Pelvic insufficiency fracture or bone metastasis after radiotherapy for cervical cancer? The added value of DWI for characterization

Objectives We sought to determine the added value of diffusion-weighted magnetic resonance imaging (DWI) in the differentiation of pelvic insufficiency fracture (PIF) from bone metastasis after radiotherapy in cervical cancer patients. Methods In the present study, 42 cervical cancer patients after radiotherapy with 61 bone lesions ( n = 40, PIFs; n = 21, bone metastasis) were included. Conventional MRI and DWI were performed in all patients. For qualitative imaging diagnosis, two sets of images were reviewed independently by three observers, including a conventional MRI set (unenhanced T1-weighted, T2-weighted, and enhanced T1-weighted images) and a DWI set (conventional MRIs, DW images, and ADC maps). The mean ADC value of each lesson was measured on ADC maps. The diagnostic performance was assessed by using the area under the receiver operating characteristic curve (A z ), and sensitivity and specificity were determined. Results For all observers, the A z value and sensitivity of the DWI set showed improvement compared with the conventional MRI set. The observer who had the least experience (3 years) demonstrated significant improvement in diagnostic performance with the addition of DWI; A z value increased from 0.804 to 0.915 ( p = 0.042) and sensitivity increased from 75.0 to 92.5% ( p = 0.035). The mean ADCs of the PIFs were significantly higher than the bone metastases ( p < 0.001); ADC values > 0.97 × 10 -3 mm 2 /s yielded an A z of 0.887, a sensitivity of 92.5%, and a specificity of 76.2%. Conclusions The addition of DWI to conventional MRI improved the differentiation of PIF from bone metastasis after RT in patients with cervical cancer. Key Points • DWI showed additive value to conventional MRI in the differentiation of PIF from bone metastasis after RT. • For qualitative diagnosis, the addition of DWI can improve diagnostic performance compared with conventional MRI alone and can particularly improve the sensitivity. • Quantitative ADC assessment showed potential value for identifying PIF from bone metastasis.