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. 2021 Sep 22:8:100377.
doi: 10.1016/j.ejro.2021.100377. eCollection 2021.

Single shot zonal oblique multislice SE-EPI diffusion-weighted imaging with low to ultra-high b-values for the differentiation of benign and malignant vertebral spinal fractures

Elisabeth Sartoretti  1   2 , Sabine Sartoretti-Schefer  1   2 , Luuk van Smoorenburg  1 , Barbara Eichenberger  1 , Árpád Schwenk  1 , David Czell  2 , Alex Alfieri  3 , Andreas Gutzeit  4 , Manoj Mannil  5 , Christoph A Binkert  1   2 , Michael Wyss  6 , Thomas Sartoretti  2   7
Affiliations

Single shot zonal oblique multislice SE-EPI diffusion-weighted imaging with low to ultra-high b-values for the differentiation of benign and malignant vertebral spinal fractures

Elisabeth Sartoretti et al. Eur J Radiol Open. .

Abstract

Purpose: To investigate the diagnostic yield of low to ultra-high b-values for the differentiation of benign from malignant vertebral fractures using a state-of-the-art single-shot zonal-oblique-multislice spin-echo echo-planar diffusion-weighted imaging sequence (SShot ZOOM SE-EPI DWI).

Materials and methods: 66 patients (34 malignant, 32 benign) were examined on 1.5 T MR scanners. ADC maps were generated from b-values of 0,400; 0,1000 and 0,2000s/mm2. ROIs were placed into the fracture of interest on ADC maps and trace images and into adjacent normal vertebral bodies on trace images. The ADC of fractures and the Signal-Intensity-Ratio (SIR) of fractures relative to normal vertebral bodies on trace images were considered quantitative metrics. The appearance of the fracture of interest was graded qualitatively as iso-, hypo-, or hyperintense relative to normal vertebrae.

Results: ADC achieved an area under the curve (AUC) of 0.785/0.698/0.592 for b = 0,400/0,1000/0,2000s/mm2 ADC maps respectively. SIR achieved an AUC of 0.841/0.919/0.917 for b = 400/1000/2000s/mm2 trace images respectively. In qualitative analyses, only b = 2000s/mm2 trace images were diagnostically valuable (sensitivity:1, specificity:0.794). Machine learning models incorporating all qualitative and quantitative metrics achieved an AUC of 0.95/0.98/0.98 for b-values of 400/1000/2000s/mm2 respectively. The model incorporating only qualitative metrics from b = 2000s/mm2 achieved an AUC of 0.97.

Conclusion: By using quantitative and qualitative metrics from SShot ZOOM SE-EPI DWI, benign and malignant vertebral fractures can be differentiated with high diagnostic accuracy. Importantly qualitative analysis of ultra-high b-value images may suffice for differentiation as well.

Keywords: ADC, Apparent Diffusion Coefficient; AUC, Area Under the Curve; DWI, Diffusion Weighted Imaging; DXA, Dual Energy X-Ray Absorptiometry; Diffusion magnetic resonance imaging; FOV, Field of View; MRI, Magnetic Resonance Imaging; MShot, Multi Shot; Magnetic resonance imaging; PET-CT, Positron Emission Tomography – Computed Tomography; ROC, Receiver Operating Characteristics; SE-EPI, Spin Echo – Echo Planar Imaging; SI, Signal Intensity; SIR, Signal Intensity Ratio; SShot, Single Shot; STIR, Short Tau Inversion Recovery; Spinal fractures; T1w, T1-weighted; T2w, T2-weighted; TSE, Turbo Spin Echo; Vertebral body; ZOOM, Zonal Oblique Multislice.

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Conflict of interest statement

Michael Wyss is a part-time employee of Philips Healthcare. The other authors declare no conflict of interest in relation to this article.

Figures

Fig. 1
Fig. 1
73 years old female patient with multiple malignant (i.e. metastatic) vertebral body fractures of thoracic vertebrae TH4 – TH6. Hyperintense signal of fractures relative to normal vertebral bodies on all DWI images with b400 (Fig. 1A), b1000 (Fig. 1B) and b2000 (Fig. 1C). The signal intensity on ADC decreases with highest values on b = 0,400 ADC images (Fig. 1D), followed by b = 0,1000 ADC images (Fig. 1E) and lowest values on b = 0,2000 ADC images (Fig. 1F). The fracture is hypointense on T1w TSE images (Fig. 1G) and inhomogeneously hyperintense on STIR T2w images (Fig. 1H). For ROI measurements the vertebral body Th6 with the most intense STIR hyperintensity was chosen (Fig. 1H).
Fig. 2
Fig. 2
69 years old female patient with osteoporotic vertebral body fracture of lumbar vertebra L3 (red arrow). Hyperintense signal of fractures relative to normal vertebral bodies on DWI with b400 (Fig. 2A) and on DWI with b1000 (Fig. 2B), but no hyperintensity on DWI with b2000 (Fig. 2C). Moderate to high signal intensity on ADC of b = 0,400 (Fig. 2D), on ADC of b = 0,1000 (Fig. 2E) and on ADC of b = 0,2000 images (Fig. 2F). The fracture is hypointense on T1w TSE images (Fig. 2G) and inhomogeneously hyperintense on STIR T2w images (Fig. 2H) (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article).
Fig. 3
Fig. 3
Boxplots depicting quantitative data. The line in the box shows the median, the lower and upper hinges correspond to the first and third quartiles. The upper/lower whisker extends from the hinge to the largest/smallest value no further than 1.5 * IQR from the hinge.
Fig. 4
Fig. 4
Receiver operating characteristics (ROC) curves for the quantitative metrics ADC and SIR.
Fig. 5
Fig. 5
Overview of qualitative data. The frequency of appearances of the fractures of interest are depicted as bar plots.
See this image and copyright information in PMC

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