MR Imaging of Primary
Bone Tumors and
Tumor- like Conditions
in Children
Sandra L.Wootton-Gorges, MDa,b,*
KEYWORDS
 Bone tumor  MR imaging  Pediatrics
 Skeletal neoplasm  Children
Radiographs remain the primary imaging modality
in characterizing primary bone tumors and tumor-
like conditions of bone (Table 1). The appearance,
location (Boxes 1 and 2), and patient age are all
important features that allow the radiologist to
offer a succinct differential diagnosis of the mass
being evaluated. MR imaging also plays a valuable
role in evaluating pediatric bone tumors because it
is superior in assessing the extent of bony, intra-
medullary, joint, and soft tissue involvement by
the neoplasm.1,2
It is preferable to perform the initial MR imaging
for intraosseous tumor before biopsy to prevent
distortion by postbiopsy changes.2 In addition,
MR imaging can help to determine the optimal
site for biopsy. The examination must include
imaging of the entire bone to evaluate for skip
lesions, and to assess the longitudinal extent of
the tumor because this helps with surgical plan-
ning.2,3 Longitudinal imaging may either be in the
sagittal or coronal plane. Highest specificity for
tumor extent is defined on T1-weighted images,3
where the tumor is typically low signal and distorts
the normal marrow architecture. Highest tumor
sensitivity is defined on short tau inversion
recovery images (STIR) images, where the tumor
is typically of high signal. Axial imaging with
small field of view phased-array coil fast spin
echo T2-weighted fat-saturated or STIR
sequences through the tumor are most useful to
determine the relationship of the tumor to the
a
Department of Radiology, University of California, Davis Medical Center, UC Davis Children’s Hospital, 4860 Y
Street, Suite 3100, Sacramento, CA 95817, USA
b
Shriner’s Hospital of Northern California, 2425 Stockton Boulevard, Sacramento, CA 95817, USA
* Department of Radiology, University of California, Davis Medical Center, UC Davis Children’s Hospital, 4860 Y
Street, Suite 3100, Sacramento, CA 95817.
E-mail address: sandra.gorges@ucdmc.ucdavis.edu
Magn Reson Imaging Clin N Am 17 (2009) 469–487
doi:10.1016/j.mric.2009.03.010
1064-9689/09/$ – see front matter ª 2009 Elsevier Inc. All rights reserved.
adjacent soft tissues, muscles, nerves, and
vascular structures.2,3 Gradient echo sequences
can confirm blood flow within the blood vessels.
Postgadolinium T1-weighted fat-saturated images
can define areas of viable tumor and areas of
tumor necrosis.2 The growth plate and adjacent
joint must be carefully analyzed for tumor involve-
ment. Although most tumors have relatively
nonspecific MR imaging signal characteristics
(low signal on T1-weighed images and high signal
on T2-weighted images) low signal on both T1-
and T2-weighted images may suggest osteo-
blastic or fibrous matrix or chronic hemorrhage.4
Most lesions containing fat, which is high signal
on T1-weighted images and low signal on STIR
images, are benign.4 This hyperintensity on T1-
weighted images must be distinguished from
subacute hemorrhage.
Peritumoral edema may be seen with either
benign or malignant tumors.4 It may be intraoss-
eous or extraosseous in location. Its signal charac-
teristics are similar to the tumor, and so care must
be taken to distinguish it from tumor. Intraosseous
edema does not alter the normal architecture of
the marrow space, and soft tissue edema does
not demonstrate mass effect.4 Marrow edema is
intermediate between fat and muscle on T1-
weighted sequences, and is high signal on T2 or
STIR images, whereas most tumors are more
heterogeneous. Edema also has a poorly defined
margin in bone, and a feathery appearance, which
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