Proton density fat fraction measurements of rotator cuff muscles: Accuracy, repeatability, and reproducibility across readers and scanners

To determine the accuracy, repeatability, and reproducibility of magnetic resonance imaging-based proton density fat fraction (MRI-PDFF) measurements of rotator cuff muscles between two readers and three different scanners. Thirty-one volunteers underwent serial shoulder MRI examinations of both left and right sides on one 1.5-T MRI scanner and two 3.0-T MRI scanners. Two independent readers measured muscular PDFF of the supraspinatus, infraspinatus/teres minor muscle, and subscapularis. MR spectroscopy-based proton density fat fraction (MRS-PDFF) was regarded as the reference standard for assessing accuracy. A “coffee break” examination method was used to test the repeatability of each scanner. Bland-Altman plots, Pearson correlation, and linear regression analysis were used to assess bias and linearity. The Wilcoxon signed-rank test and Friedman test were applied to evaluate repeatability and reproducibility. MRI-PDFF measurements indicated strong linearity (R2 = 0.749) and small bias (−0.18%) in comparison with the MRS-PDFF measurements. A very strong positive Pearson correlation (r = 0.955–0.986) between the PDFF estimates of the two repeat scans indicated excellent repeatability. The PDFF measurements showed high reproducibility, with a strong positive Pearson correlation (r = 0.668–0.698) and a small mean bias (−0.04 to −0.10%) across different scanners. MRI-PDFF measurements of rotator cuff muscles were highly accurate, repeatable, and reproducible across different readers and scanners, leading us to the conclusion that PDFF can be a reliable and robust quantitative imaging biomarker for longitudinal or multi-center studies.