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Daniela Marinho Tridente, VI FCMSCSP Gillian Lieberman, MD
A Diagnostic Chest XRay:
Multiple Myeloma
Daniela Marinho Tridente, VI
FCMSCSP
Gillian Lieberman, MD
October 2013
Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD
2
Our Learning Agenda
Introduction of our patient
His imaging data and findings
Differential diagnosis
Multiple Myeloma
Diagnostic approach of MM
Imaging Techniques on MM
Some take home points
Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD
3
The patient in question
63 years old male
No priors
Not in use of any medication
No family history
Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD
4
His chief complaint
Right infrascapular pain and pleuritic pain
Daniela Marinho Tridente, VI FCMSCSP Gillian Lieberman, MD
A chest x ray was requested,
as to evaluate for possible
fractures, bone lesions or
pleural reaction
Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD
6
Update #1: Learning Agenda
Introduction of our patient
His imaging data and findings
Differential diagnosis
Multiple Myeloma
Diagnostic approach of MM
Imaging Techniques on MM
Some take home points
Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD
7
First relevant findings
PACS, BIDMC
PA chest x ray
Multiple right-
sided rib
fractures
Destructive rib
lesion with soft
tissue component
at the right eighth
rib laterally
Multiple lytic
lucencies in the
right scapula
Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD
8
The lucencies
mentioned in the PA
are better seen at the
concurrent rib series
performed on the
same day
PACS, BIDMC
Unilateral rib series and chest PA x ray
Additional
view: CXR
Daniela Marinho Tridente, VI FCMSCSP Gillian Lieberman, MD
Comparison was made to
prior chest xrays dated July
2007 and none of the findings
were considered preexisting.
Daniela Marinho Tridente, VI FCMSCSP Gillian Lieberman, MD
Following up…
Additional scans were recommended by the radiologist, to correlate multiple
myeloma or metastases since the patient had no priors.
Daniela Marinho Tridente, VI FCMSCSP Gillian Lieberman, MD
That being so, our patient had
a skeletal survey done as well
as a Chest CT
Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD
12
Skeletal Survey: skull
PACS, BIDMC
Skull x ray, lateral view
Let’s pause for a
minute and look for
any abnormalities…
Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD
13
Skeletal Survey: skull (findings)
PACS, BIDMC
Skull x ray, lateral view
Multiple rounded
lucencies in the
skull, non-specific
but highly
compatible with
myeloma
Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD
14 PACS, BIDMC
Left femur PA x ray
Skeletal Survey:
left femur
Let’s pause for a
minute and look for
any abnormalities…
Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD
15 PACS, BIDMC
Left femur PA x ray
Skeletal Survey:
left femur
(findings)
A rounded 6.5mm
lucency is seen in the
distal left femur
adjacent to the lateral
cortex of the distal
diaphysis and could
represent a small
myelomatous lesion
Daniela Marinho Tridente, VI FCMSCSP Gillian Lieberman, MD
Additionally, osteopenia was
noted on the cervical and
thoracic spines
Daniela Marinho Tridente, VI FCMSCSP Gillian Lieberman, MD
Let’s move on and have a
look at the Chest CT…
Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD
18
Chest CT
(findings)
PACS, BIDMC
Sagital view, chest CT
Diffuse demineralization
and lytic lesions affect
nearly the entire chest
cage, consistent with
multiple myeloma
A compression deformity
of the T9 vertebral body,
with approximately 50%
loss of height
Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD
19
PACS, BIDMC
Axial view, chest CT
More on the chest CT
A 3.5 x 1.8 cm
expansile lytic
lesion is present in
the lateral, right
eighth rib with
associated soft
tissue mass in the
chest wall that
causes cortical
destruction and
pathologic fracture
Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD
20
Update #2: Learning Agenda
Introduction of our patient
His imaging data and findings
Differential diagnosis
Multiple Myeloma
Diagnostic approach of MM
Imaging Techniques on MM
Some take home points
Daniela Marinho Tridente, VI FCMSCSP Gillian Lieberman, MD
Let’s consider the differential
diagnosis of lytic lesions…
Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD
22
DDX for Lytic Lesions
http://www.radiologyassistant.nl/en/p4bc6176e56228/bone-tumor-well-defined-osteolytic-tumors-and-tumor-like-lesions.html
Here are some of
the most common
well-defined bone
tumors and tumor-
like lesions
FD: fibrous dysplasia
EG: eosinophilic granuloma
NOF: non-ossifying fibroma
SBC: simple bone cyst
ABC: aneurysmal bone cyst
CMF: chondromyxoid fibroma
Giant CT: giant cell tumour
Daniela Marinho Tridente, VI FCMSCSP Gillian Lieberman, MD
One of the ways to consider
the differential diagnosis of
lytic lesions is through the use
of the mnemonic
“FEGNOMASHIC”
Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD
24
“FEGNOMASHIC”
http://www.radiologyassistant.nl/en/p4bc6176e56228/bone-tumor-well-defined-osteolytic-tumors-and-tumor-like-lesions.html
Daniela Marinho Tridente, VI FCMSCSP Gillian Lieberman, MD
Considering that our patient
had no priors and had
negative screening tests for
the most common primary
cancer sites…
Daniela Marinho Tridente, VI FCMSCSP Gillian Lieberman, MD
… that leaves us with
Multiple Myeloma!
Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD
27
Update #3: Learning Agenda
Introduction of our patient
His imaging data and findings
Differential diagnosis
Multiple Myeloma
Diagnostic approach of MM
Imaging Techniques on MM
Some take home points
Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD
28
Let’s talk about MM
Neoplastic disorder of plasma B cells
Characteristic bone marrow infiltration and overproduction of monoclonal immunoglobulins
Accounts for 10% of all haematological malignancies (and 1% of all cancers)
Predominantly affects patients in the seventh decade
High mortality and morbidity
Healy et al, “Multiple Myeloma: A Review of Imaging Features and Radiological Techniques”, 2011
Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD
29
Standard Investigations for MM
Complete blood count
Serum biochemistry
Serum and urine eletrophoresis
Bone marrow aspirate and biopsy (GOLD
STANDARD FOR DIAGNOSIS
Healy et al, “Multiple Myeloma: A Review of Imaging Features and Radiological Techniques”, 2011
Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD
30
Update #4: Learning Agenda
Introduction of our patient
His imaging data and findings
Differential diagnosis
Multiple Myeloma
Diagnostic approach of MM
Imaging Techniques on MM
Some take home points
Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD
31
Diagnostic Criteria
(All 3 are required for diagnosis)
Monoclonal plasma cells in the bone marrow > 10% and/or presence of a biopsy-proven plasmacytoma
Monoclonal protein present in the serum and/or urine
Myeloma-related organ dysfunction (1 or more) **
[C] Calcium elevation in the blood {S. Calcium >10.5 mg/l or upper limit of normal}
[R] Renal insufficiency {S. Creatinine > 2 mg/dl}
[A] Anemia {Hemoglobin < 10 g/dl or 2 g < normal}
[B] Lytic bone lesions or osteoporosis
Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD
32
The Durie
Salmon
Staging
System
(1975)
From myeloma.org
Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD
33
The Durie Salmon PLUS
New staging system, published in 2006
later staging system used skeletal survey
as its only radiological criterion
Effort to standardize treatment approaches
and better stage the disease = improved
system
Integrates the more sensitive imaging
techniques (MRI, CT, PET/CT…)
Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD
34
Role of Radiological Imaging in MM
Initial staging of disease
Detection and characterization of
complications
Evaluation of patient’s response to
treatment
Healy et al, “Multiple Myeloma: A Review of Imaging Features and Radiological Techniques”, 2011
Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD
35
Update #5: Learning Agenda
Introduction of our patient
His imaging data and findings
Differential diagnosis
Multiple Myeloma
Diagnostic approach of MM
Imaging Techniques on MM
Some take home points
Daniela Marinho Tridente, VI FCMSCSP Gillian Lieberman, MD
Let’s consider some of the
most commonly used imaging
techniques…
Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD
37
Plain Radiography
Full skeletal survey (frontal and lateral view of skull, cervical, thoracic and lumbar spine, coned-down frontal view of the dens axis, frontal views of rib cage, humeri, femora, knees and pelvis)
Clear association between extent of disease (number of lytic lesions at presentation) and tumor load at diagnosis
Almost 80% of patients will have radiological evidence of skeletal involvement
Disadvantages: high false-negative rate (significant underestimation in diagnosis)
Healy et al, “Multiple Myeloma: A Review of Imaging Features and Radiological Techniques”, 2011
Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD
38
Computed Tomography (CT)
Great for assessing punched-out lytic lesions, expansile lesions with soft tissue masses, diffuse osteopenia and fractures (as presented earlier)
Whole-body CT is not used for screening purposes due to high radiation exposure – low dose CT techniques are being developed as an alternative to plain films and since it does not require iodine containing contrast agents (contraindicated in patients with MM due to risk of renal impairment and cast nephropathy) it appears as an attractive screening option
Healy et al, “Multiple Myeloma: A Review of Imaging Features and Radiological Techniques”, 2011
Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD
39
Volume rendering 3-dimensional reconstruction of lumbar
spine and pelvis (companion patient #1)
From Healy et al, Multiple Myeloma: a Review of Imaging Features and Radiological Techniques; 2011
Multiple “punched-out” lytic
lesions throughout lumbar
spine and pelvis
Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD
40
Whole-body MRI
Favoured imaging method for evaluating
disease within the bone marrow
Excellent correlation with survival
outcomes (due to Durie-Salmon PLUS)
Focal MRI used for narrowing the
differential diagnosis in a solitary lytic
lesion
Healy et al, “Multiple Myeloma: A Review of Imaging Features and Radiological Techniques”, 2011
Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD
41
Update #5: Learning Agenda
Introduction of our patient
His imaging data and findings
Differential diagnosis
Multiple Myeloma
Diagnostic approach of MM
Imaging Techniques on MM
Some take home points
Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD
42
Conclusions
Faced with osteolytic lesions in any patients over the age of 40 years old, MM and metastases are a must when considering possible differential diagnosis;
There is no single better imaging method to evaluate MM; as the new techniques become more available and less expensive, a combined view of them all is the best way to better access MM.
Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD
43
References
B. G. M. Durie and S. E. Salmon, “A clinical staging system for multiple myeloma. Correlation of measured myeloma cell mass with presenting clinical features, response to treatment, and survival,” Cancer, vol. 36, no. 3, pp. 842–854, 1975.
B. G. M. Durie, “The role of anatomic and functional staging in myeloma: description of Durie/Salmon plus staging system,” European Journal of Cancer, vol. 42, no. 11, pp. 1539–1543, 2006.
Healy et al, “Multiple Myeloma: A Review of Imaging Features and Radiological Techniques”, Bone Marrow Research, vol. 2011, 2011.
Angtuaco et al, “Multiple Myeloma: Clinical Review and Diagnostic Imaging”, Radiology, vol. 231, pp. 11-23, 2004.
B.G.M. Durie, “Myeloma Management Guidelines”, from myeloma.org, acessed on October 18th, 2013
Rajkumar, SV, “Clinical features, laboratory manifestations and diagnosis of multiple myeloma”, UpToDate. http://www.uptodate.com/contents/clinical-features-laboratory-manifestations-and-diagnosis-of-multiple-myeloma?source=outline_link&view=text&anchor=H22#H22. Acessed on October 17th, 2013
Woude, HJ and Smithuis, R. “Bone Tumor: well-defined osteolytic tumors and tumor-like lesions”, The Radiology Assistant, http://www.radiologyassistant.nl/en/p4bc6176e56228/bone-tumor-well-defined-osteolytic-tumors-and-tumor-like-lesions.html. Acessed October 16th, 2013
Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD
44
Acknowledgments
Claire Odom
Gillian Lieberman, MD
Ronald L. Eisenberg, MD
Jawad S. Hussain, MD