Daniela Marinho Tridente, VI FCMSCSP

Gillian Lieberman, MD October 2013

A Diagnostic Chest XRay:

Multiple Myeloma
Daniela Marinho Tridente, VI
FCMSCSP
Gillian Lieberman, MD
 Daniela Marinho Tridente, 6th year FCMSCSP
Gillian Lieberman, MD

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
2
 Daniela Marinho Tridente, 6th year FCMSCSP
Gillian Lieberman, MD

The patient in question

 63 years old male
 No priors
 Not in use of any medication
 No family history

3
 Daniela Marinho Tridente, 6th year FCMSCSP
Gillian Lieberman, MD

His chief complaint

 Right infrascapular pain and pleuritic pain

4
 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

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
6
 Daniela Marinho Tridente, 6th year FCMSCSP
Gillian Lieberman, MD

First relevant findings

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

PACS, BIDMC 7
PA chest x ray
 Daniela Marinho Tridente, 6th year FCMSCSP
Gillian Lieberman, MD

Additional
view: CXR

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 8
 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

Skeletal Survey: skull

Let’s pause for a

minute and look for
any abnormalities…

PACS, BIDMC 12
Skull x ray, lateral view
 Daniela Marinho Tridente, 6th year FCMSCSP
Gillian Lieberman, MD

Skeletal Survey: skull (findings)

Multiple rounded
lucencies in the
skull, non-specific
but highly
compatible with
myeloma

PACS, BIDMC 13
Skull x ray, lateral view
 Daniela Marinho Tridente, 6th year FCMSCSP
Gillian Lieberman, MD

Skeletal Survey:
left femur

Let’s pause for a

minute and look for
any abnormalities…

PACS, BIDMC 14
Left femur PA x ray
 Daniela Marinho Tridente, 6th year FCMSCSP
Gillian Lieberman, MD

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

PACS, BIDMC 15
Left femur PA x ray
 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

Chest CT
(findings)
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

PACS, BIDMC 18
Sagital view, chest CT
Daniela Marinho Tridente, 6th year FCMSCSP
Gillian Lieberman, MD

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

PACS, BIDMC
Axial view, chest CT
19
 Daniela Marinho Tridente, 6th year FCMSCSP
Gillian Lieberman, MD

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
20
 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

DDX for Lytic Lesions

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

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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

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

“FEGNOMASHIC”

24
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

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
27
 Daniela Marinho Tridente, 6th year FCMSCSP
Gillian Lieberman, MD

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
28
Healy et al, “Multiple Myeloma: A Review of Imaging Features and Radiological Techniques”, 2011
 Daniela Marinho Tridente, 6th year FCMSCSP
Gillian Lieberman, MD

Standard Investigations for MM

 Complete blood count
 Serum biochemistry
 Serum and urine eletrophoresis
 Bone marrow aspirate and biopsy (GOLD
STANDARD FOR DIAGNOSIS

29
Healy et al, “Multiple Myeloma: A Review of Imaging Features and Radiological Techniques”, 2011
 Daniela Marinho Tridente, 6th year FCMSCSP
Gillian Lieberman, MD

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
30
 Daniela Marinho Tridente, 6th year FCMSCSP
Gillian Lieberman, MD

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
31
Daniela Marinho Tridente, 6th year FCMSCSP
Gillian Lieberman, MD

The Durie
Salmon
Staging
System
(1975)

32
From myeloma.org
 Daniela Marinho Tridente, 6th year FCMSCSP
Gillian Lieberman, MD

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…) 33
 Daniela Marinho Tridente, 6th year FCMSCSP
Gillian Lieberman, MD

Role of Radiological Imaging in MM

 Initial staging of disease

 Detection and characterization of
complications
 Evaluation of patient’s response to
treatment

34
Healy et al, “Multiple Myeloma: A Review of Imaging Features and Radiological Techniques”, 2011
 Daniela Marinho Tridente, 6th year FCMSCSP
Gillian Lieberman, MD

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
35
 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

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)
37
Healy et al, “Multiple Myeloma: A Review of Imaging Features and Radiological Techniques”, 2011
 Daniela Marinho Tridente, 6th year FCMSCSP
Gillian Lieberman, MD

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
38
Healy et al, “Multiple Myeloma: A Review of Imaging Features and Radiological Techniques”, 2011
 Daniela Marinho Tridente, 6th year FCMSCSP
Gillian Lieberman, MD

Multiple “punched-out” lytic

lesions throughout lumbar
spine and pelvis

Volume rendering 3-dimensional reconstruction of lumbar

spine and pelvis (companion patient #1)

From Healy et al, Multiple Myeloma: a Review of Imaging 39

Features and Radiological Techniques; 2011
 Daniela Marinho Tridente, 6th year FCMSCSP
Gillian Lieberman, MD

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
40
Healy et al, “Multiple Myeloma: A Review of Imaging Features and Radiological Techniques”, 2011
 Daniela Marinho Tridente, 6th year FCMSCSP
Gillian Lieberman, MD

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
41
 Daniela Marinho Tridente, 6th year FCMSCSP
Gillian Lieberman, MD

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.
42
 Daniela Marinho Tridente, 6th year FCMSCSP
Gillian Lieberman, MD

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
43
 Daniela Marinho Tridente, 6th year FCMSCSP
Gillian Lieberman, MD

Acknowledgments
 Claire Odom
 Gillian Lieberman, MD
 Ronald L. Eisenberg, MD
 Jawad S. Hussain, MD

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