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Appropriateness Criteria

Reference Study Type Patients/Events Study Objective(Purpose of Study) Study Results Study Quality
1. Fletcher CDM, World Health Organization., International Agency for Research on Cancer. WHO classification of tumours of soft tissue and bone. 4th ed. Lyon: IARC Press; 2013. Review/Other-Dx N/A To provide an international standard for oncologists and pathologists and will serve as an guide for use in the design of studies monitoring response to therapy and clinical outcome. N/A 4
2. National Cancer Institute. Surveillance, Epidemiology, and End Results (SEER). Cancer Stat Facts: Bone and Joint Cancer.  Available at: https://seer.cancer.gov/statfacts/html/bones.html. Review/Other-Dx Data based on "per 100,00" cases. To provide cancer statistics regarding bone and joint cancer. Using statistical models for analysis, rates for new bone and joint cancer cases have been rising on average 0.4% each year over the last 10 years. Death rates have been falling on average 0.3% each year over 2006-2015. 5-year survival trends are shown below. 4
3. Lodwick GS. A probabilistic approach to the diagnosis of bone tumors. Radiol Clin North Am. 1965;3(3):487-497. Review/Other-Dx N/A To present a basic method of evaluating radiographs of bone tumors and also a prior probability matrix. No results stated in abstract. 4
4. Madewell JE, Ragsdale BD, Sweet DE. Radiologic and pathologic analysis of solitary bone lesions. Part I: internal margins. Radiol Clin North Am. 19(4):715-48, 1981 Dec. Review/Other-Dx N/A To describe the anatomic site and extent of lesions as well as the interface between tumor and normal bone. No results stated in abstract. 4
5. Ragsdale BD, Madewell JE, Sweet DE. Radiologic and pathologic analysis of solitary bone lesions. Part II: periosteal reactions. Radiol Clin North Am. 19(4):749-83, 1981 Dec. Review/Other-Dx N/A To describe preriosteal responses and their importance in predicting the biologic behavior of bone neoplasms. No results stated in the abstract. 4
6. Sweet DE, Madewell JE, Ragsdale BD. Radiologic and pathologic analysis of solitary bone lesions. Part III: matrix patterns. Radiol Clin North Am. 19(4):785-814, 1981 Dec. Review/Other-Dx N/A To describe the radiographic patterns of increased density and their significance in predicting bone tumor matrices. No results stated in abstract. 4
7. Oudenhoven LF, Dhondt E, Kahn S, et al. Accuracy of radiography in grading and tissue-specific diagnosis--a study of 200 consecutive bone tumors of the hand. Skeletal Radiol. 35(2):78-87, 2006 Feb. Observational-Dx 200 patients with bony tumors of the hand To determine the usefulness of radiography and magnetic resonance imaging in differentiating benign from malignant bony tumors of the hand and in making a tissue-specific diagnosis. By the combining of "certainly" and "probably" benign (grades I and II) and "certainly" and "probably" malignant (grades IV and V), a correct grading was obtained in 165 (82.5%) of the cases (154 of the 173 benign and 11 of the 27 malignant tumors). A correct tissue-specific diagnosis was included in the three proposed differentials in 87.5%. MRI confirmed a correct diagnosis made on radiography in 72% and improved the grading capability by correctly upgrading malignant tumors and downgrading benign tumors in, respectively, 8% and 12%. The capability to obtain a tissue-specific diagnosis improved with change of an incorrect diagnosis on radiography to a correct one on MRI in 12 cases (24%). 3
8. Caracciolo JT, Temple HT, Letson GD, Kransdorf MJ. A Modified Lodwick-Madewell Grading System for the Evaluation of Lytic Bone Lesions. AJR Am J Roentgenol. 207(1):150-6, 2016 Jul. Observational-Dx 183 bone lesions To apply a Modified Lodwick-Madewell Grading System as an alternative means to categorize lytic bone tumors into those with low, moderate, and high risks of malignancy. Of the 183 tumors, 81 were classified as grade I, 54 as grade II, and 48 as grade III. When correlating grade with pathology, we found that 76 of 81 (94%) grade I lesions were benign and 39 of 48 grade III lesions (81%) were malignant. A nearly equal number of grade II lesions proved to be benign (29/54; 54%) and malignant (28/54; 53%). 3
9. Crim J, Schmidt R, Layfield L, Hanrahan C, Manaster BJ. Can imaging criteria distinguish enchondroma from grade 1 chondrosarcoma?. Eur J Radiol. 84(11):2222-30, 2015 Nov. Observational-Dx 53 patients To minimize systematic bias and optimize agreement on imaging criteria in order to better define the accuracy of imaging criteria in the diagnosis of grade 1 chondrosarcoma. The correct diagnosis of enchondroma was made on radiographs in 43 (67.2%) of readings, and on MRI in 37/64 (57.8%). The correct diagnosis of chondrosarcoma was made on radiographs in 5/24 (20.8%) of readings, and on MRI in 14/24 (57.8%). A diagnosis of borderline lesion was made in 19/64 (29.7%) of enchondromas on radiographs and 18/64 (28.1%) on MRI. The false positive rate of radiographs for chondrosarcoma was 2/64 (3.1%) and the false positive rate of MRI was 9/64 (14.1%). There was substantial interobserver variability. Cortical thickening and bone expansion were rare but specific signs of chondrosarcoma. 2
10. Geirnaerdt MJ, Hermans J, Bloem JL, et al. Usefulness of radiography in differentiating enchondroma from central grade 1 chondrosarcoma. AJR. 1997; 169(4):1097-1104. Observational-Dx 78 patients To evaluate clinical symptoms and radiographic features that allow radiologists to differentiate between enchondroma and central grade 1 chondrosarcoma. No statistically significant correlation was found between clinical symptoms and the benign or malignant nature of the neoplasms. Grade 1 chondrosarcomas were more likely to be found in the axial skeleton and in flat bones. Also, chondrosarcomas were significantly larger than enchondromas (P<.001). Ill-defined margins and lobulated contours were the only morphologic features seen on radiographs that allowed significant discrimination (P=.004 and .009, respectively). An optimal combination of four radiographic features still left 72 of the 78 lesions with a 10%-90% probability of malignancy, indicative of poor discriminating power. Kappa values generally showed poor to fair agreement. 3
11. Niitsu M, Takeda T. Solitary hot spots in the ribs on bone scan: value of thin-section reformatted computed tomography to exclude radiography-negative fractures. J Comput Assist Tomogr 2003;27:469-74. Observational-Dx 47 patients To classify solitary, scintigraphy-positive and radiography-negative rib lesions and to clarify the features of rib fractures by using thin-section reformatted helical computed tomography (CT). The final diagnosis included 17 cases of fractures where CT findings were fracture line, focal sclerosis, and callus formation. Fourteen ribs demonstrated intramedullary, focal osteosclerosis, and 8 ribs did not demonstrate any abnormalities. Four metastatic lesions appeared as intramedullary mixture of osteolysis and osteosclerosis, or bone destruction. Four intramedullary lesions with cystic appearance remained unchanged. 3
12. Frank JA, Ling A, Patronas NJ, et al. Detection of malignant bone tumors: MR imaging vs scintigraphy. AJR. 1990; 155(5):1043-1048. Observational-Dx 106 patients To determine the relative sensitivities of MRI and scintigraphy for detecting primary malignant bone tumors and bone metastases. A retrospective analysis showed that in 30 (28%) of 106 patients, MRI performed over a limited region of interest revealed a focal abnormality consistent with tumor that was not observed on scintigraphy. Only one patient had an abnormality on scintigraphy, caused by a metastasis that was not found on MRI. In 73 (69%) of the 106 patients, the results of MRI and scintigraphy were equivalent; in 41 cases results of both techniques were normal. A McNemar analysis of the discordant cases showed MRI to be more sensitive than scintigraphy was (P<.001). 2
13. Murphey MD, Suhardja A, Senchak L, Walker E, Fanburg-Smith J, Kransdorf MJ. Imaging of unusual complications of non-ossifying fibroma. Skeletal Radiol 2016;45:1158. Review/Other-Dx 8 patients To describe the radiologic appearance of unusual complications of nonossifying fibroma including stress fracture, diffuse infarction, aneurysmal bone cyst and malignant transformation that may simulatemore aggressive disease. Patients included 5 males and 3 females (average age 14 years; age range 8–20 years).Common locations included the distal femur (50%), fibula (25%) and tibia (25%). Lesions were centered in the metaphysis in all cases. Radiographs and CTshowed a predominantly lytic lesion with a narrow zone of transition in 88 % of cases with one case revealing prominent sclerosis. Nonaggressive periosteal reaction was seen in 62 % of cases. A soft tissue mass was seen in only one case by MR. Fluid levels and relatively rapid enlargementwere also seen in one case onMR imaging. Prominent surrounding marrow and/or periosteal cuff of edema was seen in 71%of cases onMR imaging. The signal intensity of the nonossifying fibroma was low to intermediate intensity with heterogeneity in 86 % of cases on both T1 and T2- weighted MR images. One case showed diffuse high signal on T2-weighted MR and rim enhancement suggesting infection. Diffuse heterogeneous enhancement was seen in the other 2 cases following contrast administration both in the lesion and the adjacent edema. 4
14. Sundaram M, McLeod RA. MR imaging of tumor and tumorlike lesions of bone and soft tissue. AJR. 1990; 155(4):817-824. Review/Other-Dx N/A A review to examine the role of MRI in the diagnosis and staging of tumors and tumor like lesions of bone and soft tissue. For tumors of bone, the plain radiograph is not only the least expensive diagnostic test but is the most reliable predictor of the histologic nature of a given lesion. MRI is the examination of choice for staging bone tumors. CT is preferred to MRI only when the characteristics of the lesion are inadequately defined on plain radiographs, as may occur in flat bones. Although MRI is of limited value in predicting the histology of bone tumors, it is a useful tool for distinguishing round-cell tumors and metastases from stress fractures and medullary infarcts in symptomatic patients with normal radiographs. For depiction of soft-tissue masses, MRI is unrivaled. Biopsy of bone and soft-tissue tumors should follow and not precede MRI. MRI reliably shows change in tumor volume after radiation or chemotherapy and is less reliable in predicting the amount of tumor necrosis. 4
15. Assoun J, Richardi G, Railhac JJ, et al. Osteoid osteoma: MR imaging versus CT. Radiology. 1994;191(1):217-223. Experimental-Dx 19 patients To compare the performance of CT and MRI in diagnosis of osteoid osteoma. CT was more accurate than MRI in detection of the osteoid osteoma nidus in 63% of cases. MRI was better than CT in showing intramedullary and soft-tissue changes in all cases. This may produce a misleading aggressive appearance on MRIs. There was a statistically significant correlation between presence or absence of marrow or soft-tissue changes and treatment with anti-inflammatory medications (P<.05). 3
16. Gondim Teixeira PA, Lecocq S, Louis M, et al. Wide area detector CT perfusion: can it differentiate osteoid osteomas from other lytic bone lesions?. Diagn Interv Imaging. 95(6):587-94, 2014 Jun. Review/Other-Dx 56 patients To compare the enhancement dynamics of osteoid osteomas with other benign and malignant lytic bone lesions using CT perfusion. Enhancement curve morphology of the osteoid osteomas was significantly different from its mimickers. All osteoid osteomas had an early enhancement with a delay between nidus and arterial peak below 30 seconds. Eighty percent of the mimickers demonstrated a slow and progressive enhancement. The perfusion parameters of the other lytic bone lesions were similar to those of the osteoid osteomas in 46.1% of the patients. 4
17. Davies M, Cassar-Pullicino VN, Davies AM, McCall IW, Tyrrell PN. The diagnostic accuracy of MR imaging in osteoid osteoma. Skeletal Radiol. 2002; 31(10):559-569. Review/Other-Dx 43 patients To analyze the MRI appearances of a large series of osteoid osteomas, to assess the ability of MRI to detect the tumor, and to identify potential reasons for misdiagnosis. The potential for a missed diagnosis was 35% based solely on the MR investigations. This included 6 tumors which were not seen and 9 which were poorly visualized. The major determinants of the diagnostic accuracy of MRI were the MR technique, skeletal location, and preliminary radiographic appearances. There was a wide spectrum of MR signal appearances of the lesion. The tumor was identified in 65% of sequences performed in the axial plane. The nidus was present in only one slice of the optimal sequence in 27 patients. Reactive bone changes were present in 33 and soft tissue changes in 37 patients. 4
18. Liu PT, Chivers FS, Roberts CC, Schultz CJ, Beauchamp CP. Imaging of osteoid osteoma with dynamic gadolinium-enhanced MR imaging. Radiology. 2003;227(3):691-700. Observational-Dx 11 patients To compare dynamic gadolinium-enhanced T1-weighted MRI with nonenhanced T1-weighted and T2-weighted MRI and thin-section CT for the demonstration of osteoid osteomas. Compared with CT, dynamic gadolinium-enhanced MRI demonstrated the osteoid osteoma equally well in 8/11 patients and with better conspicuity in 3/11 patients, although this difference was not statistically significant (P=.69). The dynamic gadolinium-enhanced MRIs demonstrated the osteoid osteomas significantly better than the nonenhanced T1-weighted (P<.001) and T2-weighted (P<.001) MRIs. On the dynamic gadolinium-enhanced MRIs, 9 (82%) of 11 patients had peak enhancement of the osteoid osteoma in the arterial phase with early partial washout, compared with slower, progressive enhancement of the adjacent marrow. This resulted in greatest lesion to marrow contrast material enhancement in the arterial phase. One osteoid osteoma had peak enhancement in the venous phase, and one showed progressive enhancement through all phases to 150 seconds. 2
19. Sharma P, Mukherjee A, Karunanithi S, et al. 99mTc-Methylene diphosphonate SPECT/CT as the one-stop imaging modality for the diagnosis of osteoid osteoma. Nucl Med Commun. 35(8):876-83, 2014 Aug. Observational-Dx 31 patients To evaluate the utility of Tc-methylene diphosphonate (Tc-MDP) single-photon emission tomography (SPECT)/computed tomography (CT) for the diagnosis of osteoid osteoma and compare the same with three-phase planar bone scintigraphy (BS) and CT alone. There were nine equivocal lesions on planar BS and five equivocal lesions on CT, but none on SPECT/CT. The sensitivity, specificity, and accuracy of SPECT/CT were all 100%; those of CT were 77.8, 92.3, and 83.8% and those of planar BS were 100, 38.4, and 74.1%, respectively. On comparison, the area under the curve of SPECT/CT was significantly larger than that of planar BS (1.00 vs. 0.761; P=0.005) and CT (1.00 vs. 0.872; P=0.044). However, no significant difference was seen between planar BS and CT (0.761 vs. 0.872; P=0.236). 3
20. Bui KL, Ilaslan H, Bauer TW, Lietman SA, Joyce MJ, Sundaram M. Cortical scalloping and cortical penetration by small eccentric chondroid lesions in the long tubular bones: not a sign of malignancy?. Skeletal Radiol. 38(8):791-6, 2009 Aug. Review/Other-Dx 122 patients To evaluate by cross-sectional imaging the prevalence and degree of cortical scalloping by small eccentric chondromas correlated with histologic diagnosis and patient history. The chondromas ranged in size from 1.6 to 3.8 cm (mean 2.3 cm). Two lesions were located in the proximal femoral diaphysis, two in the distal femoral diaphysis, six in the distal femoral metaphysis, and one in the proximal tibial epimetaphysis. The lesions were curetted due to diagnostic uncertainty, continued pain, marked radiologic cortical penetration, or due to patient insistence on biopsy. All 11 lesions were benign, nine histologically, and two by stability over 4 and 7 years. The prevalence of cortical scalloping among eccentric chondromas was 100%. Cortical scalloping or occupancy ranged from 50 to 100% (mean 75%). 4
21. Collins MS, Koyama T, Swee RG, Inwards CY. Clear cell chondrosarcoma: radiographic, computed tomographic, and magnetic resonance findings in 34 patients with pathologic correlation. Skeletal Radiol. 32(12):687-94, 2003 Dec. Review/Other-Dx 72 patients To describe the radiographic features of clear cell chondrosarcoma, including the CT and MRI findings, and to correlate them with the histopathologic findings. Clear cell chondrosarcoma typically presents radiographically as a geographic lytic lesion located in the epimetaphyseal region of long bones. Most commonly lesions are found in the proximal femur, followed by the proximal humerus. Lesions within the proximal humerus may exhibit more aggressive features. Lesions in the axial skeleton are typically expansile and destructive, often with soft tissue extension and lack of mineralization. MRI may show the presence or absence of bone marrow edema. 4
22. Murphey MD, wan Jaovisidha S, Temple HT, Gannon FH, Jelinek JS, Malawer MM. Telangiectatic osteosarcoma: radiologic-pathologic comparison. Radiology. 2003; 229(2):545-553. Review/Other-Dx 40 patients To describe the imaging characteristics of a large series of telangiectatic osteosarcomas with pathologic findings for comparison. Lesions frequently affected the femur, tibia, and humerus. Radiographs showed geographic bone lysis, a wide zone of transition, and matrix mineralization. CT demonstrated low attenuation, MR demonstrated high signal intensity on T2-weighted images, and both demonstrated hemorrhage, which simulated the appearance of aneurysmal bone cyst. Viable sarcomatous tissue surrounding hemorrhagic and/or necrotic regions was best seen at contrast material-enhanced CT and MRI, with thick peripheral, septal, and nodular enhancement in all cases. Subtle matrix mineralization in this viable tissue was best seen at CT. An associated soft-tissue mass was also seen in 19/25 cases (76%) at CT and in 24/27 cases (89%) at MRI. 4
23. Panicek DM, Gatsonis C, Rosenthal DI, et al. CT and MR imaging in the local staging of primary malignant musculoskeletal neoplasms: Report of the Radiology Diagnostic Oncology Group. Radiology. 1997;202(1):237-246. Experimental-Dx 316 patients To assess the relative accuracies of CT and MRI in the local staging of primary malignant bone and soft-tissue tumors. The CT images were obtained with and without contrast. No contrast was used in the MR images. There was no statistically significant difference between CT and MRI in determining tumor involvement of muscle, bone, joints, or neurovascular structures. The combined interpretation of CT and MRI did not statistically significantly improve accuracy. Inter-reader variability was similar for both modalities. 2
24. Yuan Y, Zhang Y, Lang N, Li J, Yuan H. Differentiating malignant vertebral tumours from non-malignancies with CT spectral imaging: a preliminary study. Eur Radiol. 2015;25(10):2945-2950. Observational-Dx 37 patients To investigate the value of dual-energy spectral computed tomography (DESCT) for differentiating malignant vertebral tumours from non-malignancies during venous phase. The iodine density, lesion-to-muscle ratio, and lesion-to-artery ratio of the iodine density measurement for malignant vertebral tumours were significantly different from the respective values for non-malignancies (all p < 0.05). Using 0.52 as the threshold value for the lesion-to-artery iodine density ratio, one could obtain sensitivity of 85% and specificity of 100% for differentiating malignant vertebral tumours from non-malignancies, significantly higher than the qualitative diagnosis. 3
25. Aoki J, Watanabe H, Shinozaki T, et al. FDG PET of primary benign and malignant bone tumors: standardized uptake value in 52 lesions. Radiology. 2001; 219(3):774-777. Observational-Dx 52 primary bone lesions To evaluate the SUV of FDG-PET in the differentiation of benign from malignant bone lesions. There was a statistically significant difference in SUV between benign (2.18 +/- 1.52 [SD]) and malignant (4.34 +/- 3.19) lesions in total (P=.002). However, giant cell tumors (n = 5; SUV, 4.64 +/- 1.05) showed significantly higher SUV than chondrosarcomas (n = 7; SUV, 2.23 +/- 0.74) (P=.036, adjusted for multiple comparisons) and had no statistically significant difference in SUV compared with osteosarcomas (n = 6; SUV, 3.07 +/- 0.96) (P=.171). There was no statistically significant difference in SUV between fibrous dysplasias (n = 6; SUV, 2.05 +/- 0.98) and osteosarcoma (P=.127) or chondrosarcomas (P=.667). Although the number of cases was small, three chondroblastomas, one sarcoidosis, and one Langerhans cell histiocytosis showed levels of FDG accumulation as high as that of osteosarcomas. 3
26. Bredella MA, Essary B, Torriani M, Ouellette HA, Palmer WE. Use of FDG-PET in differentiating benign from malignant compression fractures. Skeletal Radiology. 37(5):405-13, 2008 May. Observational-Dx 33 patients with 43 compression fractures To evaluate the use of FDG-PET in differentiating benign from malignant compression fractures. There were 14 malignant and 29 benign compression fractures, including 5 acute benign fractures. On FDG-PET, 5 benign fractures were falsely classified as malignant (false-positive). Three of these patients underwent prior treatment with bone marrow-stimulating agents. There were two false-negative results. Sensitivity, specificity, PPV, NPV, and accuracy of FDG-PET in differentiating benign from malignant compression fractures were 86%, 83%, 84%, 71%, and 92% respectively. The difference between SUV values of benign and malignant fractures was statistically significant (1.9 +/- 0.97 for benign and 3.9 +/- 1.52 for malignant fractures, P<0.001). SUV of benign acute and chronic fractures were not statistically significant. 3
27. Dehdashti F, Siegel BA, Griffeth LK, et al. Benign versus malignant intraosseous lesions: discrimination by means of PET with 2-[F-18]fluoro-2-deoxy-D-glucose. Radiology. 1996; 200(1):243-247. Observational-Dx 20 patients To assess the ability of FDG-PET to allow differentiation of benign from malignant intraosseous lesions. SUV assessment of FDG accumulation within osseous lesions was superior to subjective visual analysis for discriminating benign from malignant lesions. With use of a 2.0 cutoff value for SUV, 14 of 15 malignant lesions were categorized correctly vs 12 of 15 correctly categorized by means of subjective image evaluation; four of five benign lesions were categorized correctly with both techniques. 2
28. Liu F, Zhang Q, Zhu D, et al. Performance of Positron Emission Tomography and Positron Emission Tomography/Computed Tomography Using Fluorine-18-Fluorodeoxyglucose for the Diagnosis, Staging, and Recurrence Assessment of Bone Sarcoma: A Systematic Review and Meta-Analysis. Medicine (Baltimore). 94(36):e1462, 2015 Sep. Meta-analysis 35 studies To investigate the performance of fluorine-18-fluorodeoxyglucose (F-FDG) positron emission tomography (PET) and PET/computed tomography (CT) in the diagnosis, staging, restaging, and recurrence surveillance of bone sarcoma by systematically reviewing and meta-analyzing the published literature. The pooled sensitivity and specificity of PET/CT to differentiate primary bone sarcomas from benign lesions were 96% (95% confidence interval [CI], 93-98) and 79% (95% CI, 63-90), respectively. For detecting recurrence, the pooled results on an examination-based level were sensitivity 92% (95% CI, 85-97), specificity 93% (95% CI, 88-96), positive likelihood ratio (PLR) 10.26 (95% CI, 5.99-17.60), and negative likelihood ratio (NLR) 0.11 (95% CI, 0.05-0.22). For detecting distant metastasis, the pooled results on a lesion-based level were sensitivity 90% (95% CI, 86-93), specificity 85% (95% CI, 81-87), PLR 5.16 (95% CI, 2.37-11.25), and NLR 0.15 (95% CI, 0.11-0.20). Good
29. Shin DS, Shon OJ, Han DS, Choi JH, Chun KA, Cho IH. The clinical efficacy of (18)F-FDG-PET/CT in benign and malignant musculoskeletal tumors. Ann Nucl Med. 22(7):603-9, 2008 Aug. Observational-Dx 91 patients To analyze the clinical efficacy of FDG-PET/CT in a relatively large group of patients with musculoskeletal tumors. Final diagnosis revealed 19 benign soft tissue tumors (mean SUV(max) 4.7), 27 benign bone tumors (5.1), 25 malignant soft tissue tumors (8.8), and 20 malignant bone tumors (10.8). There was a significant difference in SUV(max) between benign and malignant musculoskeletal tumors in total (P<0.002), soft tissue tumors (P<0.05), and bone tumors (P<0.02). Sensitivity, specificity, and diagnostic accuracy were 80%, 65.2%, and 73% in total with cutoff SUV(max) 3.8, 80%, 68.4%, and 75% in the soft tissue tumors with cutoff SUV(max) 3.8, and 80%, 63%, and 70% in the bone tumors with cutoff SUV(max) 3.7. 3
30. Treglia G, Salsano M, Stefanelli A, Mattoli MV, Giordano A, Bonomo L. Diagnostic accuracy of 18F-FDG-PET and PET/CT in patients with Ewing sarcoma family tumours: a systematic review and a meta-analysis. [Review]. Skeletal Radiol. 41(3):249-56, 2012 Mar. Meta-analysis 13 studies comprising a total of 342 patients To systematically review and meta-analyse literature data on the diagnostic performance of fluorine-18-fluorodeoxyglucose (FDG) positron emission tomography (PET) and positron emission tomography/computed tomography (PET/CT) in patients with Ewing sarcoma family tumours (ESFT). We found 13 studies comprising a total of 342 patients with ESFT. The main findings of the studies included are presented. The meta-analysis of five selected studies provided these results about FDG-PET and PET/CT in ESFT: pooled sensitivity: 96% (95% confidence interval [CI] 91-99%); pooled specificity: 92% (95% CI 87-96%); area under the ROC curve: 0.97. Good
31. Wang CK, Li CW, Hsieh TJ, Chien SH, Liu GC, Tsai KB. Characterization of bone and soft-tissue tumors with in vivo 1H MR spectroscopy: initial results. Radiology. 232(2):599-605, 2004 Aug. Observational-Dx 36 consecutive patients To determine if in vivo detection of choline by using hydrogen 1 MRS with dynamic contrast material-enhanced MRI can help differentiate between benign and malignant musculoskeletal tumors. Choline was detected in 18/19 patients with malignant tumors and in 3/17 patients with benign lesions. The 3 benign lesions included one perineurioma, one giant cell tumor, and one abscess. Choline was not detected in 14 patients with benign lesions nor in one patient with a densely ossifying low-grade parosteal osteosarcoma. In vivo hydrogen 1MRS characterized bone and soft-tissue tumors, resulting in a sensitivity of 95%, specificity of 82%, and accuracy of 89% (P<.001). 2
32. Shin DS, Shon OJ, Byun SJ, Choi JH, Chun KA, Cho IH. Differentiation between malignant and benign pathologic fractures with F-18-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography. Skeletal Radiol. 37(5):415-21, 2008 May. Observational-Dx 34 patients To evaluate the efficacy of FDG-PET/CT in differentiating malignant from benign pathologic fractures. There were 19 malignant and 15 benign fractures. In the malignant fractures, PET/CT demonstrated high (mean SUVmax 12.0, range 4.3 to 45.7). FDG uptake in bone marrow in most cases (17/19). In benign fractures, there was low FDG uptake (mean SUVmax 2.9, range 0.6 to 5.5) within cortical bone or adjacent soft tissue around the fracture, rarely in the marrow. There were significant differences in the pattern of intramedullary FDG uptake (P<0.001) and in the mean SUVmax (P<0.01) between malignant and benign fractures. The sensitivity, specificity and diagnostic accuracy of FDG-PET/CT were 89.5%, 86.7% and 88.2%, respectively, with a cut-off SUVmax set at 4.7. The time interval between fracture and PET/CT did not significantly influence FDG uptake at the fracture site. 3
33. Feldman F, Van Heertum R, Saxena C, Parisien M. 18FDG-PET applications for cartilage neoplasms. Skeletal Radiol. 34(7):367-74, 2005 Jul. Observational-Dx 29 patients To assess the value of FDG-PET in defining aggressive cartilage neoplasms, particularly those with problematic or borderline histologic, imaging and clinical characteristics. In 26 operated cases the overall sensitivity of whole-body FDG-PET in separating benign and malignant lesions was 90.9% (10/11), specificity 100% (18/18) and accuracy 96.6%. 3
34. Campbell RS, Grainger AJ, Mangham DC, Beggs I, Teh J, Davies AM. Intraosseous lipoma: report of 35 new cases and a review of the literature. Skeletal Radiol. 2003; 32(4):209-222. Review/Other-Dx 35 cases of intraosseous lipoma; 110 cases To identify the common imaging features of intraosseous lipomas on radiographs, MRI and CT, and review their histological features. The mean age at presentation is 43 years. Sex distribution is nearly equal. Lipomas occur most frequently in the lower limb (71% overall), particularly in the os calcis (32%). Other common sites include the metaphyses of long bones, where lesions are typically eccentric. Lipomas are usually well defined, but marginal sclerosis is commoner in lesions of the os calcis (61%) than at other sites (38%). Calcification is also more frequent in the os calcis (62%), and almost invariably centrally located. Calcification at other sites is less common (30%), and is more variable in appearance. Bone expansion is less common (30%), and usually minimal. Fat necrosis and cyst formation identified on MRI is common (67%), and more frequent in the os calcis. 4
35. Si MJ, Wang CS, Ding XY, et al. Differentiation of primary chordoma, giant cell tumor and schwannoma of the sacrum by CT and MRI. Eur J Radiol. 82(12):2309-15, 2013 Dec. Review/Other-Dx 22 SCs, 19 SGCTs and 8 GSSs were reviewed To evaluate criteria to differentiate sacral chordoma (SC), sacral giant cell tumor (SGCT) and giant sacral schwannoma (GSS) with CT and MRI. The mean ages of SC, SGCT and GSS were 55.1 +/- 10.7, 34.3 +/- 10.7 and 42.4 +/- 15.7 years old. SCs (77.3%) were predominantly located in the midline of lower sacrum, while most SGCTs (73.7%) and GSSs (87.5%) were eccentrically located in upper sacrum. There were significant differences in age, location, eccentricity, morphology of bone residues, intratumoral bleeding and septations. Multiple small cysts were mainly observed in SGCTs (73.7%) with large central cysts in GSSs (87.5%). SGCTs expanded mainly inside sacrum while SCs and GSSs often extended into pelvic cavity (P = 0.0022). Involvement of sacroiliac joints and muscles were also different. Ascending extension within sacral canal was only displayed in SCs. The preservation of intervertebral discs showed difference between large and small tumors (P = 0.0002), regardless of tumor type (P = 0.095). No significant difference was displayed in gender (P = 0.234) or tumor size (P = 0.0832) among three groups. 4
36. Hogeboom WR, Hoekstra HJ, Mooyaart EL, et al. MRI or CT in the preoperative diagnosis of bone tumours. Eur J Surg Oncol. 1992; 18(1):67-72. Observational-Dx 25 patients To determine the value of MRI and CT in the diagnosis of bone tumors. MRI is superior to CT as it permits multidirectional exposures. Moreover, the tumor can be readily distinguished from the neurovascular structures without injection of contrast medium. MRI gives better contrast than CT, making it possible to study the relationship to the soft tissues, bone marrow and joints more accurately. On the other hand, CT gives a better picture of the destruction of cortical bone. The exact tumor length cannot be measured with MRI or CT and neither permits an exact, reliable diagnosis. Owing to the relatively slow exposure technique in combination with respiratory movements, depiction of the thoracic wall is less satisfactory with MRI than with CT. If both techniques are available, MRI is preferred. 3
37. Bloem JL, Taminiau AH, Eulderink F, Hermans J, Pauwels EK. Radiologic staging of primary bone sarcoma: MR imaging, scintigraphy, angiography, and CT correlated with pathologic examination. Radiology. 1988; 169(3):805-810. Observational-Dx 56 patients A prospective study to determine the appropriate application of diagnostic procedures in local staging of primary bone sarcoma by comparing results of CT, MRI, Tc-99m-methylene diphosphonate scintigraphy, and angiography with resected specimens. MRI was significantly superior to CT and scintigraphy in defining intraosseous tumor length and was as accurate as CT in demonstrating cortical bone and joint involvement. It was also superior to CT in demonstrating involvement of muscle compartments. MRI was also the best modality in exhibiting the relationship between tumor and major neurovascular bundles; however, these differences were not significant. 3
38. Lange MB, Nielsen ML, Andersen JD, Lilholt HJ, Vyberg M, Petersen LJ. Diagnostic accuracy of imaging methods for the diagnosis of skeletal malignancies: A retrospective analysis against a pathology-proven reference. Eur J Radiol. 85(1):61-67, 2016 Jan. Observational-Dx 409 biopsies from 395 patients. To examine the diagnostic accuracy of imaging modalities in skeletal tumours versus pathology reports. Sensitivity and specificity were significantly different among the five modalities (p<0.0001). The sensitivity of MRI and PET/CT was better than CT, but CT had a better specificity than PET/CT. In general, these methods outperformed BS and X-ray. The sensitivity for osteolytic lesions varied significantly between modalities (p<0.0001), with MRI and PET/CT being more sensitive than CT. Differences in sensitivity were also observed in mixed lesions (p=0.0002) but not in osteosclerotic lesions. In spine lesions, MRI showed the best sensitivity followed by PET/CT and CT (p<0.0005 vs. MRI). There was no significant differences among non-spine lesions. 3
39. Feydy A, Anract P, Tomeno B, Chevrot A, Drape JL. Assessment of vascular invasion by musculoskeletal tumors of the limbs: use of contrast-enhanced MR angiography. Radiology. 238(2):611-21, 2006 Feb. Observational-Dx 30 patients To prospectively evaluate the accuracy of contrast material-enhanced MR angiography in the evaluation of vascular invasion by bone and soft-tissue tumors, with surgery serving as the reference standard. Among the 31 cases, 20 were classified as negative and 11 were classified as positive at surgery. All but 3 cases with a gap between the tumor and the vessels on MRI were classified as free and without adhesions at surgery. All cases with arterial stenoses at MR angiography had tumoral adhesion or tumoral encasement at surgery. MRI had a sensitivity of 64%, a specificity of 95%, a PPV of 88% a NPV of 83%, and an accuracy of 84% in the detection of vascular invasion on the basis of findings of partial or total encasement. MR angiography had a sensitivity of 82%, a specificity of 85%, a PPV of 75%, a NPV of 90%, and an accuracy of 84% in the detection of vascular invasion on the basis of the findings of a stenosis. 2
40. Seeger LL, Widoff BE, Bassett LW, Rosen G, Eckardt JJ. Preoperative evaluation of osteosarcoma: value of gadopentetate dimeglumine-enhanced MR imaging. AJR. 1991; 157(2):347-351. Review/Other-Dx 21 patients To determine if gadopentetate dimeglumine-enhanced MRIs could assist in the preoperative evaluation of osteosarcoma. In some instances, use of gadopentetate dimeglumine obscured differentiation of tumor from normal marrow or tumor infiltration into perineurovascular fat, and tumor extension through pseudocapsule could not be differentiated from peritumoral edema after contrast administration. Contrast enhancement did assist in differentiation of intra-articular tumor from effusion; however, synovial invasion could be identified on unenhanced T1-weighted images by loss of synovial fat and cortical disruption. These results indicate that gadopentetate dimeglumine does not assist in defining tumor margins of osteosarcoma. 4
41. Swan JS, Grist TM, Sproat IA, Heiner JP, Wiersma SR, Heisey DM. Musculoskeletal neoplasms: preoperative evaluation with MR angiography. Radiology. 1995; 194(2):519-524. Observational-Dx 23 patients To assess the ability of MR angiography to depict vascularity of musculoskeletal neoplasms. Of named vessels, 92% in proximity to tumor were noted by blinded readers. The PC technique provided supplemental data in 47% of cases, usually related to better delineation of in-plane feeder vessels and areas with pulsatile blood flow. Of the 28 branch feeder vessels, 23 were noted on both conventional arteriograms and MR angiograms in a nonblinded review, but 16 were difficult to distinguish as feeders because of lack of associated tumor blush. 2
42. Geirnaerdt MJ, Hogendoorn PC, Bloem JL, Taminiau AH, van der Woude HJ. Cartilaginous tumors: fast contrast-enhanced MR imaging. Radiology. 2000; 214(2):539-546. Observational-Dx 37 patients To differentiate between benign and malignant cartilaginous tumors with fast contrast material-enhanced MRI. Start of enhancement and the combination of start and progression of enhancement correlated significantly (P<.001) with benign and malignant tumors. Early enhancement was seen in chondrosarcoma, not seen in enchondroma, and seen in osteochondroma only when growth plates were unfused. The sensitivity was 89%, specificity 84%, PPV 84%, and NPV 89%. Differentiation of malignancy from benignity on the basis of early and exponential enhancement was possible with a sensitivity of 61%, specificity 95%, PPV 92%, and NPV 72%. 3
43. Arevalo-Perez J, Peck KK, Lyo JK, Holodny AI, Lis E, Karimi S. Differentiating benign from malignant vertebral fractures using T1 -weighted dynamic contrast-enhanced MRI. J Magn Reson Imaging. 2015;42(4):1039-1047. Review/Other-Dx 21 patients To differentiate pathologic from benign vertebral fractures, which can be challenging. Pathologic fractures had significantly higher (P < 0.01) perfusion parameters (Vp , K(trans) , wash-in slope, peak enhancement, and AUC) compared with benign fractures. We also found significant differences (P < 0.001) in all parameters between chronic and acute fractures. Vp and K(trans) were able to differentiate between pathologic and acute fractures (P < 0.01). No significant differences were found with peak enhancement (P = 0.21) and AUC (P = 0.4) between pathologic and acute fractures. 4
44. Verstraete KL, De Deene Y, Roels H, Dierick A, Uyttendaele D, Kunnen M. Benign and malignant musculoskeletal lesions: dynamic contrast-enhanced MR imaging--parametric "first-pass" images depict tissue vascularization and perfusion. Radiology. 1994; 192(3):835-843. Observational-Dx 100 patients To assess the diagnostic value of parametric MRIs that display the first pass of gadopentetate dimeglumine. A significant difference (P<.001) was found between the first pass slope values of benign (mean, 36.2% per second) and malignant (mean, 67.4% per second) lesions. First pass images depicted tissue vascularization and perfusion rather than benignity or malignancy, because there is an overlap in the slope values of highly vascular benign lesions and malignant lesions. 3
45. Douis H, Davies AM, Jeys L, Sian P. Chemical shift MRI can aid in the diagnosis of indeterminate skeletal lesions of the spine. Eur Radiol. 2016;26(4):932-940. Observational-Dx 55 patients To evaluate the role of chemical shift MRI in the characterisation of indeterminate skeletal lesions of the spine as benign or malignant. There were 45 benign lesions and 12 malignant lesions. Chemical shift imaging correctly diagnosed 33 of 45 lesions as benign and 11 of 12 lesions as malignant. In contrast, there were 12 false positive cases and 1 false negative case based on chemical shift MRI. This yielded a sensitivity of 91.7 %, a specificity of 73.3 %, a negative predictive value of 97.1 %, a positive predictive value of 47.8 % and a diagnostic accuracy of 82.5 %. 3
46. Liu LP, Cui LB, Zhang XX, et al. Diagnostic Performance of Diffusion-weighted Magnetic Resonance Imaging in Bone Malignancy: Evidence From a Meta-Analysis. [Review]. Medicine (Baltimore). 94(45):e1998, 2015 Nov. Meta-analysis 32 studies with 1507 patients. To investigate whether whole-body DW-MRI is a viable means in differentiating bone malignancy. The pooled sensitivity, specificity, and AUC were 0.95 (95% CI, 0.90-0.97), 0.92 (95% CI, 0.88-0.95), and 0.98 on a per-patient basis, and they were 0.91 (95% CI, 0.87-0.94), 0.94 (95% CI, 0.90-0.96), and 0.97 on a per-lesion basis. In subgroup analysis, there is no statistical significance found in the sensitivity and specificity of using DWI only and DWI combined with other morphological or functional imaging sequence in both basis (P > 0.05). A b value of 750 to 1000 s/mm enables higher AUC and DOR for whole-body imaging purpose when compared with other values in both basis either (P < 0.01). The ROC space did not show a curvilinear trend of points and a threshold effect was not observed. According to the Deek's plots, there was no publication bias on both basis. Good
47. Thawait SK, Marcus MA, Morrison WB, Klufas RA, Eng J, Carrino JA. Research synthesis: what is the diagnostic performance of magnetic resonance imaging to discriminate benign from malignant vertebral compression fractures? Systematic review and meta-analysis. Spine (Phila Pa 1976). 2012;37(12):E736-744. Meta-analysis 31 studies with 1685 subjects To perform a systematic review and meta-analysis to summarize and combine the published data on MRI for discriminating malignant from benign VCFs. A total of 31 studies with 1685 subjects met the selection criteria. All the studies focused on describing specific features rather than overall diagnostic performance. Signal intensity ratio on opposed phase (chemical shift) imaging 0.8 or more (OR = 164), apparent diffusion coefficient on echo planar diffusion-weighted images 1.5 x 10(-3) mm2/s or less with b value 500 s/mm2 (OR = 130), presence of other noncharacteristic vertebral lesions (OR = 55), presence of paraspinal mass (OR = 33), involvement of posterior element (OR = 28), involvement of pedicle (OR = 24), complete replacement of normal bone marrow in VCF (OR = 19), presence of epidural mass (OR = 13), and diffuse convexity of posterior vertebral border (OR = 10) were associated with malignant VCFs, whereas coexisting healed benign VCF (OR = 0.006), presence of "fluid sign" (OR = 0.08), presence of focal posterior vertebral border convexity/retropulsion (OR = 0.08), and band-like shape of abnormal signal (OR = 0.07) were associated with benign VCFs Good
48. Fayad LM, Wang X, Salibi N, et al. A feasibility study of quantitative molecular characterization of musculoskeletal lesions by proton MR spectroscopy at 3 T. AJR. 2010; 195(1):W69-75. Observational-Dx 33 patients To establish the feasibility and potential value of measuring the concentration of choline-containing compounds by proton MRS in musculoskeletal lesions at 3T. Spectral quality was excellent in 26 cases, adequate in 4 cases, and nondiagnostic in 4 cases. For malignant lesions (3 sarcomas), the choline concentrations were 1.5, 2.9, and 3.8 mmol/kg, respectively. For 5 benign lesions (two neurofibromas, two schwannomas, and one enchondroma), the choline concentrations were 0.11, 0.28, 0.13, 0.8, and 1.2 mmol/kg, respectively. For 7 benign lesions (two hematomas, two bone cysts, one lipoma, one giant cell tumor, and one pigmented villonodular synovitis), the spectra showed negligible choline content. For 3 post-treatment fibrosis cases, the choline concentration range was 0.2-0.4 mmol/kg. For the remaining 12 post-treatment fibrosis cases, the spectra showed negligible choline content. Average choline concentrations were different for malignant and benign lesions (2.7 vs 0.5 mmol/kg; P=0.01). 3
49. Wang LJ, Wu HB, Wang M, et al. Utility of F-18 FDG PET/CT on the evaluation of primary bone lymphoma. Eur J Radiol. 84(11):2275-9, 2015 Nov. Observational-Dx 19 to assess the role of F-18 FDG PET/CT in the diagnosis and therapeutic effect evaluation of primary bone lymphoma (PBL) . F-18 FDG PET/CT was positive in 94.7% (18/19) of patients. Uptake of FDG in lesions was intense with SUVmax of 15.14 +/- 11.82. Multiple involved lesions were found in 47.4% (9/19) patients, while 52.6% presented with a single involved lesion. Based on the lesions, PET detected 98.9% (87/88) lesions. Among them, 71.6% (63/88) lesions were found to be located in axial skeleton and 28.4% (25/88) in the extremity skeleton. FDG PET/CT also found the lesions infiltrate to the surrounding soft tissue in 84.2% (16/19) patients. On the syn-modality CT, the bone destruction was noted in 43.2% (38/88) of the lesions, of which 50.0% lesions presented as slight change in bone density and 50.0% as severe change. The diagnostic sensitivity of PET was much higher than that of CT (98.9% vs. 43.2%, P=0.000). PET/CT was performed for evaluation of treatment response in 13 patients. In 12 patients with complete response(CR), PET/CT found the 25 lesions were F-18 FDG fully resoluted after treatment, however, bone destruction was still presented in 72.0% (18/25) lesions. 3
50. Sharma P, Dhull VS, Reddy RM, et al. Hybrid SPECT-CT for characterizing isolated vertebral lesions observed by bone scintigraphy: comparison with planar scintigraphy, SPECT, and CT. Diagn Interv Radiol. 2013;19(1):33-40. Observational-Dx 99 patients with 108 isolated vertebral lesions To assess the role of single photon emission computed tomography-computed tomography (SPECT-CT) for characterizing isolated vertebral lesions observed by bone scintigraphy compared to planar scintigraphy, SPECT, and CT, and to evaluate the impact of SPECT-CT on patient management. Among the 108 lesions, 49 were indeterminate on planar scintigraphy, 16 on SPECT, and one each on SPECT-CT and CT. SPECT-CT was superior to both planar scintigraphy (P < 0.001) and SPECT alone (P = 0.014), but not to CT (P = 0.302). CT was superior to planar scintigraphy (P < 0.001) but only slightly superior to SPECT (P = 0.063). SPECT-CT correctly characterized 96% of the indeterminate lesions observed by planar scintigraphy. SPECT-CT had an impact on the clinical management of 60.6% patients compared to planar scintigraphy and 18.1% compared to SPECT. 3
51. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro.pdf. Review/Other-Dx N/A To provide evidence-based guidelines on exposure of patients to ionizing radiation. No abstract available. 4
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