipoblastic liposarcoma, which
are bright on T1 - weighted sequences. All of
these lesions contain fat or blood
• The most common variety of liposarcoma,
however, is myxoid liposarcoma; because this
tumor contains little fat, like most other soft-
tissue sarcomas it has a low signal on T1-
weighted pulsing sequences.
• This tumor, however, may be diagnosed on
the basis of detecting linear or clumplike foci
offat within the substance of the mass
• The MR appearance of hematomas is variable
and depends on the age of the hematoma.
• Many subacute lesions have bright signal on
T1 -weighted images.
• Hemorrhage may occur in some soft-tissue
lesions, especially sarcomas, and, when
extensive, the tumor may be mistaken for
hematoma
• Hemangiomas may have a high signal on T1 -
weighted MR sequences, but this varies
• The combination of markedly increased signal on
T2-weighted images with fibrous fatty septa on
T1-weighted images permitted an accurate
diagnosis in eight of 1 0 cases in one study
• Hyperintensity relative to skeletal muscle also
may be seen in abscesses; it is surmised this is
because of a combination of proteinaceous fluid
and hemorrhage.
• Some soft-tissue masses have little or no
signal on T2- weighted sequences. This may be
the result of low proton density, as seen in
– fibrous lesions,
– scar tissue,
– densely mineralized masses,
– air, and
– foreign bodies
• The most frequent tumor to have a short T2 is
aggressive fibromatosis
• Short T2 is not limited to benign lesions and
has been reported also for malignant fibrous
histiocytoma and malignant schwannoma
• Low signal on T2-weighted sequences also
may be related to the presence of blood
products, as seen in acute hemorrhage
Value of MR Imaging in Distinguishing
Benign from Malignant Tumors
• Criteria used to distinguish benign from malignant soft
tissue tumors include
– signal intensity,
– tumor margin,
– signal homogeneity,
– neurovascular invasion,
– signal changes in adjacent soft tissue,
– growth rate,
– size and location,
– Extension beyond one compartment, and
– bone destruction.
• No single criterion is reliable . However, when the criteria
are considered together and correlated with the clinical
findings, distinction is often possible.
• Early reports expressed uncertainty about the
reliability of MR imaging to show bone
invasion.
• Improved spatial resolution and accrued
experience permit confident assessment of
cortical bone and intramedullary invasion
• To diagnose bone invasion by a soft-tissue
mass, the combination of plain film and MR
imaging is adequate.
 MR Imaging Examination After
Chemotherapy or Radiotherapy
• MR imaging has been used to evaluate bone
and soft tissue sarcomas after chemotherapy
and radiation therapy
• Tumor volume, development of
pseudocapsules, and progression or
regression of local disease can be estimated
• The extent of tumor necrosis and the presence of
viable tumor, two critical elements in determining
tumor response and prognosis, have been more
difficult to determine
• However, decreasing tumor volume and signal
intensity or the development of a short T2 after
treatment appears to reflect a good treatment
response measured by pathologic criteria
An. R, 11 thn
An S, 12 tahun
Nn R, 21 tahun