JOURNAL CLUB

Dr Sushila Gyawali
3rd year resident
Title
■ Soft-Tissue Tumor Reporting and Data System (ST-RADS): MRI Reporting
Guideline with Multi-Institutional Validation Study of Musculoskeletal
Extremity Tumors
■ Journal of Tumor Research is an open-access, peer-reviewed journal.
■ Impact factor: 4.79
■ Received: 25-Nov-2022, Reviewed/Revised, Published: 27-Dec-2022,
Authors
■ Department of Radiology, UT Southwestern Medical Center
– Avneesh Chhabra,
– Oganes Ashikyan,
– Raghu Ratakonda,
– Gitanjali Bajaj (also in the Department of Radiology, University of
Arkansas for Medical Sciences),
– Uma Thakur Department of Radiology,
– Parham Pezeshk
■ Department of Radiology, The University of Texas ,Anderson Cancer Center
– Yin Xi1, Marwa Zaid, William Murphy, Rajendra Kumar, Behrang Amini
■ Department of Orthopaedic Surgery, UT Southwestern Medical Center
– Alexandra Callan
Introduction.
■ Soft tissue tumors of the extremities are frequently encountered.
■ Benign soft tissue tumors outnumbered malignant tumors, with a ratio of
100 to 1.
■ Malignant soft tissue tumors place a substantial financial burden on the
health system (costs up to $100,000 per patient).
■ USG: screening purpose with some diagnosis.
■ MRI is crucial for assessing soft tissue tumors, providing detailed insights
for characterization,biopsy, and surgical planning.
■ However, it can be challenging to differentiate between benign and
malignant tumors.
■ Absence of validated, standardized MRI guidelines to help
radiologists distinguish between benign and malignant soft
tissue tumors.
■ Experienced musculoskeletal radiologists from three tertiary
care centers developed the Soft-tissue Tumor Reporting And
Data System (ST-RADS), modeled after the BI-RADS system
for breast tumors.
■ This study aims to assess the multi-reader reliability of ST-
RADS and its accuracy in differentiating benign from
malignant tumors.
 MATERIALS AND METHODS
■ Retrospective, cross-sectional multiinstitutional and multi-
reader study involving three institutions.

Inclusion criteria: Exclusion criteria

Musculoskeletal soft tissue tumors of upper and Incomplete imaging sets.

lower extremities with histology proof via biopsy Lack of final clinical
and/or final post-surgical histology and with diagnosis, e.g., lack of
complete MR imaging sets of arthroscopy for parameniscal
1. Adipocytic cyst or final clinical diagnosis
2. T2-hyperintense tumors and tumor-like lesions of Gout.
(hyperintense than muscle signal) and
3. T2-hypointense masses and tumor-like lesions
ST-RADS consensus document
■ Created by reviewing WHO document,
– WHO classification of soft tissue tumors
– Guide to place a spectrum of commonly encountered histologies in
various categories of ST-RADS
■ Consensus opinion of tumor imaging experts from all three institutes
■ Input from clinicians and expert methodologists from the primary
institution
■ All soft tissue tumors were classified into one of the ST-RADS categories
0-VI.
 Complete MRI study
• T1WI , fluid-sensitive sequence (fat-suppressed T2WI, T2WI, or IR), and
Post-contrast fat-suppressed T1WI.
• Must cover the entire tumor in at least one plane.
 Incomplete MRI: lacks any of these sequences.(except if additional required
sequences obtained within 2 weeks.
 DWI: not universally adopted, can supplement when available.

Classification Category Management Likelihood of

malignancy
ST-RADS 0 Incomplete imaging Further imaging is N/A
necessary

ST-RADS I No lesion identified No further imaging

follow-up Essentially 0%
 STRADS 2
■ Exhibits specific imaging characteristics:
1. Uniform fat signal on all sequences with complete suppression on fat
saturation or inversion recovery images and no appreciable enhancement and
<10 cm.
2. Completely calcified hypointense lesions confirmed with radiographs or CT.
3. Fluid intensity mass connected to a joint or bursa with no intravenous
contrast enhancement.
4. Shows no enhancement or thin (<2 mm) peripheral and/or septal
enhancement on the post-contrast study with no significant diffusion
restriction.
5. Except in otherwise classic lesions, such as plantar fibroma, Morton’s
neuroma, elastofibroma dorsi, hemangioma and arthritis related nodules
6. DWI, if obtained, shows moderate to marked hyperintensity on both DWI and
ADC images, with a mean ADC value >1 . 5-3.0 × 10^-3 mm^2/s
Classification Category Management Likelihood of
malignancy

ST-RADS II Definitely benign no follow-up needed Essentially 0%

Adipocytic tumors T2-hyperintense Lesions T2-hypointense Lesions

Lipomatosis Geyser Plantar fibroma ,

Lipoma Parameniscal cyst Hemangioma Gout
Fibrolipoma of nerve Paralabral cyst
Dermatolipoma Venous malformation Degloving
Fat necrosis lesion Ganglion cyst
Hematoma
Hemangioma
Lymphedema,
lipoma arborescence
Elastofibroma
 STRADS III
■ Exhibits specific imaging characteristics:
• Fluid intensity lesion adjacent to a joint or bursa, possibly a
septated ganglion cyst.
• Fibrous tissue signal lesions in relation to fascia and muscles, e.g.,
classic palmar or plantar fibromatosis (moderate- marked
hypointense on T1W and T2W imaging).
• Intramuscular lesions such as a myxoma, which can be
pathognomonic but may show heterogeneous enhancement,
hence placed in ST-RADS III instead of II or IV.
• Other tumors or tumor-like lesions with typical imaging features,
e.g., lipoma with metaplastic calcification or ossification, myositis
ossificans, benign peripheral nerve sheath tumors, synovial
chondromatosis, Tenosynovial Giant Cell Tumor (TSGCT),
Desmoid, and angiolipoma.
■ Post-contrast imaging may exhibit no enhancement or thin (<2 mm)
peripheral and/or septal enhancement with ganglion cyst or bursitis, or
variable enhancement with other lesions.
■ DWI, if obtained, exhibits moderate-marked hyperintensity of the lesion
on DWI and mild-moderate hyperintensity on ADC images, with
generally a mean ADC value=1.2-2.0 × 10^-3 mm^2/s.
■ Caution needed with certain lesions such as TSGCT and myxoid lesions.
Classification Category Management Likelihood of
malignancy
ST-RADS III Probably benign Follow-up in 3 months, Less than or equal to
six months, one year, 2%
and two years or
<2years/ shorter-term
follow-up if the lesion
resolves or significantly
regresses

Adipocytic tumors T2-hyperintense Lesions T2-hypointense Lesions

Lipoblastoma (1), Myxoma (7), Desmoid (4),

Angiolipoma (7),
Myolipoma of soft tissue (1),
Chondroid lipoma (1),
Spindle cell / pleomorphic
lipoma (6)
Bursitis(Rheumatoid,
subtendinous, adventitial) (4),
Hematoma (3),
Intraneural ganglion (2),
Seroma (1),
Benign PNST (3),
Cysticercosis (1),
Mycobacterial TS (1), Abscess
(1), Desmoid (1)
TSGCT (4),
Desmoplastic fibroblastoma (7),
Ossifying fibromyxoid tumor
(2), Pilomatricoma (2),
Fibroma of tendon sheath (1),
Granular cell tumor (1)
STRADS IV
■ Tumors exhibiting mixed intensity, a solid appearance < less than 5 cm
maximum length,
■ A lipomatous lesion with multiple septations without a solid focal
nodule or myxoid change.
■ On post-contrast imaging, there is variable enhancement.
■ DWI, if obtained, exhibits moderate marked hyperintensity of the lesion
on DWI and mild-moderate hyperintensity on ADC images, with
generally a mean ADC value>1.1 × 10-3mm2/s
■ Representative tumors include atypical lipomatous lesion, solitary fibrous
tumor, and Gardner fibroma
Classification Category Management Likelihood of
malignancy
ST-RADS IV Suspicious for Tissue diagnosis or More than 2% and less
malignancy or follow-up in 4-6 weeks than 50%
indeterminate interval, and regular
interval follow-up for
upto 2years

Adipocytic tumors T2-hyperintense Lesions T2-hypointense Lesions

Atypical lipomatous tumor and Cellular fibromatosis (1)

Well-differentiated liposarcoma
(13)
STRADS V

■ On MRI, these tumors exhibit mixed intensity and a solid mass,

■ Lipomatous lesion containing
– multiple thick septations or
– solid nodule (s), and/ or
– myxoid changes or a lipid poor T2 hyperintense enhancing mass.
■ These lesions show variable and solid enhancement with diffusion restriction and mean ADC
values <1.1 × 10-3 mm2/s.
■ As with other myxoid tumors, myxoid sarcomas typically have areas of higher mean ADC
■ Representative tumors in this category include malignant peripheral nerve sheath tumor synovial
sarcoma undifferentiated pleomorphic sarcoma, myxofibrosarcoma melanoma, and lymphoma.
Classification Category Management Likelihood of
malignancy

ST-RADS V Highly suggestive of Tissue diagnosis More than or equal to

malignancy 50%

Adipocytic tumors T2-hyperintense Lesions T2-hypointense Lesions

Dedifferentiated liposarcoma Sarcoma (5),
(11), Synovial sarcoma (3),
Myxoid liposarcoma (6)
Undifferentiated pleomorphic
sarcoma (5),
Extraskeletal osteosarcoma (6),
Synovial sarcoma (3),
Fibrosarcomaepithelioid (5)
myxofibrosarcoma (3),
Fibromyxoid sarcoma (1),
Sarcoma NOS (1),
 Classification Category Management Likelihood of
malignancy
ST-RADS VI Known biopsy-proven Surgical excision or N/A
malignancy or recurrent further treatment as
malignancy in the clinically appropriate
tumor bed

• Solid nodule or residual/growing mass with imaging features like the pre-intervention lesion in the
tumor bed suggests tumor recurrence.
• Post-contrast imaging typically shows solid nodular enhancement or enhancement similar to the
tumor prior to intervention in such cases.
• DWI, if obtained, shows diffusion restriction and mean ADC<1.1 × 10-3 mm2/s or similar to that of
the pre-intervention tumor
■ The consensus document was edited, shared electronically and
discussed during conference calls among experienced radiologists
■ Once agreed upon, multi-reader testing was performed at all three sites.
■ To validate and test the ST-RADS classification system, a range of
commonly encountered tumors from all three categories were
selected.
– adipocytic tumors ,T2-hyperintense and T2-hypointense tumors
– covering a broad spectrum of common and uncommon histologies
identified by the WHO classification
■ Tumors were categorized as hyperintense or hypointense based on their
predominant appearance on T2WI, with at least 50% or more of the
tumor exhibiting either hyperintensity or hypointensity,
■ The principal investigator conducted a training session on three
separate occasions to standardize the understanding of the
STRADS consensus document before independent scoring
■ A random sample of soft tissue tumors with complete MR
imaging with proven histopathological diagnoses were
collected and shared among the three institutes using Microsoft
PowerPoint presentations.
■ A total of 200 soft tissue tumors (100 adipocytic tumors, 50
T2-hyperintense tumors, and 50 T2-hyponitense tumors) were
evaluated.
■ The data sets were anonymized, and the readers of each site
were presented with tumors from the other site.
■ The tumors were displayed with most-representative images. The
readers were blinded to the final histological diagnosis and the
interpretation of the other readers.
■ Eight Musculoskeletal radiologists evaluated the studies with
their attending level experience ranging from 2 years post-
fellowship to more than 30 years of interpreting MR imaging of
soft tissue tumors
■ A musculoskeletal fellow controlled all data and compiled all
interpretations in an Excel database (Windows 10, Microsoft,
Redwood, WA).
Data analysis
■ Intra-Class Correlation Coefficient (ICC ) was used to assess
inter-reader agreement and the reliability of the guideline
system.
■ Areas under the receiver operating curve (AUC) were
calculated.
■ Sensitivity and specificity were also calculated with I/II/III as
benign and IV/V as malignant with final histology diagnosis
based on biopsy and/or surgery serving as the reference
standard.
RESULTS
Dataset ICC Interpretation
T2-hyperintense 0.69 Good
T2-hypointense masses 0.51 Fair
Adipocytic tumors 0.72 Good

Dataset Sensitivity Specificity

T2-hyperintense 93% 71%
T2-hypointense masses 64% 84%
Adipocytic tumors 96% 63%
Diagnostic performance

■ AUC
• 0.89 for adipocytic masses,
• 0.82 for T2-hyperintense
masses and
• 0.79 for T2-hypointense
masses
Stratified ICC by years of
experience (<10 years vs. ≥
10 years) were also
reported
 DISCUSSION
■ The system showed good AUC (Area Under the Curve) for both
adipocytic (0.89) and T2hyperintense and T2-hypointense lesions (0.82,
0.79).
■ Inter-reader agreement for differentiating benign and malignant soft
tissue masses on MRI has not been reported before.
■ The overall sensitivity for detecting malignancy using the ST-RADS
scoring system for adipocytic(96% ) and T2-hyperintense(93%) masses
is higher when compared to the sensitivity of the BI-RADSs system
(87.2%)
■BI-RADS scoring system specificity (90.1%) outperforms the ST-
RADS system (71%, 84% ,63%)
■ AUC in BI-RADS is 0.93, slightly higher than this study's results for
adipocytic tumors (0.89)and T2-hyperintense masses (0.82).
■ The average ICC amongst adipocytic and T2-hyperintense tumor
types was ~0.7 (good) among 8 MSK-trained radiologists, similar to
Cietto, et al. who reported average intrareader kappa of 0.71 based
on 12 radiologists interpreting mammograms following the BI-RADS
scoring system
■ STRADS helps to categorize soft tissue tumors effectively (describing
imaging and characterizing lesions).
■ Like other RADS, it provides clear categories based on the likelihood
of cancer, along with suggestions for next steps.
■ STRADS use ensures consistent terminology, reducing errors in
interpreting images.
■ Standardized reporting terms improve communication between
clinicians and patients, reducing confusion.
 Pros
• Study was a tertiary multicenter collaborative study involving 8 MSK
radiologists with different experience levels ranging from 2 years to over
30 years of attending-level expertise.
• None of the radiologists had seen the cases before, and they didn't know
the pathology results when interpreting the images.
• Testing the system with readers of different experience levels suggests it
can be used by both general radiologists and experienced
oncoradiologists.
• The less experienced readers did better, possibly because they were more
careful. However, all readers were trained in musculoskeletal radiology
and routinely conducted tumor boards.
Pros
■ The categorical reporting system helps manage uncertain soft tissue
lesions by offering clear guidelines for the next steps.
■ It can help decide if a lesion requires invasive procedures like biopsy
or surgery, saving time and effort by avoiding unnecessary procedures.
■ This system will facilitate data collection and provide new
opportunities for education, quality assurance, peer review, and
research.
Cons
■ Use of PowerPoint presentations for case presentation, which may
have hindered detailed evaluation due to lack of real-time windowing
and image scrolling
■ Ideally, the system should be tested and re-tested prospectively before
widespread use. It is hoped that more widespread use of the STRADS
will lead to further validation, refinement, and acceptance.
■ The study followed processes similar to the validation of other existing
guidelines, such as BI-RADS and LI-RADS.
■ Future work incorporating advanced imaging sequences would be
more beneficial such as DWI and dynamic contrast imaging, similar to
the PI-RADS system used for prostate cancer guidelines.
 CONCLUSION

■ As of the current date, this study is the largest to reveal the inter-reader
agreement in the domain of soft tissue sarcoma and for different
categories of soft tissue tumors.
■ The ST-RADS guideline is intended to be a dynamic document that can
be further refined by larger society participation and updated in response
to future user feedback and new scientific data.
■ It is hoped that increased use of ST-RADS will lead to further
validation, refinement, and acceptance.
Thank you!