MRI of Bone Marrow Radiologic-Pathologic Correlation...Lecture Objectives • Discuss MRI marrow...
Transcript of MRI of Bone Marrow Radiologic-Pathologic Correlation...Lecture Objectives • Discuss MRI marrow...
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Marilyn J. Siegel, M.D.Mallinckrodt Institute of Radiology
Washington University School of MedicineSt. Louis, MO
and Visiting Scientist, AFIP, Washington, DC
MRI of Bone Marrow Radiologic-Pathologic Correlation
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Conflict of Interests
• None
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Lecture Objectives
• Discuss MRI marrow techniques • Review normal bone marrow anatomy• Describe MR features of normal marrow• Recognize MR findings of pathologic
marrow
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Part I: Techniques
• 2 techniques, vary with clinical indications
• Dedicated MRI of limited body part for evaluation of localized pain or to follow focal lesion
• Whole body MRI is used for staging, restaging and surveillance
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Basic Pulse Sequences
• Dedicated MRI:–T1-Wt, FS T2-Wt, Gd–images through area of interest–multiple planes
• Whole body MRI–STIR only–Vertex to toes, coronal plane
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Part II: Normal Bone MarrowHistology
• Red Marrow –cellular, active or myeloid marrow–red & white blood cells & platelets
»(& minimal yellow marrow)• Yellow Marrow
–inactive or fatty marrow–fat cells
»(& minimal red marrow)
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Red and Yellow Marrow:Different Chemical Composition
YELLOW
• 15%
• 80%
• 5%
RED
• 40%
• 40%
• 20%
Water
Fat
Protein
MRI appearance of marrow reflects the relative fractions of red & yellow marrow
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PART III:MRI: Normal Marrow
• Red Marrow– T1: intermediate (> muscle < fat)– STIR/FS: intermediate (>muscle > fat)
• Yellow Marrow– T1 : bright (= fat)– STIR/FS : black (< muscle)
• T1: “Fat finder” sequence• FST2: “Pathology finder” sequence
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Normal Marrow
T1 FST2
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MR Normal Marrow:Variations in Distribution
• Conversion of red to yellow marrow occurs during growth and development and has a predictable and orderly pattern
• You need to know this to avoid mistakes in diagnosis
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Patterns of Marrow Distribution
• Neonate: virtually all red marrow • Shortly after birth red-to-yellow marrow
conversion begins–Overall: extremities to axial–In a given bone: epiphysis/apophysis →
diaphysis → metaphysis
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Marrow ConversionAppendicular to Axial Conversion
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Marrow Distribution
•Adult distribution by age 25 years
•From nearly 100% red marrow at birth to 40% red marrow in adulthood
Vogler JB III. Radiology 1998; 168:679-693.
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Variations in Marrow Distribution
•Red marrow persists in the proximal humeral and femoral metaphyses
•Red marrow can persist in the proximal humeral epiphyses
– subchondral, curvilinear focus
–other patterns are abnormal
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Bone Marrow Variations:Vertebral Marrow Distribtution
• Yellow marrow around basivertebral vein common in children
• Other patterns common in adults
• Islands of fat can mimic metastases
Ricci C. Radiology 1990;177:83-88.
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Summary Key Points: Criteria for Normal Marrow
• Shows expected signal intensities on all image sequences
• Shows expected distribution in the skeleton for patient age
• Is symmetric• % of fatty marrow increases with age
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PART IV: Marrow Pathology
• Reconversion• Replacement (tumor)• Depletion (post tx)• Fibrosis (post tx)
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Marrow Reconversion
• Opposite of conversion• Generally symmetric• Causes:
–Chronic anemia – Increased 02 needs
»altitude, athletes, smokers–Granulocyte colony stimulating factor –Cyanotic heart disease
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Reconversion
Axial skeleton responds first, followed by extremities
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Reconversion: Sickle Cell Anemia
• Increased red cells• No fat cells to generate
signal• T1:= /> muscle < fat• STIR/Fat sat T2 :
–> muscle > fatINTERMEDIATE
T1 FST2
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Marrow Replacement
• Implantation of cells in marrow that do not normally exist there
• Follows red marrow distribution–Vertebrae > pelvis > femur > skull
• Causes–Hematologic tumors-lymphoma, leukemia–Metastases
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Marrow Replacement: Imaging
• T1 WT: intermediate SI–> muscle < fat
• STIR/Fat Sat: very bright• Can be diffuse or focal• Predominates in red
marrow (axial skeleton)
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Review:Hyperplasia or Tumor?
• Distinguishing criteria:– Red marrow: orderly distribution
» Tumor: random distribution– Red marrow: usually symmetric bilaterally
» Tumor: usually asymmetric– Red marrow: minimally bright on STIR/FS
» Tumor: extremely bright
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Hyperplasia or Tumor?STIR (or Fat Sat) Images
Red marrow SI: = or slightly > muscle
Tumor infiltration SI: >>>>> muscle
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Metastases: Diagnostic Pitfalls
• Osteomyelitis • Compression fractures• Trauma• Marrow infarction• Reconversion• Normal variants
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Osteomyelitis
• Infection increases marrow cellularity and water content (edema)
• T1: =/> muscle < fat–intermediate
• FS: > fat (bright)• Soft tissue edema
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Malignant Compression Fracture
• Abnormal signal intensity • May involve pedicle, posterior element
or entire vertebral body• Convex posterior cortex• Epidural mass• Paraspinal soft tissue mass• Marrow enhancement post gadolinium
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Osteoporotic Fracture
• Partial body involvement–Usually involves end plate
• Signal of spared marrow is normal• Thoracolumbar junction• Clustering of abnormalities• Thin paraspinal soft tissue mass• Improves in 6 to 8 weeks
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Pathologic and Osteoporotic Fractures
T1-GD MRI
Abn SI
Mass
T1-WT MRI
Nl SI
No mass
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Vascular Mediated Disorders:Edema
• Results in increased extracellular water• Signal changes are those of water• T1: > muscle < fat• STIR/FS: bright signal (> fat/ > muscle)• Regionally limited• Causes: trauma, inflammation• Mimics tumor, infection**
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Acute Marrow Infarction
• Sequela of – marrow packing by tumor – treatment (steroids)
• Acute infarction– T1: low SI (= or > muscle)– FS: high SI (>muscle > fat)
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Treatment-related Changes
• Effects of chemo- & radiation therapy–Myeloid depletion –Myelofibrosis
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Fatty ReplacementMarrow Depletion
• Absence of red marrow• Marrow signal = fat• T: high signal (bright)• FS: low signal (dark)
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Myelofibrosis
• Marrow replacement by fibrosis
• Low signal all sequences– =/> muscle < fat
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Other Diseases: Low Signal Intensity
• Gaucher disease–Marrow replacement by
glucocerebroside-laden cells• Hemosiderin deposition
–Marrow replacement by iron –Usually from transfusion therapy
• Paget disease
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To Sum It Up………• Fat is usually bad, but OK in the marrow• T1: Normal fat is bright
– Darker is bad• STIR/FS: Normal fat is black
– Brighter is bad
T1
FST2