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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 37  |  Issue : 3  |  Page : 125-128

To elucidate the difference in diagnostic accuracy of radiological and histological modalities of bone tumors: A tertiary care experience


Department of Orthopedic Surgery, King George Medical College, Lucknow, Uttar Pradesh, India

Date of Submission15-Sep-2022
Date of Acceptance26-Oct-2022
Date of Web Publication15-Dec-2022

Correspondence Address:
Siddharth Deshwal
Department of Orthopedic Surgery, King George Medical College, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jbjd.jbjd_25_22

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  Abstract 

Introduction: The objective of this study was to retrospectively compare the difference in diagnostic accuracy of radiological and histological modalities of bone tumors. Materials and Methods: Imaging techniques such as X-ray, computerized tomography (CT) scan, and magnetic resonance imaging (MRI) were compared with the Histological findings in 1314 patients with bone tumors. Results: Histologically, 27.4% were malignant bone tumors, whereas 72.60% were benign. The X-rays showed a diagnostic accuracy of 87.3%, with sensitivity of 81.8%, specificity of 90.0%, positive predictive value (PPV) of 79.5%, and negative predictive value (NPV) of 91.2%. CT scan presented a diagnostic accuracy of 76.08%, with 80.4%, 68.5%, 74.1%, and 78.4% of sensitivity, specificity, PPV, and NPV, respectively. The MRI documented a diagnostic accuracy of 97.4%, sensitivity of 97.7%, specificity of 96.8%, PPV of 98.05%, and NPV of 96.4%. Conclusion: These data showed a good correlation between radiological and histological modalities.

Keywords: Bone tumors, diagnostic, diagnostic accuracy, imaging, results


How to cite this article:
Kumar D, Kumar S, Kumar A, Deshwal S, Kumar A, Agarwal P. To elucidate the difference in diagnostic accuracy of radiological and histological modalities of bone tumors: A tertiary care experience. J Bone Joint Dis 2022;37:125-8

How to cite this URL:
Kumar D, Kumar S, Kumar A, Deshwal S, Kumar A, Agarwal P. To elucidate the difference in diagnostic accuracy of radiological and histological modalities of bone tumors: A tertiary care experience. J Bone Joint Dis [serial online] 2022 [cited 2023 Feb 6];37:125-8. Available from: http://www.jbjd.in/text.asp?2022/37/3/125/363848




  Introduction Top


Cancer is the leading cause of death (23%) following cardiac failure.[1] Tumors can be benign or malignant, primary or secondary. It is challenging to know the exact incidence of each bone tumor because there are lesions found incidentally on radiological imaging, and histological diagnosis is not always done, mainly in the presence of benign bone tumors.[2],[3],[4] Primary malignant bone tumors represent only 0.2% of overall neoplasms. In spite of this small percentage, they are responsible for morbidity and mortality in young patients.[1],[2]

These focal bone lesions can be approached through clinical information, radiographic findings suggestive of benign/malignant nature, margin appearance, periosteal reaction, and mineralization of bone. However, in addition, computerized tomography (CT) scan and magnetic resonance imaging (MRI) help better differentiate between bone matrix and bone mineralization,[5],[6],[7],[8] which are used in making differentials and are used to determine lesion extension. Bone scintigraphy helps to find bone activity and lesion multiplicity. Positron emission tomography scan is also beneficial as it shows local metabolic activity in spite of all these data; it is not consistently enough to classify a bone tumor. Bone biopsy, either image-guided or open incisional, is never the first diagnostic approach; however, it is considered to be the gold standard.[1],[5],[7],[9],[10],[11]

It is essential not to under- or overtreat focal bone lesions to provide the best treatment and outcome to the patient. Histological examination and radiological imaging (X-ray, CT, and MRI) have played the central role in the confirmation of many benign and malignant bone lesions. However, individually, they carry some flaws in the confirmation of bone tumors. So we intended to use radiological imaging and histology to diagnose bone tumors, taking open incisional biopsy as the gold standard.


  Materials and Methods Top


This retrospective study was carried out at the tertiary center from March 2017 to December 2020. All the patients were observed in the outpatient department (OPD) including new registration and referrals. Ethical clearance was approved by the Institutional Ethical Review Board. All patients were enrolled in this study after obtaining the consent.

The patients with a suspicious clinical diagnosis of bone tumor were advised X-ray and in whom tumor findings were found to be included in the selection criteria. These patients were advised further diagnostic workup in the form of CT, MRI, histopathological examination, and so on.

A total of 1314 OPD patients were taken for this study. The patients’ clinical files were analyzed and the patients who had at least one additional complementary diagnostic examination, being X-ray, CT, or MRI, were included.

Statistical analysis

All statistical analyses were performed by using 21.0 version of SPSS software (SPSS Inc., Chicago, IL, USA). Descriptive statistics are expressed as mean, frequency, and percentage.


  Results Top


From a total of 1314 patients, histologically, 954 patients (72.6%) had a benign tumor of the bone, whereas 360 patients (27.4%) had a malignant tumor [Table 1]. Majority of the cases were from the province of Uttar Pradesh and the surrounding states of Northern India. In the malignant tumor group, 318 were primary bone tumors (96 Ewing’s sarcoma, 6 fibrosarcoma, 18 chondrosarcoma, and 198 osteosarcoma), whereas 42 were secondary bone tumors. [Table 2] and [Table 3] document the comparison of histological diagnosis with X-ray of bone tumors. X-rays of all 1314 patients were taken, out of which 94 malignant tumors had a wrong diagnosis of benign tumors and 82 benign tumors were classified as malignant, with a diagnostic accuracy of 88.3%. CT was done for 262 patients for diagnostic evaluation, alone or in combination with other investigations. The comparison of histological versus CT diagnosis of bone tumors is showed in [Table 4] and [Table 5]. With this technique, the diagnostic accuracy was found to be 76.08%. Out of the 1314 patients, MRI was done in 657 patients, subsequent to other complementary diagnostic means or not. The results obtained in the comparison of histological with MRI diagnosis in these patients are displayed in [Table 6] and [Table 7]. In our study, MRI diagnostic accuracy was found to be of 96.9%. [Figure 1][Figure 2][Figure 3] show the comparison of X-ray, CT, and MRI with histological findings of bone tumors in the form of pie chart.
Table 1: Frequency of bone tumors

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Table 2: Comparison of histological vs. X-ray diagnosis of bone tumors

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Table 3: Sensitivity, specificity, diagnostic accuracy, PPV and NPV of X-ray diagnosis

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Table 4: Comparison of histological vs. CT diagnosis of bone tumors

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Table 5: Sensitivity, specificity, diagnostic accuracy, PPV, and NPV of CT diagnosis

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Table 6: Comparison of histological vs. MRI diagnosis of bone tumors

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Table 7: Sensitivity, specificity, diagnostic accuracy, PPV, and NPV of MRI diagnosis

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Figure 1: Comparison of X-ray vs. histological diagnosis of bone tumors

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Figure 2: Comparison of CT vs. histological diagnosis of bone tumors

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Figure 3: Comparison of MRI vs. histological diagnosis of bone tumors

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  Discussion Top


Bone tumors are relatively uncommon with respect to a wide array of cancers. Bone tumor is a challenging problem for orthopedic surgeons and pathologists, especially in developing countries due to unawareness, limited diagnosis, and facilities. Scarcity of literature on bone tumors is due to its uncommon nature.

There are very few reports that compare radiological imaging and histological findings in the diagnosis of bone tumors. Our results were comparable to the studies available in the literature. Lee et al.[12] reported a sensitivity of 80% and a specificity of 93% in assessing the radiographic appearance of bone tumors. The more extensive African study from Negash et al.[1] obtained a lower diagnostic accuracy of 84%, with a Cohen’s kappa value of 0.82, similar to ours of 0.8.

Our study is one of the earliest in our country to compare radiological investigations with histological findings. We compared CT vs. histological findings that revealed sensitivity 80.4%, specificity 68.5%, diagnostic accuracy 76.08%, positive predictive value (PPV) 74.1%, and negative predictive value (NPV) 78.4%, whereas MRI documented sensitivity, specificity, diagnostic accuracy, PPV, and NPV of 97.7%, 96.8%, 97.4%, 98.05%, and 96.4%. respectively.

We found that X-ray and MRI have a good diagnostic capacity for bone tumors. CT showed comparatively less forgiving results as these were done in limited cases such as intraosseous tumors and osteoid osteoma or when 3D reconstruction is required for planning mega prosthesis.

Needle biopsy was conclusive only in 30% (394) of cases, whereas in remaining 70% (920) of the cases, patients were subjected to either incisional or excisional biopsy for confirmation of diagnosis.

[Table 8] shows comparison of radiological vs. histopathological diagnosis of benign and malignant bone tumors.
Table 8: Comparison of radiological diagnosis vs. histopathological diagnosis of bone tumors

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Ideally, every case should be confirmed by doing histopathological examination but our institute is a government setup and it is not possible to do open biopsy under anesthesia in every case due to high overload. Also some of the bone tumors have classical X-ray findings that do not need further diagnostic workup and are directly managed or left for watchful negligence with further follow-up.

Out of the 1314 patients, 138 cases have classical X-ray findings (simple bone cyst, osteochondroma, enchondroma, and fibrous dysplasia) and we have done definitive treatment in these cases without doing any further diagnostic workup including histopathological examination. The biopsy report was found to be similar when tumor tissue was sent for histopathological examination at the time of surgery.

Bone scintigraphy was not used as a diagnostic tool in any patient and revealed to be useful in corroborating the presence or absence of the pathology previously suggested by an imaging exam, so it was considered to be a second-line investigation with special value in patients with a primary known malignant tumor, to determine the presence and extension of metastatic disease.[2],[7]

It is also essential to focus that the radiological diagnosis helps to prevent wrong classification of a lesion as being a metastatic malignancy and prevents emotional burden of patients. Radiological tools help not only in ascertaining a clinical diagnosis but also in decision-making of surgical treatment and many a times they prevent unnecessary delay in the initiation of treatment because of long waiting period of histopathological examination reports. In view of the above discussion, we can say that radiological and histological tools go hand-in-hand for making diagnosis of bone tumors and both have their specific value for the management of these tumors.


  Conclusion Top


This study was done to correlate the histological findings with available imaging techniques (X-ray, CT, and MRI) in diagnosing bone tumors. We found a good connection among X-ray, MRI findings, and histological findings. CT showed comparatively less forgiving results as these were done in limited cases such as intraosseous tumors and osteoid osteoma or when CT with 3D reconstruction was required for planning mega prosthesis and so on. Needle biopsies were conclusive only in 30% (394) of the cases, whereas the remaining 70% (920) of the cases were subjected to either incisional or excisional biopsy for confirmation of diagnosis. This strengthens the use of imaging techniques to evaluate focal bone lesions; however, results of the wrong diagnosis may be considered by clinicians, and the requisition of bone biopsy must be regarded whenever available.

Financial support and sponsorship

Not applicable.

Conflicts of interest

The authors declare no competing interests.



 
  References Top

1.
Negash B, Admasie D, Wamisho B, Tinsay MW Bone tumors at Addis Ababa University, Ethiopia: Agreement between radiological and histopathological diagnosis, a 5-year analysis at Black-Lion Teaching Hospital. IJMMS 2009;1-4:119-25.  Back to cited text no. 1
    
2.
Franchi A Epidemiology and classification of bone tumors. Clin Cases Miner Bone Metab 2012;9:92-5.  Back to cited text no. 2
    
3.
Wu J, Hockman M Bone Tumors: A Practical Guide to Imaging. New York, NY: Springer; 2012. p. 1-9.  Back to cited text no. 3
    
4.
Czerniak B Dorfman and Czerniak’s Bone Tumors. 2nd ed. Elsevier; 2015.  Back to cited text no. 4
    
5.
Costelloe CM, Madewell JE Radiography in the initial diagnosis of primary bone tumors. Am J Roentgenol 2013;200:3-7.  Back to cited text no. 5
    
6.
Morley N, Omar I Imaging evaluation of musculoskeletal tumors. Cancer Treat Res 2014;162:9-29.  Back to cited text no. 6
    
7.
Pommersheim WJ, Chew FS Imaging, diagnosis, and staging of bone tumors: A primer. Semin Roentgenol 2004;39:361-72.  Back to cited text no. 7
    
8.
Gulia A, Puri A, Chorge S, Panda PK Epidemiological data and case load spectrum of patients presenting to bone and soft tissue disease management group at a tertiary cancer center. Indian J Cancer 2016;53:333-8.  Back to cited text no. 8
    
9.
Aly A, Shaaban H, Abou-Sinna I. Accuracy of fine needle aspiration cytology in the diagnosis of bone lesions with radiological assistance: Experience from the National Cancer Institute, Cairo University, Egypt. Egypt J Radiol Nucl Med 2014;45:127-35.  Back to cited text no. 9
    
10.
Settakorn J, Lekawanvijit S, Arpornchayanon O, Rangdaeng S, Vanitanakom P, Kongkarnka S, et al. Spectrum of bone tumors in Chiang Mai University Hospital, Thailand according to WHO classification 2002: A study of 1,001 cases. J Med Assoc Thai 2006;89:780-7.  Back to cited text no. 10
    
11.
Hau M, Kim J, Kattapuram S, Hornicek FJ, Rosenberg AE, Gebhardt MC, et al. Accuracy of CT-guided biopsies in 359 patients with musculoskeletal lesions. Skelet Radiol 2002;31:349-53.  Back to cited text no. 11
    
12.
Lee JH, Reinus WR, Wilson AJ. Quantitative analysis of the plain radiographic appearance of unicameral bone cyst. Invest Radiol 1999;34:28-37.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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