Fluid-fluid levels in bone neoplasms: variation of T1-weighted signal intensity of the superior to inferior layers—diagnostic significance on magnetic resonance imaging

The diagnostic relevance of the relative T1-weighted (T1W) and T2-weighted (T2W)/short tau inversion recovery (STIR) MRI signal intensity characteristics of the superior to inferior fluid layers within fluid-fluid levels (FFLs) found in bone tumours was investigated. A retrospective analysis was performed of MRI studies of 2,568 patients presenting with a suspected bone tumour over an 8-year period. Final diagnosis was made by biopsy/surgical resection or characteristic imaging/clinical findings. Subjects were divided by the absence/presence of FFLs and benign/malignant histology. Cases with FFLs were sub-categorised by the relative signal intensity of the superior/inferior layer as high/low or low/high on T1W and T2W/STIR sequences. Out of the total of 2,568 cases, 214 (8.3%, CI 7.3–9.5%) had FFLs and 2,354 (91.7%, CI 90.5–92.7%) had no FFLs. All 214 cases with FFLs had T2W/STIR sequences available, all demonstrating high/low signal intensity characteristics; 135/214 (63.1%, CI 56.2–69.6%) were benign and 79/214 (36.9%, CI 30.4–43.8%) were malignant. Out of the 214 patients, 151 had T1W sequences performed; 52 showed high/low signal intensity, of which 30 (57.7%, CI 34.2–71.3%) were benign and 22 (42.3%, CI 28.7–56.8%) were malignant (P = 0.06 compared with no FFL group); 50 showed low/high signal intensity, of which 40 (80%, CI 66.3–90.0%) were benign and ten (20%, CI 10.0–33.7%) were malignant (P = 0.0000, compared with the no FFL group). The low/high and high/low groups had a significantly greater proportion of benign and malignant lesions, respectively (P = 0.015). In conclusion, all FFLs showed high/low signal intensity characteristics on T2W/STIR sequences. Low/high signal on T1W was significantly associated with benign disease. Malignancy may occur slightly more frequently with high/low signal on T1W.