Recommended
More Related Content
Similar to Imaging Differentiation of Pathological Fractures caused by primary and secondary bine tumors: A journal club
Similar to Imaging Differentiation of Pathological Fractures caused by primary and secondary bine tumors: A journal club (20)
More from Kaushal Kafle
More from Kaushal Kafle (15)
Recently uploaded
Recently uploaded (20)
Imaging Differentiation of Pathological Fractures caused by primary and secondary bine tumors: A journal club
- 1. Journal Club Presenter: Dr. Kaushal Raj Kafle Moderator : Dr. Rishi Ram Paudel
- 2. Imaging Differentiation of Pathologic Fractures Caused by Primary and Secondary Bone Tumors
- 3. Journal Metrics • Cite Score : 5.6 • Impact Factor : 4.531 • ISI Rank : 43/136 (Radiology Nuclear medicine and medical imaging ) • Eigenfactor Score : 0.017 • Article Influence : 0.967 • SNIP : 1.408 • SJR : 1.007
- 4. Abstract
- 5. Participants • A combined search in the pathology and imaging databases of the institution over a period of almost 7 years (September 2002 to December 2009) was performed for cases with a histologic diagnosis of pathologic fracture.
- 6. • Inclusion criteria – imaging evaluation with one or more modalities • Radiographs • Computed tomography (CT) scans – axial and at least one longitudinal plane • Magnetic resonance imaging (MRI) scans – T1-weighted (T1W) and fluid-sensitive sequences • Exclusion criteria – cases in which cross-sectional imaging was not available – incomplete as defined by the inclusion criteria.
- 7. Examination Series Imaging Modality Total sample Group A PBT Group B MBT Xray one or more projections of the fractured bone 61 11 50 CT Scan thin-sectioned axial images through the involved area 30 4 26 MRI standard T1W and fat- suppressed T2W images in two planes 20 8 12
- 8. Image analysis • Radiographs – Fracture Shape (Linear, Jagged, Curved), – Bone Cortex Around The Fracture (Sclerotic, Lytic) – Bone Marrow Adjacent To The Fracture (Ill-defined Lesion, Geographic Lesion, Normal) – Presence/Absence And Type Of Mineralization (Chondroid, Osteoid, Unclear) – Presence/Absence Of Periosteal Reaction – Soft-tissue Mass, Cortex Extension, And Joint Extension.
- 9. Image analysis • CT scans – Density Of Tissues Around The Fracture Site (Isodense Or Hyperdense Relative To Fatty Marrow), – Margins Of The Tissues (Well-, Partly-, Or Ill-defined) – Fracture Shape (Linear, Jagged, Curved), – Status Of Bone Cortex Around The Fracture (Sclerotic, Lytic) – Soft-tissue Mass, And Presence Or Absence Of Periosteal Reaction.
- 10. Image analysis • MRI scans – Signal Intensity Of The Fracture Site Relative To Muscle in T1W And Fat-suppressed T2W Images (Hypo-, Iso-, Or Hyperintense), – Heterogeneity Of Tissues Around The Fracture Site On T1W And T2W Images (Minimal, Moderate, Marked), – Margin Of Signal Around The Fracture Site (Well-, Partly-, Or Ill-defined, Or Infiltrative) – Presence Or Absence Of Abnormal Signal In Muscles Adjacent To The Fracture,
- 11. • MRI Scans – Type Of Muscle Signal Abnormality If Present (Feathery, Nodular) – Presence Or Absence Of Internal Low Signal Septations Around The Fracture Site – Soft-tissue Mass – Periosteal And/Or Intracortical Signal Abnormality – Joint Extension – Contrast Enhancement.
- 12. Statistical Methods • Age distribution, time interval between symptom onset and imaging : Student’s t-test for independent samples. • Sex distribution : Fisher’s exact test. • Significant different radiological feature between the two fracture types – sensitivity, specificity, positive and negative predictive value – A probability level of 0.05 was considered statistically significant.
- 13. Back ground • Pathologic fractures occur in bones that are weakened by disease, including a variety of metabolic disorders and skeletal neoplasms. • The preoperative differentiation of a pathologic fracture due to MBT from one due to PBT is of paramount importance for surgical intervention and subsequent treatment planning. • An incorrect preoperative diagnosis may lead to excessive morbidity, including the need for amputation and the potential for poor patient outcome.
- 14. • Previous authors have described the imaging characteristics of pathologic fractures on various imaging modalities, and particular emphasis has been focused on differentiating these entities from stress fractures • There have been no prior reports describing distinguishing imaging features of pathologic fractures due to PBTs and MBTs.
- 15. Research Question • Describe pre-treatment imaging features of pathologic fractures caused by PBTs and MBTs • Determine if radiographic or cross-sectional features exist that differentiate fractures with underlying PBT from those with MBT.
- 16. PICO statement • Population : Patients with biopsy established diagnosis of a pathologic fracture • Intervention : The radiographs, CT scans, and MRI scans were retrospectively reviewed for the presence of multiple imaging features • Comparison : Describe pre-treatment imaging features of pathologic fractures caused by PBTs and MBTs • Outcome : For the imaging features which was statistically significant, the sensitivity, specificity, positive and negative predictive value in predicting a PBT as the underlying lesion was measured
- 19. Study outcomes and analysis
- 23. Discussion • Treatment of PBT vs MBT – MBT internal fixation or joint arthroplasty – Pain relief and rapid mobilization and ambulation – PBT Planned resection with adjuvant and neoadjuvant therapy – Immediate amputation may be needed if local hematoma facilitates the dissemination of tumor
- 24. • Presence of mineralization either on radiography or CT scan within the lesion at the fracture site proved highly specific and sensitive for predicting an underlying PBT, with its absence carrying a high negative predictive value. • The presence of mineralization should prompt the underlying PBT, whereas its absence should be thought of as more predictive of MBT.
- 25. • A soft-tissue mass on radiographs was also highly specific with high negative predictive value but had poor sensitivity
- 26. Authors’ Conclusion • Pathologic fractures caused by PBT and MBT may be differentiated by a few specific radiographic and CT imaging features, though MRI was poor for characterization of the underlying lesion.
- 27. Internal Validity • Study Design – Retrospective Cross-sectional Evaluation Of Predefined Characters In Radiographs, CT Scan and MRI • Population – Pathological fracture in histologically Diagnosed Bone Tumors And Metastatic Lesions • Randomization – Consensus Of Two Radiologist Blinded To Pathology And Official Dictated Imaging Report
- 28. External Validity • Level III evidence • Generalisable to pathological fractures with suspected underlying malignancy • All relevant measures evaluated on Xray CT and MRI
- 29. Limitation of study • Small number of cases with PBT • Only applicable to those who have sustained fracture and are suspected to have underlying malignancy, • Cant be generalised to patient presenting with bone lesion without fracture • Interpretation of the studies in consensus, in which the assessment of the imaging findings might have benefited from calculation of interobserver variability
- 30. Limitation of study • Validation of Pathology Reports • Single vs Multiple lesions considered
- 31. Application • Useful For Diagnostic Purposes • May Potentially Be Used For Guidance of a Biopsy Procedure In Patients With Pathologic Fracture • Biopsy may yield negative result due to aspiration of blood clot from fracture site or absence of extraosseous mass , radiological suspicion can assist in tailoring the surgical treatment • Presence of mIneralization on CT can assist the target site for optimal apporach for adequate tumor material
Editor's Notes
- Authors Radio Radio Ortho Patho patho Location John Hopkins Hospital North Carolina USA
- Cite Score : Citations / no of citable articles in 2 year Same year Impact Factor 2016 No of Times articles published in 2014-2015 were cited in 2016 / Total no of citable articles published in 15-15 ISI rank : International Scientific Ranking Eigenfactor : importance of a specific journal based on number of incoming citations from highly ranked journals : More impact of the journal to the scientific community AI : Eigenfactor score/ % of all articles recorded in JCR published in a specific journal SNIP Source Normalised impact per paper : No of citations given in present year to pubication of Scimago Journal Rank : Prestige metric based on idea that all citations are not created equal
- Patients wih histological diagnosis of pathological fracture
- additional post-contrast T1W images were available in 13/20 (65%) of the latter studies
- The pathological reports were used as reference standard to define PBT as positive cases and MBT as negative cases Student T test compares the mean of 2 normally distributed samples Probabilistic estimate of likelihood that the samples randomly selected were from same population Fischer Exact Test is a non parametric test for meausrement of level of significance for cross tabulated frequency of variable. And is useful for evaluation of categorical datas and aslo for small sample size
- High sensitivity : Not to miss potential disease , likelihood a PBT is identified as PBT, gives correct diagnosis of disease High NPV : shows reliability of the identifying radiological feature, if absent rules out the possibilty of PBT accurately Specificity : Probabilty of getting a negative result when the person doesnot have disease the presence of mineralization either on radiography or CT scan within the lesion at the fracture site proved highly specific and sensitive for predicting an underlying PBT, with its absence carrying a high negative predictive value. Therefore, the presence of mineralization should prompt the radiologist to suggest an underlying PBT, whereas its absence should be thought of as more predictive of MBT.
- Bias Inclusion and exclusion criteria validity Internal validity is the extent to which you can be confident that a cause-and-effect relationship established in a study cannot be explained by other factors.
- A limitation of our study is the small number of cases with pathologic fractures due to an underlying PBT. Future studies on larger number of series are necessary to confirm and extend our results. In addition, specialized imaging modalities, such as PET are unlikely to provide discriminatory information about the primary site, as even fractures without an underlying lesion demonstrate FDG avidity [18]. Whole-body imaging techniques with PET or MRI may assist characterization of the fracture site by detecting other lesions in the body. Advanced MRI techniques need to be studied further; in our study, diffusion-weighted and chemical shift imaging were employed only in a limited number of patients, precluding the inclusion of the respective results in the statistical analysis in our study. It is imperative that the results of this study are applied only to patients who have sustained a fracture and are suspected of having an underlying malignancy; they should not be generalized to subjects with a bone lesion who do not present with a fracture. Another limitation is the interpretation of the studies in consensus, in which the assessment of the imaging findings might have benefited from calculation of interobserver variability
- The imaging features identified in this study are useful not only for diagnostic purposes, but also may potentially be used for guidance of a biopsy procedure in patients with pathologic fractures. In patients with high suspicion for malignant disease, a biopsy is recommended after detection of the lesion. However, in some centers, the patient may routinely proceed to surgical stabilization without a biopsy; in such cases, a PBT may be incorrectly treated as a MBT.Additionally, biopsy of a pathologic fracture sitemay fail in the absence of an extraosseous component when the needle is inserted into the fracture gap or in the presence of marked hemorrhage at the fracture site, as the aspirated sample may include only blood clot without any lesional material [17]. In such cases, suspicion raised by the radiologist regarding the underlying etiology of the fracture by imaging could assist in tailoring the surgical treatment, thus improving the patient’s outcome. Furthermore, when biopsy is performed, the presence of mineralization on CT can assist the radiologist to select a suspicious target and an optimal approach, in order to obtain adequate tumor material.