The ethics committee approved this study of the First Central Hospital of Tianjin (2017N078KY); all participants provided written informed consent form before examination. All patients underwent whole-body DWI and water-fat separation Dixon examination before treatment. Marrow biopsy was also taken within 1 week before or after MRI. A retrospective review was performed by 2 radiologists (S Xia, X Ji, with 22 and 10 years of experience, respectively) to determine focal indeterminate marrow abnormalities in consensus.

The inclusion criteria for focal indeterminate marrow abnormalities in the present study were as follows: (I) focal marrow abnormalities on conventional MRI; (II) normal trabecular pattern of the involved bone maintained on CT or PET/CT performed within 2 weeks from the MRI examination date; (III) no specific feature for malignant lesions: no cortical violation or extra-osseous soft-tissue extension on MRI; and (IV) no specific imaging features for benign lesions, such as hemangioma, bone island, Modic type 1 vertebral endplate change or Schmorl’s node in the spines, cystic lesion, osteonecrosis, and obvious benign tumors with specific imaging findings in the long bone.

From February 2015 to July 2017, all 63 patients with MM confirmed by pathology were included in the study. Among these 63 MM patients, 20 were excluded due to normal MRI findings, 3 were excluded due to images with motion artifacts or deformation, and another 5 were excluded because they had no thoracolumbar lesions. Finally, the study included 35 patients with multinodular lesions in the thoracolumbar spine on whole-body DWI; the selection of patients and lesions are shown in Figure 1.

Flow chart of participants and FL selection. WB, whole body; MRI, magnetic resonance imaging; DWI, diffusion-weighted imaging; STIR, short-time inversion recovery; PET, positron emission tomography; CT, computed tomography; FL, focal lesion.

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