DOI: 10.1148/rg.245045048
RadioGraphics 2004;24:1317-1330
© RSNA, 2004
Fast STIR Whole-Body MR Imaging in Children1
Christian J. Kellenberger, MD,
Monica Epelman, MD,
Stephen F. Miller, MD and
Paul S. Babyn, MD
1 From the Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, ON, Canada. Presented as an education exhibit at the 2003 RSNA scientific assembly. Received March 17, 2004; revision requested April 14 and received May 13; accepted May 13. All authors have no financial relationships to disclose. Address correspondence to C.J.K., Department of Radiology and Magnetic Resonance, University Children’s Hospital Zurich, Steinwiesstrasse 75, CH 8032 Zurich, Switzerland (e-mail: c_kellenberger@yahoo.co.uk).
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Abstract
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Fast spin-echo short inversion time inversion-recovery (STIR) whole-body magnetic resonance (MR) imaging is an evolving technique that allows imaging of the entire body in a reasonable time. Its wide availability and lack of radiation exposure makes this method appealing for the evaluation of children. Since 2001, the authors conducted 140 pediatric whole-body MR imaging studies and correlated the findings with those from conventional imaging examinations. Bone marrow lesions, including marrow infiltration from lymphoma, metastases, and tumor-related edema, appeared with high signal intensity and were more easily detected on STIR images than with scintigraphy. Focal parenchymal lesions could be distinguished by their slightly different signal intensity, but pathologic lymph nodes could not be differentiated from normal nodes on the basis of signal intensity. The STIR technique is highly sensitive for detection of pathologic lesions, but it is not specific for malignancy; thus, the method cannot be used to differentiate benign conditions from malignant neoplastic lesions. Although fast STIR whole-body MR imaging permits evaluation of the entire skeleton and all viscera with a single examination, more experience and data are needed to determine its efficacy for staging neoplasms and assessing other multifocal disease in children.
© RSNA, 2004
Index Terms: Magnetic resonance (MR), inversion recovery • Magnetic resonance (MR), in infants and children
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Introduction
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Whole-body MR imaging with fast spin-echo (SE) short inversion time inversion-recovery (STIR) sequences is a promising method to study the entire body in a reasonable time and without the use of ionizing radiation. In adults, fast SE STIR whole-body MR imaging has been shown to be of value for evaluation of metastatic bone disease (1,2), for staging the whole body in patients with breast carcinoma (3), and in the assessment of multifocal disease such as polymyositis (4). In children, it has been suggested that fast SE STIR whole-body MR imaging is as reliable as other conventional imaging studies for staging newly diagnosed small cell tumors (5). Since November 2001, we have conducted 140 whole-body fast SE STIR MR imaging studies in children. Based on this experience, we discuss the technique and illustrate possible clinical applications correlated with conventional imaging, including computed tomography (CT), ultrasonography (US), and scintigraphy.
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Technique
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Whole-body MR imaging with fast SE STIR sequences can be performed on almost every body MR imaging system. We use a 1.5-T imager (Signa Horizon LX EchoSpeed or Signa CV/i, GE Medical Systems, Milwaukee, Wisc) and a body coil. Patients are positioned supine with their arms usually placed at their sides. After localizing sequences are performed, the entire body is imaged from the vertex to the heels with coronal fast SE STIR sequences acquired in two to six overlapping stations. The section thickness is chosen so that complete anterior-to-posterior coverage is possible with 15–32 sections per station, depending on the anatomic location imaged. If more than 24 sections are required per station, we perform two acquisitions. Table 1 shows the typical technical parameters used for fast SE STIR whole-body imaging at our institution.
Young children who cannot cooperate may need sedation for a whole-body MR imaging study. At our institution, the sedatives are delivered by a radiology nurse under supervision of an attending radiologist according to departmental and published guidelines (6–9). Children under the age of 6 months are generally sedated with oral chloral hydrate (50–100 mg/kg, maximum dose 2000 mg). Children over 6 months of age generally receive intravenous pentobarbital (4–6 mg/kg, maximum dose 200 mg). All children are monitored with pulse oximetry throughout the sedation and recovery phase until discharge criteria are met (ie, satisfactory and stable cardiovascular and respiratory status, presedation level of responsiveness).
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Signal in Fast SE STIR Images
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The STIR sequences are sensitive to both soft-tissue and osseous abnormalities because of their added proton density, T1, and T2 contrast with inherent suppression of signal from fat (10–17). Most pathologic tissues are proton rich and have prolonged T1 relaxation and T2 decay times, resulting in high signal intensity on fast SE STIR images. Suppression of signal from fat is based on T1 relaxation differences between fat and other tissues. It is achieved by adjusting the inversion time between the initial 180° inverting pulse and the 90° excitation pulse, such that longitudinal magnetization of fat is nulled at the time of the 90° pulse and does not contribute to the fast SE signal. Hence, fat suppression is not tissue specific, and signal from tissues with similar short T1 relaxation times (eg, proteinaceous fluids, melanin, paramagnetic tissue) will also be suppressed (18). Because the T1 relaxation time of tissues that take up gadolinium may be reduced to that of fat, the signal of these tissues will also be nulled (so-called negative enchancement effect) (Fig 1). Therefore, fast SE STIR imaging should be performed before administration of gadolinium.
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Figure 1a. Fast SE STIR images of a 1-month-old girl before (a) and after (b) administration of gadolinium. Normally bright renal parenchyma decreases in signal because of the T1-shortening effect of gadolinium (negative enhancement effect). Pathologic lesions that take up gadolinium may similarly decrease in signal and become inconspicuous on contrast material-enhanced fast SE STIR images.
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Figure 1b. Fast SE STIR images of a 1-month-old girl before (a) and after (b) administration of gadolinium. Normally bright renal parenchyma decreases in signal because of the T1-shortening effect of gadolinium (negative enhancement effect). Pathologic lesions that take up gadolinium may similarly decrease in signal and become inconspicuous on contrast material-enhanced fast SE STIR images.
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Lesion detection is generally achieved on the basis of the contrast between the signal intensities of pathologic and normal tissues. Table 2 lists the signal intensities of different tissues, and Figure 2 illustrates normal findings. Fluid exhibits the highest signal intensity on fast SE STIR images; therefore, effusions, ascites, and edema are very conspicuous. Cerebrospinal fluid and fluid-filled organs (gallbladder, bladder, bowel) show similar high signal intensity. Other pathologic lesions (eg, lymphoma, metastasis) are less intense than fluid, and their conspicuity depends on their relative intensity with respect to surrounding or adjacent tissue.
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Figure 2a. Normal fast SE STIR whole-body MR images of a 5-year-old girl. Fluid, such as cerebrospinal fluid or contents of the gallbladder or bladder, has the highest signal intensity on STIR images (a, b). Hematopoietic marrow, seen in the central skeleton and proximal femoral metaphyses, is isointense or slightly hyperintense relative to muscle (b, c). Fatty marrow, seen in epiphyses and diaphyses of the lower extremities, is isointense relative to subcutaneous tissue (d). All lymphatic tissue, including the thymus and spleen, exhibits high signal intensity. Normal adenoids, tonsils, and lymph nodes are readily visible (arrows in a, b).
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Figure 2b. Normal fast SE STIR whole-body MR images of a 5-year-old girl. Fluid, such as cerebrospinal fluid or contents of the gallbladder or bladder, has the highest signal intensity on STIR images (a, b). Hematopoietic marrow, seen in the central skeleton and proximal femoral metaphyses, is isointense or slightly hyperintense relative to muscle (b, c). Fatty marrow, seen in epiphyses and diaphyses of the lower extremities, is isointense relative to subcutaneous tissue (d). All lymphatic tissue, including the thymus and spleen, exhibits high signal intensity. Normal adenoids, tonsils, and lymph nodes are readily visible (arrows in a, b).
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Figure 2c. Normal fast SE STIR whole-body MR images of a 5-year-old girl. Fluid, such as cerebrospinal fluid or contents of the gallbladder or bladder, has the highest signal intensity on STIR images (a, b). Hematopoietic marrow, seen in the central skeleton and proximal femoral metaphyses, is isointense or slightly hyperintense relative to muscle (b, c). Fatty marrow, seen in epiphyses and diaphyses of the lower extremities, is isointense relative to subcutaneous tissue (d). All lymphatic tissue, including the thymus and spleen, exhibits high signal intensity. Normal adenoids, tonsils, and lymph nodes are readily visible (arrows in a, b).
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Figure 2d. Normal fast SE STIR whole-body MR images of a 5-year-old girl. Fluid, such as cerebrospinal fluid or contents of the gallbladder or bladder, has the highest signal intensity on STIR images (a, b). Hematopoietic marrow, seen in the central skeleton and proximal femoral metaphyses, is isointense or slightly hyperintense relative to muscle (b, c). Fatty marrow, seen in epiphyses and diaphyses of the lower extremities, is isointense relative to subcutaneous tissue (d). All lymphatic tissue, including the thymus and spleen, exhibits high signal intensity. Normal adenoids, tonsils, and lymph nodes are readily visible (arrows in a, b).
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Bone and Marrow
Normal bone marrow varies in signal depending on the relative amounts of fatty and hematopoietic marrow (19). Fatty marrow does not show much signal intensity and is isointense relative to subcutaneous tissue. Hematopoietic marrow is isointense relative to or minimally brighter than muscle (Fig 2).
Most marrow abnormalities have long T1 and T2 values, resulting in high signal intensity much greater than that of muscle. With this feature, fast SE STIR imaging allows direct visualization of tumor deposits and tumor-related edema within marrow (20,21), in contrast to bone scintigraphy in which bone or marrow involvement can be identified only if there is tumor-induced osteoblastic activity.
Marrow infiltration in childhood lymphoma and bone metastasis is usually focal (Figs 3–6), but diffuse marrow infiltration may sometimes occur in solid tumors such as rhabdomyosarcoma (Fig 7) or neuroblastoma (22). Diffuse marrow abnormalities are also seen in leukemia and in marrow hyperplasia caused by anemia or treatment with granulocyte-colony stimulating factor (22–24).
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Figure 3a. Anaplastic large cell lymphoma in a 9-year-old boy. (a) Fast SE STIR whole-body MR image demonstrates a cortical bone lesion with increased marrow signal intensity in the right tibia (arrow) and two additional small bright subcutaneous lesions (arrowheads). (b) US scan shows that these subcutaneous lesions represent solid hypoechoic nodules, which subsequently were proved to be lymphomatous at biopsy. (c) Lateral radiograph of the right tibia demonstrates cortical destruction (arrow). (d) Anterior view from gallium 67 scintigraphy shows tracer uptake in the tibial lesion (arrow) and in one soft-tissue nodule (arrowhead).
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Figure 3b. Anaplastic large cell lymphoma in a 9-year-old boy. (a) Fast SE STIR whole-body MR image demonstrates a cortical bone lesion with increased marrow signal intensity in the right tibia (arrow) and two additional small bright subcutaneous lesions (arrowheads). (b) US scan shows that these subcutaneous lesions represent solid hypoechoic nodules, which subsequently were proved to be lymphomatous at biopsy. (c) Lateral radiograph of the right tibia demonstrates cortical destruction (arrow). (d) Anterior view from gallium 67 scintigraphy shows tracer uptake in the tibial lesion (arrow) and in one soft-tissue nodule (arrowhead).
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Figure 3c. Anaplastic large cell lymphoma in a 9-year-old boy. (a) Fast SE STIR whole-body MR image demonstrates a cortical bone lesion with increased marrow signal intensity in the right tibia (arrow) and two additional small bright subcutaneous lesions (arrowheads). (b) US scan shows that these subcutaneous lesions represent solid hypoechoic nodules, which subsequently were proved to be lymphomatous at biopsy. (c) Lateral radiograph of the right tibia demonstrates cortical destruction (arrow). (d) Anterior view from gallium 67 scintigraphy shows tracer uptake in the tibial lesion (arrow) and in one soft-tissue nodule (arrowhead).
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Figure 3d. Anaplastic large cell lymphoma in a 9-year-old boy. (a) Fast SE STIR whole-body MR image demonstrates a cortical bone lesion with increased marrow signal intensity in the right tibia (arrow) and two additional small bright subcutaneous lesions (arrowheads). (b) US scan shows that these subcutaneous lesions represent solid hypoechoic nodules, which subsequently were proved to be lymphomatous at biopsy. (c) Lateral radiograph of the right tibia demonstrates cortical destruction (arrow). (d) Anterior view from gallium 67 scintigraphy shows tracer uptake in the tibial lesion (arrow) and in one soft-tissue nodule (arrowhead).
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Figure 4a. Initial staging in a 13-year-old girl with stage IV Hodgkin disease. (a, b) Fast SE STIR whole-body MR images demonstrate lymphomatous involvement as evidenced by enlarged hilar, mediastinal, and axillary lymph nodes (arrowheads in a), nodular thymus (arrowhead in b), and a hypointense focal splenic lesion (large arrow in b). Multifocal bone marrow lesions are seen in the spine, pelvis, and right femur (small arrows). (c, d) Contrast-enhanced CT images show enlarged lymph nodes, a nodular thymus, and a focal lesion in the spleen (arrow in d). (e) Anterior view from 67Ga scintigraphy helps confirm nodal involvement, seen as increased tracer uptake in left axillary and mediastinal lymph nodes (arrowheads). Skeletal involvement is visible only in the sacrum (arrows); the other bone marrow lesions seen on MR images are not evident. Results from a previous blind bone marrow biopsy had been negative.
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Figure 4b. Initial staging in a 13-year-old girl with stage IV Hodgkin disease. (a, b) Fast SE STIR whole-body MR images demonstrate lymphomatous involvement as evidenced by enlarged hilar, mediastinal, and axillary lymph nodes (arrowheads in a), nodular thymus (arrowhead in b), and a hypointense focal splenic lesion (large arrow in b). Multifocal bone marrow lesions are seen in the spine, pelvis, and right femur (small arrows). (c, d) Contrast-enhanced CT images show enlarged lymph nodes, a nodular thymus, and a focal lesion in the spleen (arrow in d). (e) Anterior view from 67Ga scintigraphy helps confirm nodal involvement, seen as increased tracer uptake in left axillary and mediastinal lymph nodes (arrowheads). Skeletal involvement is visible only in the sacrum (arrows); the other bone marrow lesions seen on MR images are not evident. Results from a previous blind bone marrow biopsy had been negative.
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Figure 4c. Initial staging in a 13-year-old girl with stage IV Hodgkin disease. (a, b) Fast SE STIR whole-body MR images demonstrate lymphomatous involvement as evidenced by enlarged hilar, mediastinal, and axillary lymph nodes (arrowheads in a), nodular thymus (arrowhead in b), and a hypointense focal splenic lesion (large arrow in b). Multifocal bone marrow lesions are seen in the spine, pelvis, and right femur (small arrows). (c, d) Contrast-enhanced CT images show enlarged lymph nodes, a nodular thymus, and a focal lesion in the spleen (arrow in d). (e) Anterior view from 67Ga scintigraphy helps confirm nodal involvement, seen as increased tracer uptake in left axillary and mediastinal lymph nodes (arrowheads). Skeletal involvement is visible only in the sacrum (arrows); the other bone marrow lesions seen on MR images are not evident. Results from a previous blind bone marrow biopsy had been negative.
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Figure 4d. Initial staging in a 13-year-old girl with stage IV Hodgkin disease. (a, b) Fast SE STIR whole-body MR images demonstrate lymphomatous involvement as evidenced by enlarged hilar, mediastinal, and axillary lymph nodes (arrowheads in a), nodular thymus (arrowhead in b), and a hypointense focal splenic lesion (large arrow in b). Multifocal bone marrow lesions are seen in the spine, pelvis, and right femur (small arrows). (c, d) Contrast-enhanced CT images show enlarged lymph nodes, a nodular thymus, and a focal lesion in the spleen (arrow in d). (e) Anterior view from 67Ga scintigraphy helps confirm nodal involvement, seen as increased tracer uptake in left axillary and mediastinal lymph nodes (arrowheads). Skeletal involvement is visible only in the sacrum (arrows); the other bone marrow lesions seen on MR images are not evident. Results from a previous blind bone marrow biopsy had been negative.
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Figure 4e. Initial staging in a 13-year-old girl with stage IV Hodgkin disease. (a, b) Fast SE STIR whole-body MR images demonstrate lymphomatous involvement as evidenced by enlarged hilar, mediastinal, and axillary lymph nodes (arrowheads in a), nodular thymus (arrowhead in b), and a hypointense focal splenic lesion (large arrow in b). Multifocal bone marrow lesions are seen in the spine, pelvis, and right femur (small arrows). (c, d) Contrast-enhanced CT images show enlarged lymph nodes, a nodular thymus, and a focal lesion in the spleen (arrow in d). (e) Anterior view from 67Ga scintigraphy helps confirm nodal involvement, seen as increased tracer uptake in left axillary and mediastinal lymph nodes (arrowheads). Skeletal involvement is visible only in the sacrum (arrows); the other bone marrow lesions seen on MR images are not evident. Results from a previous blind bone marrow biopsy had been negative.
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Figure 5a. Stage IV thoracic neuroblastoma in a 4-year-old boy. (a) Chest radiograph shows a posterior mediastinal mass (arrowheads). (b) Axial contrast-enhanced T1-weighted fat-saturated image demonstrates involvement of the spinal canal and vertebral body. (c, d) Fast SE STIR whole-body MR images demonstrate a paraspinal mass (arrowheads) and multiple focal bone marrow lesions (arrows) that were not present on bone (e) or metaiodobenzylguanidine (MIBG) (f) scintigrams.
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Figure 5b. Stage IV thoracic neuroblastoma in a 4-year-old boy. (a) Chest radiograph shows a posterior mediastinal mass (arrowheads). (b) Axial contrast-enhanced T1-weighted fat-saturated image demonstrates involvement of the spinal canal and vertebral body. (c, d) Fast SE STIR whole-body MR images demonstrate a paraspinal mass (arrowheads) and multiple focal bone marrow lesions (arrows) that were not present on bone (e) or metaiodobenzylguanidine (MIBG) (f) scintigrams.
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Figure 5c. Stage IV thoracic neuroblastoma in a 4-year-old boy. (a) Chest radiograph shows a posterior mediastinal mass (arrowheads). (b) Axial contrast-enhanced T1-weighted fat-saturated image demonstrates involvement of the spinal canal and vertebral body. (c, d) Fast SE STIR whole-body MR images demonstrate a paraspinal mass (arrowheads) and multiple focal bone marrow lesions (arrows) that were not present on bone (e) or metaiodobenzylguanidine (MIBG) (f) scintigrams.
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Figure 5d. Stage IV thoracic neuroblastoma in a 4-year-old boy. (a) Chest radiograph shows a posterior mediastinal mass (arrowheads). (b) Axial contrast-enhanced T1-weighted fat-saturated image demonstrates involvement of the spinal canal and vertebral body. (c, d) Fast SE STIR whole-body MR images demonstrate a paraspinal mass (arrowheads) and multiple focal bone marrow lesions (arrows) that were not present on bone (e) or metaiodobenzylguanidine (MIBG) (f) scintigrams.
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Figure 5e. Stage IV thoracic neuroblastoma in a 4-year-old boy. (a) Chest radiograph shows a posterior mediastinal mass (arrowheads). (b) Axial contrast-enhanced T1-weighted fat-saturated image demonstrates involvement of the spinal canal and vertebral body. (c, d) Fast SE STIR whole-body MR images demonstrate a paraspinal mass (arrowheads) and multiple focal bone marrow lesions (arrows) that were not present on bone (e) or metaiodobenzylguanidine (MIBG) (f) scintigrams.
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Figure 5f. Stage IV thoracic neuroblastoma in a 4-year-old boy. (a) Chest radiograph shows a posterior mediastinal mass (arrowheads). (b) Axial contrast-enhanced T1-weighted fat-saturated image demonstrates involvement of the spinal canal and vertebral body. (c, d) Fast SE STIR whole-body MR images demonstrate a paraspinal mass (arrowheads) and multiple focal bone marrow lesions (arrows) that were not present on bone (e) or metaiodobenzylguanidine (MIBG) (f) scintigrams.
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Figure 6a. Renal cell carcinoma in a 7-year-old boy. (a, b) Fast SE STIR whole-body MR images obtained at initial staging demonstrate a left renal mass and retroperitoneal lymph node metastases. A subtle hyperintense marrow lesion is seen in the L2 vertebral body (arrow in b). (c, d) Corresponding reformatted coronal (c) and axial (d) contrast-enhanced CT images show the renal tumor with retroperitoneal metastases and a small lytic lesion involving the L2 vertebral body (arrow in d). (e) Posterior view from bone scintigraphy does not reveal the vertebral lesion. (f, g) Follow-up fast SE STIR whole-body MR images, obtained after left nephrectomy and chemotherapy, demonstrate disease progression with new liver metastases (arrowheads in g) and help confirm the previously suggested bone metastasis. The L2 and L3 vertebral bodies show pathologic fractures and increased marrow signal intensity (arrows in f). (h) Only at follow-up did the bone scintigraphic findings become abnormal, with a posterior view showing increased tracer uptake at L2 (arrow).
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Figure 6b. Renal cell carcinoma in a 7-year-old boy. (a, b) Fast SE STIR whole-body MR images obtained at initial staging demonstrate a left renal mass and retroperitoneal lymph node metastases. A subtle hyperintense marrow lesion is seen in the L2 vertebral body (arrow in b). (c, d) Corresponding reformatted coronal (c) and axial (d) contrast-enhanced CT images show the renal tumor with retroperitoneal metastases and a small lytic lesion involving the L2 vertebral body (arrow in d). (e) Posterior view from bone scintigraphy does not reveal the vertebral lesion. (f, g) Follow-up fast SE STIR whole-body MR images, obtained after left nephrectomy and chemotherapy, demonstrate disease progression with new liver metastases (arrowheads in g) and help confirm the previously suggested bone metastasis. The L2 and L3 vertebral bodies show pathologic fractures and increased marrow signal intensity (arrows in f). (h) Only at follow-up did the bone scintigraphic findings become abnormal, with a posterior view showing increased tracer uptake at L2 (arrow).
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Figure 6c. Renal cell carcinoma in a 7-year-old boy. (a, b) Fast SE STIR whole-body MR images obtained at initial staging demonstrate a left renal mass and retroperitoneal lymph node metastases. A subtle hyperintense marrow lesion is seen in the L2 vertebral body (arrow in b). (c, d) Corresponding reformatted coronal (c) and axial (d) contrast-enhanced CT images show the renal tumor with retroperitoneal metastases and a small lytic lesion involving the L2 vertebral body (arrow in d). (e) Posterior view from bone scintigraphy does not reveal the vertebral lesion. (f, g) Follow-up fast SE STIR whole-body MR images, obtained after left nephrectomy and chemotherapy, demonstrate disease progression with new liver metastases (arrowheads in g) and help confirm the previously suggested bone metastasis. The L2 and L3 vertebral bodies show pathologic fractures and increased marrow signal intensity (arrows in f). (h) Only at follow-up did the bone scintigraphic findings become abnormal, with a posterior view showing increased tracer uptake at L2 (arrow).
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Figure 6d. Renal cell carcinoma in a 7-year-old boy. (a, b) Fast SE STIR whole-body MR images obtained at initial staging demonstrate a left renal mass and retroperitoneal lymph node metastases. A subtle hyperintense marrow lesion is seen in the L2 vertebral body (arrow in b). (c, d) Corresponding reformatted coronal (c) and axial (d) contrast-enhanced CT images show the renal tumor with retroperitoneal metastases and a small lytic lesion involving the L2 vertebral body (arrow in d). (e) Posterior view from bone scintigraphy does not reveal the vertebral lesion. (f, g) Follow-up fast SE STIR whole-body MR images, obtained after left nephrectomy and chemotherapy, demonstrate disease progression with new liver metastases (arrowheads in g) and help confirm the previously suggested bone metastasis. The L2 and L3 vertebral bodies show pathologic fractures and increased marrow signal intensity (arrows in f). (h) Only at follow-up did the bone scintigraphic findings become abnormal, with a posterior view showing increased tracer uptake at L2 (arrow).
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Figure 6e. Renal cell carcinoma in a 7-year-old boy. (a, b) Fast SE STIR whole-body MR images obtained at initial staging demonstrate a left renal mass and retroperitoneal lymph node metastases. A subtle hyperintense marrow lesion is seen in the L2 vertebral body (arrow in b). (c, d) Corresponding reformatted coronal (c) and axial (d) contrast-enhanced CT images show the renal tumor with retroperitoneal metastases and a small lytic lesion involving the L2 vertebral body (arrow in d). (e) Posterior view from bone scintigraphy does not reveal the vertebral lesion. (f, g) Follow-up fast SE STIR whole-body MR images, obtained after left nephrectomy and chemotherapy, demonstrate disease progression with new liver metastases (arrowheads in g) and help confirm the previously suggested bone metastasis. The L2 and L3 vertebral bodies show pathologic fractures and increased marrow signal intensity (arrows in f). (h) Only at follow-up did the bone scintigraphic findings become abnormal, with a posterior view showing increased tracer uptake at L2 (arrow).
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Figure 6f. Renal cell carcinoma in a 7-year-old boy. (a, b) Fast SE STIR whole-body MR images obtained at initial staging demonstrate a left renal mass and retroperitoneal lymph node metastases. A subtle hyperintense marrow lesion is seen in the L2 vertebral body (arrow in b). (c, d) Corresponding reformatted coronal (c) and axial (d) contrast-enhanced CT images show the renal tumor with retroperitoneal metastases and a small lytic lesion involving the L2 vertebral body (arrow in d). (e) Posterior view from bone scintigraphy does not reveal the vertebral lesion. (f, g) Follow-up fast SE STIR whole-body MR images, obtained after left nephrectomy and chemotherapy, demonstrate disease progression with new liver metastases (arrowheads in g) and help confirm the previously suggested bone metastasis. The L2 and L3 vertebral bodies show pathologic fractures and increased marrow signal intensity (arrows in f). (h) Only at follow-up did the bone scintigraphic findings become abnormal, with a posterior view showing increased tracer uptake at L2 (arrow).
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Figure 6g. Renal cell carcinoma in a 7-year-old boy. (a, b) Fast SE STIR whole-body MR images obtained at initial staging demonstrate a left renal mass and retroperitoneal lymph node metastases. A subtle hyperintense marrow lesion is seen in the L2 vertebral body (arrow in b). (c, d) Corresponding reformatted coronal (c) and axial (d) contrast-enhanced CT images show the renal tumor with retroperitoneal metastases and a small lytic lesion involving the L2 vertebral body (arrow in d). (e) Posterior view from bone scintigraphy does not reveal the vertebral lesion. (f, g) Follow-up fast SE STIR whole-body MR images, obtained after left nephrectomy and chemotherapy, demonstrate disease progression with new liver metastases (arrowheads in g) and help confirm the previously suggested bone metastasis. The L2 and L3 vertebral bodies show pathologic fractures and increased marrow signal intensity (arrows in f). (h) Only at follow-up did the bone scintigraphic findings become abnormal, with a posterior view showing increased tracer uptake at L2 (arrow).
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Figure 6h. Renal cell carcinoma in a 7-year-old boy. (a, b) Fast SE STIR whole-body MR images obtained at initial staging demonstrate a left renal mass and retroperitoneal lymph node metastases. A subtle hyperintense marrow lesion is seen in the L2 vertebral body (arrow in b). (c, d) Corresponding reformatted coronal (c) and axial (d) contrast-enhanced CT images show the renal tumor with retroperitoneal metastases and a small lytic lesion involving the L2 vertebral body (arrow in d). (e) Posterior view from bone scintigraphy does not reveal the vertebral lesion. (f, g) Follow-up fast SE STIR whole-body MR images, obtained after left nephrectomy and chemotherapy, demonstrate disease progression with new liver metastases (arrowheads in g) and help confirm the previously suggested bone metastasis. The L2 and L3 vertebral bodies show pathologic fractures and increased marrow signal intensity (arrows in f). (h) Only at follow-up did the bone scintigraphic findings become abnormal, with a posterior view showing increased tracer uptake at L2 (arrow).
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Figure 7a. Rhabdomyosarcoma in a 17-year-old girl. Fast SE STIR whole-body MR images obtained at initial staging demonstrate diffusely increased marrow signal intensity in the central skeleton (marrow infiltration proved with biopsy) and additional focal lesions in the distal femora (arrows in b). The paraspinal soft-tissue mass seen at the thoracoabdominal junction (arrowheads in c) was thought to represent the primary tumor. Enlarged lymph nodes are shown in the retroperitoneum and mediastinum (arrows in a, d).
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Figure 7b. Rhabdomyosarcoma in a 17-year-old girl. Fast SE STIR whole-body MR images obtained at initial staging demonstrate diffusely increased marrow signal intensity in the central skeleton (marrow infiltration proved with biopsy) and additional focal lesions in the distal femora (arrows in b). The paraspinal soft-tissue mass seen at the thoracoabdominal junction (arrowheads in c) was thought to represent the primary tumor. Enlarged lymph nodes are shown in the retroperitoneum and mediastinum (arrows in a, d).
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Figure 7c. Rhabdomyosarcoma in a 17-year-old girl. Fast SE STIR whole-body MR images obtained at initial staging demonstrate diffusely increased marrow signal intensity in the central skeleton (marrow infiltration proved with biopsy) and additional focal lesions in the distal femora (arrows in b). The paraspinal soft-tissue mass seen at the thoracoabdominal junction (arrowheads in c) was thought to represent the primary tumor. Enlarged lymph nodes are shown in the retroperitoneum and mediastinum (arrows in a, d).
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Figure 7d. Rhabdomyosarcoma in a 17-year-old girl. Fast SE STIR whole-body MR images obtained at initial staging demonstrate diffusely increased marrow signal intensity in the central skeleton (marrow infiltration proved with biopsy) and additional focal lesions in the distal femora (arrows in b). The paraspinal soft-tissue mass seen at the thoracoabdominal junction (arrowheads in c) was thought to represent the primary tumor. Enlarged lymph nodes are shown in the retroperitoneum and mediastinum (arrows in a, d).
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Lymphatic Tissue
Normal lymphatic tissue, including the spleen, thymus, organs of the Waldeyer ring, and lymph nodes, has high signal intensity on STIR images (Fig 2) (10,13). In our experience, nodular lymphomatous lesions of the spleen (Fig 4) and thymus (Fig 8) have slightly lower signal intensity than that of normal parenchyma. Because normal and pathologic lymph nodes show similar high signal intensity, distinction of pathologic nodes must be based on size criteria, as in other imaging modalities (Figs 4, 6). We consider nodes as abnormal if they are enlarged (short-axis diameter exceeding 1 cm), if there are multiple small nodes, or if nodes are observed in a region where normally no lymph nodes are detected.
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Figure 8a. Nodular sclerosing Hodgkin disease in a 14-year-old girl. (a) Fast SE STIR whole-body MR image demonstrates hypointense nodules within the thymus (arrows). (b) Axial contrast-enhanced CT scan shows nodular enlargement of the thymus (arrows).
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Figure 8b. Nodular sclerosing Hodgkin disease in a 14-year-old girl. (a) Fast SE STIR whole-body MR image demonstrates hypointense nodules within the thymus (arrows). (b) Axial contrast-enhanced CT scan shows nodular enlargement of the thymus (arrows).
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Parenchymal Organs
Because normal kidneys have high signal intensity similar to that of the spleen, infiltrative renal lesions are usually slightly hypointense relative to renal parenchyma (Fig 6). The normal liver and pancreas show homogeneous low signal intensity and are typically isointense relative to muscle (10). Hepatic signal may be diffusely decreased because of increased iron content (in newborns, hemosiderosis) or fatty liver. Most focal hepatic lesions are hyperintense relative to normal parenchyma (Fig 6). As air-filled lung does not have any signal, consolidation or lung nodules are evident as high-signal-intensity lesions (Fig 9).
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Figure 9a. Choriocarcinoma in a 16-year-old boy who presented with enlarged inguinal lymph nodes. (a, b) Fast SE STIR whole-body MR images, obtained after inguinal lymph node resection, demonstrate a heterogeneous pelvic mass (arrowheads in a), bright lung nodules (arrows in a), and a seroma in the left inguina (arrow in b). The left testis is enlarged and less intense than the right (arrowheads in b), an appearance suggestive of a testicular mass. (c) Contrast-enhanced CT image shows three lung nodules (arrows). (d) Transverse US image of the pelvis demonstrates a solid mass (arrowheads) behind the bladder. (e) Longitudinal US image demonstrates a mixed solid and cystic mass in the left testis (arrowheads).
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Figure 9b. Choriocarcinoma in a 16-year-old boy who presented with enlarged inguinal lymph nodes. (a, b) Fast SE STIR whole-body MR images, obtained after inguinal lymph node resection, demonstrate a heterogeneous pelvic mass (arrowheads in a), bright lung nodules (arrows in a), and a seroma in the left inguina (arrow in b). The left testis is enlarged and less intense than the right (arrowheads in b), an appearance suggestive of a testicular mass. (c) Contrast-enhanced CT image shows three lung nodules (arrows). (d) Transverse US image of the pelvis demonstrates a solid mass (arrowheads) behind the bladder. (e) Longitudinal US image demonstrates a mixed solid and cystic mass in the left testis (arrowheads).
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Figure 9c. Choriocarcinoma in a 16-year-old boy who presented with enlarged inguinal lymph nodes. (a, b) Fast SE STIR whole-body MR images, obtained after inguinal lymph node resection, demonstrate a heterogeneous pelvic mass (arrowheads in a), bright lung nodules (arrows in a), and a seroma in the left inguina (arrow in b). The left testis is enlarged and less intense than the right (arrowheads in b), an appearance suggestive of a testicular mass. (c) Contrast-enhanced CT image shows three lung nodules (arrows). (d) Transverse US image of the pelvis demonstrates a solid mass (arrowheads) behind the bladder. (e) Longitudinal US image demonstrates a mixed solid and cystic mass in the left testis (arrowheads).
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Figure 9d. Choriocarcinoma in a 16-year-old boy who presented with enlarged inguinal lymph nodes. (a, b) Fast SE STIR whole-body MR images, obtained after inguinal lymph node resection, demonstrate a heterogeneous pelvic mass (arrowheads in a), bright lung nodules (arrows in a), and a seroma in the left inguina (arrow in b). The left testis is enlarged and less intense than the right (arrowheads in b), an appearance suggestive of a testicular mass. (c) Contrast-enhanced CT image shows three lung nodules (arrows). (d) Transverse US image of the pelvis demonstrates a solid mass (arrowheads) behind the bladder. (e) Longitudinal US image demonstrates a mixed solid and cystic mass in the left testis (arrowheads).
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Figure 9e. Choriocarcinoma in a 16-year-old boy who presented with enlarged inguinal lymph nodes. (a, b) Fast SE STIR whole-body MR images, obtained after inguinal lymph node resection, demonstrate a heterogeneous pelvic mass (arrowheads in a), bright lung nodules (arrows in a), and a seroma in the left inguina (arrow in b). The left testis is enlarged and less intense than the right (arrowheads in b), an appearance suggestive of a testicular mass. (c) Contrast-enhanced CT image shows three lung nodules (arrows). (d) Transverse US image of the pelvis demonstrates a solid mass (arrowheads) behind the bladder. (e) Longitudinal US image demonstrates a mixed solid and cystic mass in the left testis (arrowheads).
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Clinical Application
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Because fast SE STIR whole-body MR imaging allows the entire body to be imaged within a short time and without the use of radiation, this technique may be useful as a whole-body screening tool in children. However, its value in comparison to nuclear medicine studies, such as bone scintigraphy, MIBG scintigraphy, 67Ga scintigraphy, and fluorine 18 fluorodeoxyglucose positron emission tomography, needs to be explored further. Because fast SE STIR whole-body MR imaging has been shown to be more sensitive than bone scintigraphy for detection of cortical bone and bone marrow metastasis (1,2,5), it can be used to assess skeletal involvement in malignancies such as neuroblastoma, rhabdomyosarcoma, Ewing sarcoma, and other tumors that metastasize to bone. In childhood lymphoma, in which marrow involvement is usually focal and can be missed at blind biopsy (25,26), fast SE STIR whole-body MR imaging is useful as a complementary imaging tool to detect otherwise unrecognized marrow involvement. Because malignant involvement of parenchymal organs, lymph nodes, and soft tissues can also be detected, fast SE STIR whole-body MR imaging may prove to be useful for staging the entire body. Since inflammatory and traumatic bone lesions also exhibit high signal intensity on STIR images (15,27,28), fast SE STIR whole-body MR imaging has the potential for evaluation of nonmalignant multifocal skeletal disease. We have used this technique to determine the extent of bone involvement in Langerhans cell histiocytosis (Fig 10). Others have suggested its use for assessing multifocal osteomyelitis (29) and child abuse (30). Because hemangiomas and vascular malformations show high signal intensity with STIR sequences (31,32), we have used the whole-body technique to assess the extent and presence of visceral involvement in neonatal hemangiomatosis (Fig 11) and in extensive vascular malformations.
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Figure 10a. Langerhans cell histiocytosis in a 6-year-old boy who presented with lower back pain. (a) Fast SE STIR whole-body MR image demonstrates increased marrow signal intensity in the collapsed vertebral body L5 (vertebra plana) without an associated soft-tissue mass (arrow). No further bone involvement was seen. (b) T2-weighted fat-saturated sagittal image does not show any spinal stenosis. (c) Posterior view from bone scintigraphy demonstrates bilateral increased activity at the level of L5 (arrow), a finding that initially suggested spondylolysis or spondylolisthesis. (d) Three-dimensional surface-shaded CT image shows the degree of collapse of the L5 vertebral body.
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Figure 10b. Langerhans cell histiocytosis in a 6-year-old boy who presented with lower back pain. (a) Fast SE STIR whole-body MR image demonstrates increased marrow signal intensity in the collapsed vertebral body L5 (vertebra plana) without an associated soft-tissue mass (arrow). No further bone involvement was seen. (b) T2-weighted fat-saturated sagittal image does not show any spinal stenosis. (c) Posterior view from bone scintigraphy demonstrates bilateral increased activity at the level of L5 (arrow), a finding that initially suggested spondylolysis or spondylolisthesis. (d) Three-dimensional surface-shaded CT image shows the degree of collapse of the L5 vertebral body.
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Figure 10c. Langerhans cell histiocytosis in a 6-year-old boy who presented with lower back pain. (a) Fast SE STIR whole-body MR image demonstrates increased marrow signal intensity in the collapsed vertebral body L5 (vertebra plana) without an associated soft-tissue mass (arrow). No further bone involvement was seen. (b) T2-weighted fat-saturated sagittal image does not show any spinal stenosis. (c) Posterior view from bone scintigraphy demonstrates bilateral increased activity at the level of L5 (arrow), a finding that initially suggested spondylolysis or spondylolisthesis. (d) Three-dimensional surface-shaded CT image shows the degree of collapse of the L5 vertebral body.
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Figure 10d. Langerhans cell histiocytosis in a 6-year-old boy who presented with lower back pain. (a) Fast SE STIR whole-body MR image demonstrates increased marrow signal intensity in the collapsed vertebral body L5 (vertebra plana) without an associated soft-tissue mass (arrow). No further bone involvement was seen. (b) T2-weighted fat-saturated sagittal image does not show any spinal stenosis. (c) Posterior view from bone scintigraphy demonstrates bilateral increased activity at the level of L5 (arrow), a finding that initially suggested spondylolysis or spondylolisthesis. (d) Three-dimensional surface-shaded CT image shows the degree of collapse of the L5 vertebral body.
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Figure 11a. Neonatal hemangiomatosis in an 8-month-old girl. Fast SE STIR whole-body MR images demonstrate multiple bright lesions in the subcutaneous tissues (arrows). No visceral involvement is seen. Linear areas of high signal intensity in the right upper lobe (arrowheads in a) likely represent atelectasis caused by sedation.
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Figure 11b. Neonatal hemangiomatosis in an 8-month-old girl. Fast SE STIR whole-body MR images demonstrate multiple bright lesions in the subcutaneous tissues (arrows). No visceral involvement is seen. Linear areas of high signal intensity in the right upper lobe (arrowheads in a) likely represent atelectasis caused by sedation.
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Limitations
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Although the STIR technique is highly sensitive for detection of pathologic lesions, it is not specific for malignancy (12). Inflammatory, infectious, traumatic, and necrotic changes, as well as benign lesions such as cysts and hemangiomas, cannot be differentiated from malignant neoplastic lesions. This limitation restricts the application of fast SE STIR whole-body MR imaging in oncologic patients after treatment, because therapy-induced marrow changes, such as edema, necrosis, fibrosis, or red marrow hyperplasia, cannot be differentiated from viable tumor (Fig 12).
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Figure 12a. Stage II Hodgkin disease in a 12-year-old girl. (a, b) Fast SE STIR whole-body MR images demonstrate residual bulky enlargement of the thymus (arrowheads in a) and marrow changes. Bone marrow signal intensity in the central skeleton and metaphyses of the long bones is diffusely increased, likely representing marrow hyperplasia after granulocyte-colony stimulating factor therapy. In addition, several diaphyseal and epiphyseal lesions with the characteristic appearance of osteonecrosis are seen in the femora and tibiae (arrows in b). On MR images, such therapy-induced marrow changes can be impossible to differentiate from lymphomatous involvement. (c) Contrast-enhanced CT image demonstrates residual asymmetric enlargement of the thymus (arrowhead).
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Figure 12b. Stage II Hodgkin disease in a 12-year-old girl. (a, b) Fast SE STIR whole-body MR images demonstrate residual bulky enlargement of the thymus (arrowheads in a) and marrow changes. Bone marrow signal intensity in the central skeleton and metaphyses of the long bones is diffusely increased, likely representing marrow hyperplasia after granulocyte-colony stimulating factor therapy. In addition, several diaphyseal and epiphyseal lesions with the characteristic appearance of osteonecrosis are seen in the femora and tibiae (arrows in b). On MR images, such therapy-induced marrow changes can be impossible to differentiate from lymphomatous involvement. (c) Contrast-enhanced CT image demonstrates residual asymmetric enlargement of the thymus (arrowhead).
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Figure 12c. Stage II Hodgkin disease in a 12-year-old girl. (a, b) Fast SE STIR whole-body MR images demonstrate residual bulky enlargement of the thymus (arrowheads in a) and marrow changes. Bone marrow signal intensity in the central skeleton and metaphyses of the long bones is diffusely increased, likely representing marrow hyperplasia after granulocyte-colony stimulating factor therapy. In addition, several diaphyseal and epiphyseal lesions with the characteristic appearance of osteonecrosis are seen in the femora and tibiae (arrows in b). On MR images, such therapy-induced marrow changes can be impossible to differentiate from lymphomatous involvement. (c) Contrast-enhanced CT image demonstrates residual asymmetric enlargement of the thymus (arrowhead).
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Although parenchymal lesions in the liver, spleen, kidneys, lungs, and brain are readily detected, smaller parenchymal lesions may be missed because of the low spatial resolution of the whole-body technique. In addition, possible motion artifacts from respiration or vessel pulsation may obscure parenchymal lesions.
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Conclusions
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Fast SE STIR whole-body MR imaging is a sensitive radiation-free technique for screening the entire body in a reasonable time and is easily applicable for assessing skeletal, marrow, and soft-tissue disease in children. Because abnormal findings may be nonspecific, they must be interpreted in context with the clinical setting and other imaging results. In our experience, the most valuable benefit of this technique is the detection of bone marrow disease missed with blind biopsy and other conventional imaging techniques. The future role of fast SE STIR whole-body MR imaging in the staging of pediatric neoplasms and assessment of other multifocal disease should be defined by further prospective trials.
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Footnotes
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Abbreviations: MIBG = metaiodobenzylguanidine,
SE = spin echo,
STIR = short inversion time inversion-recovery
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References
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Abstract
Introduction
