a diagnostic chest xray: multiple myeloma

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


3

The patient in question

63 years old male

No priors

Not in use of any medication

No family history


4

His chief complaint

Right infrascapular pain and pleuritic pain


A chest x ray was requested,

as to evaluate for possible

fractures, bone lesions or

pleural reaction


6

Update #1: Learning Agenda




Multiple Myeloma





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


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


Comparison was made to

prior chest xrays dated July

2007 and none of the findings

were considered preexisting.


Following up…

Additional scans were recommended by the radiologist, to correlate multiple

myeloma or metastases since the patient had no priors.


That being so, our patient had

a skeletal survey done as well

as a Chest CT


12

Skeletal Survey: skull

PACS, BIDMC

Skull x ray, lateral view

Let’s pause for a

minute and look for

any abnormalities…


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


14 PACS, BIDMC

Left femur PA x ray

Skeletal Survey:

left femur

Let’s pause for a

minute and look for

any abnormalities…


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


Additionally, osteopenia was

noted on the cervical and

thoracic spines


Let’s move on and have a

look at the Chest CT…


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


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


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Multiple Myeloma





Let’s consider the differential

diagnosis of lytic lesions…


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

http://www.radiologyassistant.nl/data/bin/a509797a2e5179_TEK-BOT-WELL.jpg


One of the ways to consider

the differential diagnosis of

lytic lesions is through the use

of the mnemonic

“FEGNOMASHIC”


24

“FEGNOMASHIC”


http://www.radiologyassistant.nl/data/bin/a509797a2e6d90_TAB-Lucent-bone-lesions.png


Considering that our patient

had no priors and had

negative screening tests for

the most common primary

cancer sites…


… that leaves us with

Multiple Myeloma!


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Multiple Myeloma





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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


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Standard Investigations for MM

Complete blood count

Serum biochemistry

Serum and urine eletrophoresis

Bone marrow aspirate and biopsy (GOLD

STANDARD FOR DIAGNOSIS



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Multiple Myeloma





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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


32

The Durie

Salmon

Staging

System

(1975)

From myeloma.org


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…)


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Role of Radiological Imaging in MM

Initial staging of disease

Detection and characterization of

complications

Evaluation of patient’s response to

treatment



35





Multiple Myeloma





Let’s consider some of the

most commonly used imaging

techniques…


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)



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



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


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



41





Multiple Myeloma





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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.


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

http://www.uptodate.com/contents/clinical-features-laboratory-manifestations-and-diagnosis-of-multiple-myeloma?source=outline_link&view=text&anchor=H22#H22





































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Acknowledgments

Claire Odom

Gillian Lieberman, MD

Ronald L. Eisenberg, MD

Jawad S. Hussain, MD

a diagnostic chest xray: multiple myeloma

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