William D. Zimmer, M.D.

., Thomas H. Berquist, M.D.

Richard A. McLeod, M.D.
‘I

Franklin H. Sim, M.D.

Bone Tumors: Magnetic Resonance
Douglas J. Pritchard, M.D.
4

. Thomas C. Shives, M.D. Imaging versus Computed

Lester E. Wold, M.D.
Gerald R. May, M.D. Tomography’

4, The magnetic resonance (MR) imaging

characteristics of bone tumors are de-
) scribed and the clinical utility of MR
imaging in patient evaluation is reported.
4 Fifty-two patients with skeletal lesions
4 were examined with a Picker MR imager M AGNETIC resonance (MR) imaging is well suited for examining
(0.i5-T resistive magnet). Twenty-five the skeletal system. Especially good images are obtained in the
patients had primary malignancies, seven appendicular skeleton, where breathing and peristaltic artifacts are
had benign bone neoplasms, 15 had skel- avoided. Because of its increased contrast capabilities, MR imaging
.. , etal metastases, and five had neoplasm can enable better detection and delineation of bone tumors, compared
simulators. Forty-five patients had CT with other modalities. The MR image characteristics of several types
scans available for comparison. For dem- of bone tumors have previously been described (1-6).
V onstrating the extent of tumor in marrow, We investigated the utility of MR imaging in the evaluation of bone
MR was superior to CT in 33% of cases, tumors, attempted to identify criteria useful in distinguishing various
‘ about equal to CT in 64%, and inferior to types of tumors, and compared MR with computed tomography
CT in 2%. For delineating the extent of (CT).
tumor in soft tissue, MR was superior to
CT in 38% of cases and about equal to CT
MATERIALS AND METHODS
in 62%. CT was superior in all cases for
#{248} demonstrating calcific deposits and To date, we have examined with MR imaging 52 patients with bone tumors
pathologic fractures. In four patients or conditions mimicking bone tumors. We attempted to examine all patients
- with metal prostheses or surgical clips, with primary malignant or indeterminate bone tumors who were expected
MR was superior to CT in documenting to require surgery. Most of the patients were referred for MR by three of the
authors who are orthopedic surgeons (F.H.S., D.J.P., and T.C.S.). Because of
recurrent tumor because of artifactual
this referral pattern, the study includes a disproportionate number of primary
-. 4 degradation of the CT image. Direct sag-
tumors compared with metastatic tumors. Similarly, the distribution of lesions
ittal and coronal images from MR permit in this study does not reflect the true proportion of benign lesions seen at our
accurate assessment of the relationship of institution, because most patients with obvious benign neoplasms on plain
tumor to adjacent normal structures, in- films underwent surgery without CT or MR examinations. The ages of the
cluding the physis, joints, and neurovas- 33 men and 19 women ranged from 6 months to 81 years (median, 23
p cular structures. MR is useful in the eval- years).
uation of bone tumors: it is of greatest All examinations were performed using an MR imager with a 0.i5-T re-
.- ‘4 value in evaluations of the peripheral sistive magnet (Picker International, Highland Heights, Ohio). When time
allowed, images were obtained in all three planes (sagittal, coronal, and axial).
skeleton, the medullary canal, soft
Images were obtained in at least the axial plane in all patients. Early in the
tissues, and postoperative tumor recur-
study, a wide variety of pulse sequences were tried. For the more recent pa-
rence. With a 0.i5-T magnet, MR is less tients, partial-saturation (TE = 40 msec, TR = 500 msec), spin-echo (TE 60
useful in the evaluation of the axial skel- msec, TR = 2,000 msec), and inversion-recovery (TI 500 msec, TE 40 msec,
-C eton and cortical bone. TR = 2,000 msec) multisection pulse sequences were used (7). All sections were
iO mm thick and contiguous.
- ‘A Index terms: Bone neoplasms, computed- The body coil (35 X 52 cm) was used to examine the axial skeleton and
tomographic diagnosis, 40.1211 Bone neoplasms,
#{149} pelvis. Extremities were examined in the head coil (25 cm) to improve image
Pt magnetic resonance study, 40.129 Bone
#{149} neoplasms, quality. Surface coils were not available during this study.
metastases, 40.33 A calculated Ti or T2 relaxation time image was obtained when possible.
T2 calculations were obtained using spin-echo sequences (TE = 40 msec, TR
Radiology 1985; 155:709-718 = 2,100 msec and TE 80 msec, TR = 2,100 msec) with the same attenuator
setting. Inversion-recovery sequence (TI = 400 msec, TR 2,iOO msec) with
the above spin-echo 40-msec sequence was used to calculate Ti. With current
software, three i-cm-thick sections, each requiring 8 minutes, are necessary
to calculate Ti and T2. The average examination lasted 45-60 minutes for each
patient when Ti and T2 could be calculated.
1 From the Departments of Diagnostic Radiology Most of the CT examinations were performed with Picker 600, Picker 1200,
(W.D.Z., T.H.B., RAM., G.R.M.), Orthopedics (F.H.S.,
or EM! 7070 (Omnimedical; Anaheim, Calif.) units. CT sections were 10mm
D.J.P., T.C.S.), and Pathology (L.E.W.), Mayo Clinic
A and Mayo Foundation, Rochester, Minnesota. Re- thick, with spacing of iO or 15 mm.
ceived November 19, 1984; accepted and revision re- The image characteristics of each tumor, as compared with normal bone
quested December 27; revision received February 4, and soft tissue, were noted for each pulsing sequence. MR findings were re-
1985. trospectively correlated with findings from other imaging modalities and
C RSNA, 1985 with surgical pathologic findings. Gross pathology specimens were sectioned

709
Figure 1

4,

‘H

to correspond to MR images in either the We focused on the contribution of MR radiologist’s bias for an aesthetically
coronal or the sagittal plane. Extraosseous imaging and CT in enabling detection of pleasing image compared with a less
extent and longitudinal extent in the me- the lesion, prediction of its malignancy or pleasing image containing better informa-
dullary canal (including epiphyseal in- benignancy, and delineation of its anatomic tion.
volvement) were specifically noted by the extent. MR images and CT hard-copy films
consulting pathologist. All imaging studies were reviewed. The anatomic extent on MR
were independently reviewed by three of images was compared with that on CT scans RESULTS
us (W.D.Z., T.H.B., and RAM.). Three re- by noting the following for each modality
Of 52 patients, 32 had primary neo-
viewers were used in an attempt to balance in each patient: cortical destruction; tumor
plasms of bone (25 malignant and
the potential bias for MR imaging of a extent in the medullary canal; size of mass
skeletal radiologist active in MR imaging in extraosseous soft tissue; and neurovas- seven benign). The primary malignant
with the potential bias against MR imaging cular, fat, muscle, and joint involvement. neoplasms included ten osteosarcomas,
of the other two reviewers who were more The extent of a lesion was subdivided into six chondrosarcomas, four lymphomas,
accustomed to seeing lesions on CT scans. these categories in an attempt to control the three Ewing sarcomas, a fibrosarcoma,

710 . Radiology June 1985

 Ewing sarcoma of left femur.
a. CT scan shows higher density in invaded bone marrow, compared with
normal fatty marrow on the right. Soft-tissue extension is suggested by more
soft-tissue density on the left than the right and by loss of the fatty septa
between muscles. Abrupt change in linear attenuation coefficient at junction
of cortex and soft tissues causes artifact that degrades image.
b. SE sequence (TE 40 msec, TR = 2,000 msec). MR with long TR shows
high-signal sarcoma mass invading the surrounding muscles. Limits of mass
are shown better by MR than by CT. Patent femoral artery (arrow) is com-
pressed medially but is not invaded by tumor. This is not apparent on CT
scan without the use of contrast material. Because of strong tumor signal at
long repeat times, the invaded marrow looks like normal marrow. No bone
involvement is appreciated at this sequence.
c. SE sequence (TE 40 msec, TR 150 msec). MR with short TR shows bony
involvement with decreased intramedullary signal and thickened, dirty-
appearing cortex. Soft-tissue mass is poorly seen.

ments were added to the MR unit. Be-

Table 1
cause of the magnet strength and lim-
Tumor Signal Relative to Normal Marrow Signal for Commonly Used Pulse itations of patient motion, the images
Sequences
of the lower extremity have been of a
SE with Short TR SE with Long TR better quality than images of the axial
(relatively Ti- (relatively T2- skeleton and upper extremities. Tho-
IR’ (Ti-weighted) weighted) weighted)
racic and abdominal examinations with
Tumor of higher signal 0 0 14 our machine were inferior in spatial
than marrow
resolution to those with CT, even
Tumor of about equal 1 (osteochondroma) 2 (osteochondroma and 1 (sclerotic on CT
signal to marrow chondrosarcoma) scans and plain though they were superior in contrast
films)
resolution.
Tumor of lower signal 16 20 6
than marrow
No medullary extent of 4 4 6
tumor Lesion Detection
Pulse sequence not 31 26 25
performed Detection of bone tumors using MR
Total 52 52 52 imaging requires application of many
C TI = 400 or 500 msec, TE 40 msec, TR 1,000-2,000 msec. of the same principles used in inter-
, t TE = 40 msec, TR 500-600 msec. pretation of plain films and CT scans
I TE = 40 msec, TR 4,000 msec or TE = 60 msec, TR 2,000 msec.
‘ _4 § Five tumors were sclerotic on CT scans and plain films; sixth was chondroblastic osteosarcoma. (8). Cortical expansion, thinning, and
destruction; periosteal new bone; and
soft-tissue masses all can be identified
and an adamantinoma. Fifteen patients on the MR image. Forty-six of the 52 with MR imaging.
‘ had metastatic lesions. Four had os- patients underwent MR imaging as the Normal medullary bone gives a high
teomyelitis that could not be distin- last diagnostic test before surgery. The signal with MR because of abundant
guished from neoplasm, and one had median time from MR imaging to sur- fat. Normal cortical bone gives a very
4 an internal iliac artery aneurysm gery was 3 days. low signal. We identified three criteria
causing sacral destruction . Twenty- In 52 cases, there were 52 sets of for tumor detection which take ad-
eight of the patients had lower-ex- plain films, six plain tomograms, 31 vantage of the superior contrast reso-
tremity lesions, three had upper-ex- radionuclide bone scans, and 45 CT lution of MR imaging.
tremity lesions, and 21 had axial skel- scans (including recent studies per- First, tumor involving medullary
eton lesions. Seven of the malignancies formed elsewhere before the patient bone alters the normal signal of mar-
V represented recurrence of a previously was referred to our institution). CT row. Because of prolonged T2 of the
p resected malignant lesion (osteosarco- scans were available for correlation on tumor, signal intensity typically in-
ma, chondrosarcoma, two neurofibro- all seven of the benign primary tumors, creases with spin-echo sequences that
sarcomas, leiomyosarcoma, undiffer- 22 of the 25 malignant primary tumors, have long repeat times (TE 60 msec,
entiated sarcoma, and metastatic ma- and 13 of the i5 metastatic lesions. Our TR = 2,000 msec). Inversion-recovery
lignant fibrous histiocytoma). results concentrate on MR images and (TI = 500 msec, TR 2,000 msec) and
Forty-nine of the 52 lesions were the comparison of MR imaging with partial-saturation (TE 40 msec, TR
confirmed at surgery. Three metastatic CT. 500 msec) sequences most often show
hematogenous lesions had histologic The technical quality of the MR im- decreased signal intensity because of
proof of the primary lesions but no ages in our study increased with time, long Ti (Table i). There were several
surgical proof at the metastatic site seen as hardware and software improve- exceptions to these trends. Seven le-

Volume 155 Number 3 Radiology 711

#{149}
sions did not show increased signal on Figure 3
spin-echo sequences with long repeat
times. Six of the seven lesions were
sclerotic or were shown to contain
calcium on plain films or CT scans; the
seventh was a chondroblastic osteo-
4
sarcoma.
Second, when MR imaging enabled
detection of cortical invasion by tumor,
the signal was always increased in the
bony cortex. Invaded cortex appears
gray and mottled (“dirty cortical
bone”) rather than black (normal ab-
sence of signal from the bone cortex)
(Fig. 1). This difference is most obvious
in spin-echo sequences (TE 60 msec,
‘p
TR = 2,000 msec) with long repeat
times. Invaded cortical bone loses its
sharp interface with medullary bone
and with the surrounding soft
tissues.
Third, changes in the soft tissues-
including tumor extension, hemor-
I
rhage, effusions, and edema-are ac-
curately demonstrated because of the
superior soft-tissue contrast capability
of MR. The intraosseous and extraos-
seous components of a tumor were a.
often of different signal intensity, even
Recurrence of metastatic malignant fibrous histiocytoma in right femur.
on a single section (Fig. 1). Most com-
a. A 72-year-old man had retroperitoneal malignant fibrous histiocytoma resected 5 years
monly, the soft-tissue component was previous to MR imaging. Eight months before MR. he underwent curettage of a pathologic
of higher signal intensity than the in- fracture of right femoral shaft and internal fixation using two Vitallium plates and 30 screws.
traosseous component. On a single se- This was followed by radiation and chemotherapy.
quence, changes in the soft tissues were b. CT scan was interpreted as showing no definite evidence of recurrence. Soft-tissue mass 4
can be seen in retrospect after correlation with MR image.
sometimes the only obvious abnor-
c. SE sequence (TE 40 msec, TR = 4,000 msec). Metallic artifact precludes evaluation of femur.
mality reflecting a subtle underlying There is an unequivocal 8-cm-diameter, high-intensity (because of long TR) soft-tissue mass
bone lesion (Fig. 2). Three of the re- surrounding the femoral shaft. Disarticulation of right lower extremity 5 days later showed
current tumors described in the fol- recurrent grade 3-4 malignant fibrous histiocytoma.
lowing paragraph were detected solely
on the basis of soft-tissue changes.
Radiopaque materials cause consid-
erable artifact on CT scans but not on MR Characterization of Tumors msec. T2 values of the uncalcified
MR images. For this reason, MR imag- portion of two malignant lesions were
ing is superior to CT in enabling de- Several criteria were used to at- 126 and 139 msec; for two benign le-
tection of recurrent tumor in the pres- tempt to distinguish benign from ma- sions, the T2 values were 143-205
ence of nonferromagnetic metallic lignant lesions. Calculated measure- msec.
prostheses, fixation devices, or surgical ments of relaxation times (Ti and T2) For all 52 patients and for every
clips. In three of the seven patients were obtained in 13 cases (Table 2), pulse sequence, the intramedullary
with recurrent tumor, surgical clips did Relaxation times were not obtained in tumor signal was compared with the V

not cause significant artifact on CT the many patients who could not tol- normal marrow signal. Judging from
.4
scans. In the remaining four patients, erate additional time in the magnet. tumor signal alone, we found no sig-
the CT scan was significantly degraded Data obtained with spectroscopically nificant difference between benign
because of metal artifacts. In one of evaluated samples revealed that Ti and malignant tumors. Both gave H
these patients, the recurrent tumor was values were accurate above 100 msec lower signal than normal marrow on
missed using CT because of artifact and that T2 values were accurate from inversion-recovery sequences and on
from an internal-fixation device (Fig. 25 to 200 msec, with an increase in the partial-saturation sequences (spin-echo
3). Another patient with suspected re- standard deviation above this level (J. with short repeat times). Both the be-
current neoplasm and a metallic pros- E. Gray, unpublished data). Ti values nign and the malignant tumors gave
thesis underwent MR imaging only; for normal marrow ranged from 195 to increased signal on spin-echo Se-
CT was not used because of the obvious 307 msec, and T2 values from 80 to 116 quences with long repeat times. Le-
superiority of MR imaging in this set- msec (Table 2). Relaxation times for sions containing calcium or causing 4,
ting. An earlier CT scan was rendered small bones were difficult to assess ac- sclerosis may show decreased signal on
indeterminate by artifact. The MR curately because of the small area any spin-echo or inversion-recovery
image was free of significant artifact available for measurement. In a patient sequence compared with normal mar-
and accurately demonstrated recurrent with osteomyelitis of the distal tibia, row signal.
neoplasm (Fig. 4). the uninvolved marrow had a higher Many of the criteria for differen-
Ti than expected, possibly due to hy- tiating benign from malignant lesions
peremia. Ti values for malignancies with the use of plain films and CT
ranged from 404 to 887 msec; for be- scans are applicable to MR images (8).
nign lesions, the range was 375-628 All seven benign neoplasms were

712 Radiology
#{149} June 1985
 Figure 4

.1,

C.

Soft-tissue recurrence of chondrosarcoma.

a. Six years before MR imaging, a custom hip prosthesis was placed after resection of grade 2 chondrosarcoma.
b. CT scan 3 years after resection. CT was not repeated at the current visit because of the availability and superiority
I. of MR in this setting.
C. SE sequence (TE = 40 msec, TR = 4,000 msec). Prosthesis appears as black core and causes minimal artifact. Bone
b cortex appears as black ring (arrows). Recurrent sarcoma extends primarily anteriorly, with smaller extension
medially and laterally. Low-intensity areas within mass correspond to calcific deposits. Muscles on the right
are of abnormally low signal. This may be related to radiation therapy received postoperatively.

that were irregular and poorly defined

Table 2
were seen only in malignancies. Eleven
Calculated Relaxation Times in 13 Cases of Bone Tumors
lesions had such an appearance: a
Normal chondrosarcoma, a leiomyosarcoma, a
Lesion Tumor Marrow
neurofibrosarcoma, two lymphomas,
Ti (msec) (9 cases) a Ewing sarcoma, and five osteosarco-
Chondroblastic osteosarcoma 404 278 mas. These areas of inhomogeneity
Clear cell chondrosarcoma 464 ...
probably correspond to areas of hem-
Lymphoma 509 195-212
787-887 orrhage, necrosis, or an admixture of
Rhabdomyosarcoma ...

Mesenchymal sarcoma 462-562 262 bone and tumor (Fig. 5).

Osteochondroma 537-595 132-246’ If there is a sharp, smooth, well-
Osteochondroma 375-628 307 defined low-signal border between the
Hemangioma 533 228
tumor and the adjacent marrow, the
Osteomyelitis 572-613 404-433
T2 (msec)(4 cases) lesion is likely benign. Such well-de-
Osteoblastic osteosarcoma i26 80 fined interfaces were noted in only two
Clear-cell chondrosarcoma i39 ...
of the 40 malignant lesions (one ada-
Aneurysmal bone cyst 143-205 8i
mantinoma and one clear-cell chon-
Hemangioma 205 116
drosarcoma) but in four of the 12 be-
* Small bones of feet make these values less accurate. nign lesions (two aneurysmal bone
t Increased Ti possibly due to hyperemia.
i Sclerotic portion of tumor had a T2 of 70 msec.
cysts [Fig. 6] and in two cases of Staph-
ylococcus aureus osteomyelitis [Fig. 7]).
In one patient, MR images (obtained
at the time of diagnostic biopsy)
sharply delineated from the adjacent of the i6 lesions were tumors of carti- showed high contrast between an os-
normal marrow and surrounding soft lage or osteoid origin (Fig. 4). The other teosarcoma and normal marrow with
tissues. Four of these were expansile. A two lesions were a pelvic leiomyosar- partial saturation sequences (TE = 40
soft-tissue mass was present in 33 of the coma with dystrophic calcification and msec, TR = 500 msec). After 6 weeks
40 malignant lesions. an internal iliac artery aneurysm with and chemotherapy, a second exami-
Matrix mineralization was not as calcified thrombus. nation using the same sequence
reliably seen on MR images as on CT Inhomogeneities other than calcium showed the lesion to be of the same
scans. It appeared as punctate areas of within the tumors have value in pre- intensity as normal marrow, making
no signal (black) in 16 lesions. Fourteen dicting malignancy. Inhomogeneities detection of the lesion difficult.

Volume 155 Number 3 Radiology 713

#{149}
 Figure 5

4.

5’

Osteoblastic osteosarcoma of proximal right tibia.

a. CT scan shows mineral-producing lesion with some soft-tissue thickening medially.
b. SE sequence (TE 40 msec, TR 2,000 msec). Typical appearance of malignancy, although there is no soft-tissue mass. Tumor is of lower ..,

intensity than normal marrow, and its signal is inhomogeneous. Predominantly low signal corresponds to extent of calcification seen on
plain films and CT scan. Scattered areas of higher and lower signal are typical of malignancy and could be due to hemorrhage, necrosis, V

or calcification. Tumor is not separated from the normal marrow by a rim of low density, as is true of many benign lesions (see Fig. 6). Cortex
is somewhat indistinct at several locations around periphery, suggesting cortical invasion. Posteriorly, there is a thin rim of high signal
of unknown cause. Popliteal artery (arrow) is clearly not invaded. Note normal black appearance of patellar tendon (arrowhead).
c. SE sequence (TE 40 msec, TR 500 msec). Sagittal image shows tumor abutting but not crossing the physis. Distal extent is also well
4
shown.
d. Specimen from above-knee amputation 2 days after MR imaging shows tumor abutting but not crossing the epiphyseal plate. Tumor invaded
the cortex and elevated the periosteum. There was no soft-tissue invasion.

‘1

C1.4

Primary aneurysmal bone cyst of distal right femur.

a. CT scan shows lytic lesion that is fairly well surrounded by a calcified rim. Osteogenic sarcoma could not be excluded
on basis of plain films or CT scans. There is some soft-tissue density extrinsic to the calcified rim.
b. SE sequence (TE = 40 msec, TR = 2,000 msec). Typical appearance of benign lesion. Bulk of lesion is of higher intensity
than normal marrow. Lesion is surrounded completely by a shell of very low intensity. This shell clearly separates the
C,
lesion both from the normal medullary canal and from the surrounding fat. A clear interface with fat was not appreciated
with CT (see a). There is higher than normal signal in adductor muscles medially, probably corresponding to hemorrhage
or edema. Popliteal vessels (arrow) are separated from lesion by low-density rim and fat.

Extent of Tumors on MR Images resolution was inferior to that of CT derwent both MR and CT examina-
and CT Scans scans. However, even in this group of tions, CT was more accurate than MR
CT and MR were compared in their patients, MR images were sometimes in showing cortex destruction. CT was
ability to depict the extent of bone tu- more accurate, because of superior superior to MR in demonstrating ma-
mors as determined by surgical pa- contrast capabilities, than CT scans trix mineralization and pathologic
thology (Tables 3 and 4). In MR images were in showing extent of tumor. fractures. CT was also better at imaging
of poor or only fair quality, spatial For 18% of the 45 patients who un- normal cortical bone. MR imaging was

714 Radiology
#{149} June 1985
 Figure 7

a. c.
Osteomyelitis (Staphylococcus aureus) involving both distal tibias.
a. Lytic lesion crosses epiphyseal plate of distal right tibia.
b. SE sequence (TE 40 msec, TR = 500 msec). Sagittal image shows lesion (arrow), whose signal is equal to that of
normal marrow on this sequence. Lesion crossing the physis can be detected because of the low-intensity interface
with normal marrow.
c. SE sequence (TE = 40 msec, TR 2,000 msec). Lesions are seen in both distal tibial metaphyses. Lesions are of higher
signal than normal tibial marrow. Low-intensity shell separates lesions from normal marrow. Appearance is typical
of benign lesion. Multiplicity suggests infection rather than primary neoplasm. Achilles tendons appear black.
p Muscles appear as an intermediate gray.

In the group of 22 patients with pri-

Table 3
mary malignant bone tumors who un-
‘4 Comparison of CT and MR in Defining Extent of All Lesions
derwent both MR imaging and CT
CT Much CT and MR MR Much (Table 4), MR was superior to CT in
Criterion Better About Equal Better Total showing tumor extent in the medullary
Cortical destruction 8 35 2 45 canal in 41% of patients (Fig. i), the size
Extent in medullary canal I 29 15 45 of the extraosseous soft-tissue mass in
Presence or absence of joint involvement 0 42 3 45
50%, and the extent of skeletal muscle
Soft-tissue mass size 0 28 17 45
Neurovascular involvement 1 35 9 45 invasion in 68% (Fig. 2). MR imaging
Muscle involvement 1 22 22 45 was superior to CT in showing joint
Fat involvement 0 42 3 45
involvement in one patient and neu-
Note-Includes 45 of 52 MR examinations (20 poor or only fair quality. 25 good or excellent quality); rovascular involvement in 32% of pa-
,f seven MR examinations are not included because no comparable CT scan was available.
tients. In 14% of patients, CT scans
showed cortical invasion not demon-
strated on MR images.
In a patient with lymphoma of the
distal femur, radiographs showed ir-
better than CT in showing the extent of tection of joint involvement in 7% of regular demineralization of the proxi-
the tumor within the medullary canal patients, neurovascular involvement mal tibia, suggesting the possibility of
‘ in 33% of patients, in showing the size in 20%, and fat involvement in 7%. Use multicentric lymphoma. Sagittal MR
of the extraosseous soft-tissue mass in of coronal and sagittal planes, com- images showed unequivocally normal
38%, and in showing the extent of bined with improved soft-tissue con- marrow indicative of disuse osteopo-
skeletal muscle invasion in 49%. MR trast, provides this advantage for MR rosis in the tibia. In another patient
was better than CT in facilitating de- imaging. with osteosarcoma of the femur, MR

Volume 155 Number 3 Radiolov 715

#{149}
Figure 8

#1

#{149}0

4
Grade 4 osteosarcoma in distal left femur. Patient had above-knee amputation on the right 3 years earlier for grade 4 osteosarcoma.
a. Sclerotic lesion in diaphysis of femur, with a biopsy defect laterally.
b. SE sequence (TE = 40 msec, TR = 600 msec). Coronal image shows proximal extent of sarcoma and biopsy site.
c. SE sequence (TE = 40 msec, TR = 600 msec). Coronal image inferior to the site in b shows three distal skip lesions (arrows) that were not .4

detected on CT scans or plain films.

d. Coronal pathology specimen shows the largest skip lesion distal to bulk of sarcoma.

images showed several skip lesions in

the marrow (Fig. 8) that were not de-
Table 4
tected on plain films or CT scans. Comparison of CT and MR in Defining Extent of Primary Malignant Lesions
A subjective overall comparison of CT Much CT and MR MR Much
MR imaging with CT was made by re- Criterion Better About Equal Better Total
trospectively deciding which would Cortical destruction 3 19 0 22
.4

have been more useful if only one Extent in medullary canal 0 13 9 22

modality could have been selected. Of Presence or absence of joint involvement 0 21 1 22
0
Soft-tissue mass size 0 11 11 22
45 cases in which CT and MR were Neurovascular involvement 0 15 7 22
used, MR was preferred in 27 and CT in Muscle involvement 0 7 15 22
Fat involvement 0 22 0 22
seven, with no strong preference in i i. I
Tumor location was a significant factor. Note-Includes 22 of 25 MR examinations (nine of poor or only fair quality, 13 of good or excellent
quality); three MR examinations are not included because no comparable CT scan was available.
MR was generally more accurate for C,.

evaluating peripheral lesions, while

CT was more useful for evaluating
central lesions. bone cyst with an increased signal in- If only axial images are obtained, a le-
*
tensity on spin-echo pulsing (5). sion localized to the diaphyseal me-
Every tumor in the present study dullary canal (Fig. 2) may be missed
DISCUSSION
was visible on MR images. There was because both intramedullary fat and
Initial reports have shown the one patient whose recurrent tumor was tumor have similar signal intensities
promise of MR for orthopedic imaging, not detected on CT scans (Fig. 3) and with a long TR (2,000 msec). The small
including the evaluation of bone tu- another patient who was not examined difference in relaxation times is diffi-
mors. Brady et al. (1) described four with CT because of artifact degradation cult to appreciate in a small structure
giant-cell tumors with decreased signal from a metal prosthesis on previous CT such as the cross-sectional area of the
on spin-echo pulsing; the decreased scans (Fig. 4). Berquist (3) found that all medullary canal of a long bone. Sagittal I
signal was probably due to a decrease of the orthopedic plates, screws, pros- or coronal views can usually demon-
in the T2/T1 ratio. Moon et al. (2) de- theses, and surgical clips commonly strate the lesion, even with the same
scribed a metastatic lesion of the ver- used at our institution were nonfer- spin-echo sequence (TE 60 msec, TR
4
tebral body which had a decreased romagnetic. Consequently, MR imag- = 2,000 msec). However, an inver-
signal relative to the adjacent normal ing is superior to CT when these me- sion-recovery sequence (TI 500 msec,
vertebral body. This lesion was asso- tallic objects are present after opera- TR = 2,000 msec) is of most use in pro-
ciated with a greatly prolonged Ti and tion. viding good soft-tissue contrast when I
a slightly elevated T2. Berquist (3) de- In our experience, the spin-echo se- the initial spin-echo sequence does not
scribed a telangiectatic osteosarcoma quence with a long repeat time (TE clearly differentiate marrow from
with low signal intensity. We have 60 msec, TR = 2,000 msec) has been tumor. The main advantages to the
previously described an aneurysmal most useful in evaluating bone tumors. partial-saturation sequence (TE 40

716 Radiology
#{149} June 1985
 msec, TR = 600 msec) are that it can be 33% (4 of 12) of the benign lesions. In Skip lesions localized to the marrow
performed more quickly and it is rela- one patient, MR images allowed us to can be seen on MR images, even when
tively Ti weighted. This is useful when predict preoperatively that a lesion was they are not evident on plain films or
, I time is an important factor, as in an likely benign (aneurysmal bone cyst) CT scans. MR images can show the
anxious or claustrophobic patient. when findings on CT scans and plain presence or absence of joint and epi-
‘ Greater T2 weighting is possible using films suggested Ewing sarcoma. physeal involvement, which is not well
longer TE and TR values. The poten- CT is better than MR imaging for depicted on CT scans because of the
.4 tially better sensitivity with greater T2 showing normal cortex, while MR axial format of CT. In our opinion, co-
CIZ weighting should be considered in imaging is better than CT for showing ronal or sagittal images are essential to
light of the increased examination time normal marrow because normal mar- define longitudinal involvement of the
needed for longer TR values. Our ex- row emits high signal when MR is medullary cavity and soft tissues. Co-
perience with pulse sequences with used. ronal and sagittal images also aid in
longer TE and TR values is too limited Because of its superior spatial reso- clarifying the anatomic relationship
.1 to enable strong conclusions regarding lution and ability to demonstrate between a soft-tissue mass and a nor-
their use in the imaging of bone tu- mineral as an area of increased signal, mal anatomic structure (vessel, nerve,
1 mors. CT is better than MR imaging in muscle; Fig. i), but this type of infor-
Lesions in bone marrow yield a de- showing pathologic fractures and mation can usually be obtained on axial
* creased signal on inversion-recovery mineralization. The relatively poor MR images.
and partial-saturation sequences (TE spatial resolution of MR imaging will MR imaging has potential in exami-
‘ 40 msec, TR = 500 msec). Uncalcified improve as hardware and software nations of the tumor response tora-
k marrow
with long
lesions
repeat
on spin-echo
times (TE
sequences
60 msec,
improve.
In general, MR is better than CT in
diotherapy or chemotherapy. In our
series, only one patient underwent MR
1 TR = 2,000 msec) give increased signal. showing the extent of tumor in marrow imaging both before and after preop-
These results are due to an increase of and soft tissues. Marrow lesions are erative chemotherapy. In this case, the
‘4 both Ti and T2 in bone tumors corn- often not visible on plain films and are previously high-contrast lesion was
pared with normal marrow. On spin- subtle on CT scans. The general supe- difficult to detect on the postche-
. echo sequences, calcified or sclerotic riority of MR is due to two main factors. motherapeutic study.
4 regions (including osteoblastic metas- First, MR is able to show high-contrast In summary, MR imaging is occa-
tases and lesions that produce osteoid differences between soft-tissue struc- sionally helpful in the diagnosis of
V or cartilage) give decreased signal rel- tures that are of about equal density on tumor type. Plain films remain supe-
C’ ative to normal marrow, depending on CT. This is because, on a CT scan, den- nor for enabling prediction of the
the amount of calcification in the le- sities of adjacent soft-tissue structures histologic diagnosis, with CT and MR
may differ by only a fraction of a per- imaging helpful in rare instances. The
Cortical lesions on both spin-echo centage while, for an MR image, in- signal intensity of MR has not been
, and inversion-recovery sequences tensities of the same adjacent soft-tissue useful in enabling prediction of ma-
show a signal where there should be structures may differ by several hun- lignancy or benignancy. Further work
none. Cortical involvement appears as dred milliseconds, owing to differ- is necessary to determine if Ti and T2
a shade of gray rather than the normal ences in nuclear spin density, Ti, and are of any use for prediction of the
uniform black rim surrounding the T2 (6). This contrast superiority of MR histologic diagnosis. On an MR image,
. rnedullary canal. over CT is most commonly used in poorly defined irregular inhomo-
MR imaging does not allow predic- distinguishing a soft-tissue mass from geneities other than calcium within a
Jr tion of the malignancy or benignancy skeletal muscle, which are of about tumor are highly suggestive of malig-
of a tumor by its signal intensity alone. equal density on CT images not en- nancy. A well-defined, smooth, low-
V We were able to obtain Ti and T2 in hanced by contrast material (Fig. 2). intensity border between the tumor
only 13 patients. On the basis of these MR is also superior to CT in distin- and normal marrow suggests benig-
limited data, benign and malignant guishing tumor from unopacified nancy.
‘. tumors cannot be differentiated by loops of bowel. Another advantage of MR imaging is superior to CT in
their relaxation times. MR is that the presence or absence of demonstrating the extent of tumor
Occasionally, the intraosseous por- vascular involvement is shown on within the medullary canal and soft
8 tion of a tumor was of different (usu- images without the risk of intravenous tissues. MR imaging becomes more
. ally lower) signal intensity than ex- contrast material. Blood vessels may valuable, relative to CT, as one pro-
trasseous soft-tissue mass. This differ- appear black, white or target-like (9), ceeds distally from the axial skeleton.
ence may be due to the extraosseous depending on the flow velocity and MR imaging should be useful in eval-
1 portion being composed of purely pulse sequence. Figure 2b shows that uations for metastases in a patient with
tumor cells, while the intraosseous MR imaging depicts vascular structures a known primary lesion when the bone
. portion is composed of tumor mixed better than CT does. In our opinion, the scan is positive and the plain film
* with residual bone of low signal in- degree to which soft-tissue mass in- findings are normal. Such metastases
tensity. volves adjacent structures such as involving exclusively the marrow
The presence of poorly defined in- muscles, nerves, and blood vessels is cavity are difficult to identify on CT
homogeneities other than calcium usually adequately shown on axial MR scans. MR imaging is occasionally
‘ within a primary bone tumor suggests images. useful in demonstrating that a demin-
malignancy. This MR finding was Second, MR permits direct coronal eralized area is the result of disuse os-
#{188} present in more than one-fourth (ii of and sagittal imaging. This is particu- teoporosis and not tumor invasion
40) of the malignant lesions in our larly valuable in delineating the lon- from an adjacent bone. It is valuable
study. When present, it enabled a reli- gitudinal extent of a primary malig- when the optimal surgical approach
able prediction of malignancy. A sign nancy in the medullary canal (Figs. 1 demands precise knowledge of tumor
of benignancy is a well-defined low- and 5). This longitudinal extent is of extent, as in limb-salvage operations.
signal rim between the lesion and the critical importance in planning the Skip lesions in the marrow which are
adjacent marrow: this was noted in 5% level for amputation or the limits of missed on plain films and CT scans can
(2 of 40) of the malignant lesions but in resection for a limb-salvage operation. be detected with the use of MR imag-

Volume 155 Number 3 Radiology 717

#{149}
ing. It is the procedure of choice to in the coronal or sagittal plane. With 4. Cohen MD, Klatte EC, Baehner R, et al.
Magnetic resonance imaging of bone marrow
enable detection of recurrent tumor in this format, the examination can be
disease in children. Radiology 1984; 151:
postoperative patients with nonfer- completed in less than 30 minutes. 715-718.
romagnetic metallic prostheses, fixa- The contribution of MR to bone 5. Zimmer WD, Berquist TH, Sim FH, et al.
tion devices, and surgical clips. tumor imaging is expected to increase Magnetic resonance imaging of aneurysmal
bone cyst. Mayo Clin Proc 1984; 59:633-
After the detection of a malignant- as technical advances are accom- *
636.
or indeterminate-appearing lesion in plished. U 6. Steiner RM, Falke T, Taminiau A, desPlantes
the pelvis or extremities on plain films, Gz. The value of magnetic resonance
MR is recommended as the next imag- Correspondence and reprints: Thomas H. imaging in the preoperative evaluation of
ing test. A supplemental CT scan of the Berquist, M.D., Mayo Clinic, 200 First Street SW, primary malignant bone tumors. Paper pre-
Rochester, Minnesota 55905. sented at the annual meeting of the American
extremity is rarely required. Currently, Roentgen Ray Society, Las Vegas, April 9-13,
imaging tests performed after plain 1984.
films include MR of the primary lesion References 7. Pykett IL, Newhouse JH, Buonanno FS, et al. 4
to evaluate local extent and CT of the Principles of nuclear magnetic resonance
1. Brady TJ, Gebhardt MC, Pykett IL, et al.
imaging. Radiology 1982; 143:157-168.
chest to search for metastases (CT re- NMR imaging of forearms in healthy vol-
8. LukensJA, McLeod RA, Sim FH. Computed
mains superior to MR in this regard). unteers and patients with giant-cell tumor of
tomographic evaluation of primary osseous
bone. Radiology 1982; 144:549-552.
Images should be obtained in at least malignant neoplasms. AJR 1982; 139:45-48.
2. Moon KLJr., Genant HK, Helms CA, Chafetz
two planes (axial and either coronal or 9. Mills CM, Brant-Zawadzki M, Crooks LE, et t
NI, Crooks LE, Kaufman L Musculoskeletai
sagittal) to determine the extent of in- al Nuclear magnetic resonance: principles
applications of nuclear magnetic resonance.
of blood flow imaging. AJR 1984; 142:165-
volvement. Both Ti- and T2-weighted Radiology 1983; 147:161-171.
170.
4’
images are required, but often one can 3. Berquist TH. Magnetic resonance imaging:
preliminary experience in orthopedic radi-
be done in the axial plane and the other
ology. Magnetic Resonance Imaging 1984;
2:41-52.

C’

.*

718 Radiology
#{149} June 1985