Bone Disease in Plasma. Cell Dyscrasias

Transcription

1 Bone Disease in Plasma July 2004 Cell Dyscrasias Courtesy of Dr. Ferris Hall Sarah Billmeier Harvard Medical School Year III

2 Objectives Characterization of the plasma cell neoplasms Radiologic work up of Multiple Myeloma A Visual Journey Multiple Myeloma: Lytic Multiple Myeloma: Osteopenic Sclerotic Plasma Cell Neoplasms Diffuse: Sclerotic Multiple Myeloma Solitary: Sclerotic Plasmacytoma Multifocal: POEMS 2

3 Definitions Multiple Myeloma (MM) = monoclonal malignant proliferation of plasma cells Plasmacytoma = discrete, solitary mass of neoplastic monoclonal plasma cells in either bone or soft tissue (extramedullary). Absence of multiple lesions, marrow plasmacytosis or other features of MM. Progresses to MM in 50-60%. POEMS = syndrome of Polyneuropathy, Organomegally, Endocrinopathy, Monoclonal gammopathy & Skin problems MGUS = Monoclonal Gammopathy of Undetermined Significance: Presence of M-protein in urine without evidence of multiple myeloma. With long term follow up 25% develop MM. 3

4 Multiple Myeloma Minimal diagnostic criteria: Presence of >10% plasma cells in the BM or plasmacytoma m Serum or urine monoclonal protein Related organ or tissue impairment ( calcium, renal insufficiency, anemia, lytic bone lesions, hyperviscosity, amyloidosis, recurrent infections) Epidemiology: MM represents 1-2% of all malignant disease & 10-33% hematologic malignancies. Incidence increases with age. Men > Women. Blacks >Whites Presentation: Bone pain precipitated by movement = most common. Other common symptoms include weakness, fatigue and weight loss. 4

5 Staging of MM Durie & Salmon Based on staging and other prognostic indicators median survival ranges from 5 years to 15 months Systemic tx is indicated for Stage II & III patients Stage I Low cell mass All of the following Present: Hgb > 10 g/dl Serum IgG < 5 g/dl Serum IgA <3 g/dl Normal serum calcium Urine monoclonal prtn excretion <4 g/day No generalized lytic bone lesions Stage III - High Cell Mass >1 of the following: Hgb <8.5 g/dl Serum IgG > 7 g/dl Serum IgA > 5 g/dl Serum calcium >12 mg/dl Urine monoclonal prtn excretion >12 g/day Advanced lytic bone lesions Stage II Intermediate cell mass Fitting neither I nor III 5

6 The Skeletal Survey The skeletal survey used at dx of MM to detect bone pathology for: Establishment of a baseline for future follow-up Assessment of fracture risk Staging The skeletal survey in an adult consists of plain radiographs of the skull (AP and lateral) ribs (AP global, AP on the lower thoracic grid, two oblique views) spine (AP and lateral of cervical, thoracic and lumbar areas) pelvis (AP) femurs (AP and lateral) humerus (AP and lateral) Bone scintigraphy is less sensitive than plain films in identifying lytic lesions. Most lesions of MM are not apparent unless a fracture occurred or the lesion is in a healing phase. 6

7 MRI for lesion detection in MM? Several studies suggest that MR is superior to radiographs for detection of lesions in the spine. The Durie and Salmon staging system was developed in 1975 when only plain film was available to image the skeleton. Baur A. et al. Cancer Sep 15. Spine imaging of the same patient using MRI and plain film Currently, MRI is not standardly used in MM patients. 7

8 Role for PET? By directly imaging the increased metabolic activity of the bone marrow PET may be able to: detect early lesions missed by skeletal surveys or MRI may be useful to monitor response to therapy Currently PET is not commonly used for MM imaging. 8 PACS, BIDMC

9 What Causes Lytic Lesions in MM? Formation of osteolytic lesions involves uncoupling of bone resorption and formation Glass DA 2nd. Patel MS. Karsenty G. NEJM 2003 Dec 25. Patients taking bisphosphonates (which inhibit osteoclasts) do not have an increase in bone formation within lytic lesions Long search for a secreted factor that activates osteoclasts Myeloma cells secrete RANKL to increase osteoclast activity and DKKI to inhibit osteoblasts, creating a bias toward negative bone balance 9

10 A Visual Journey by Case Series Multiple Myeloma: Lytic Patient 1: GW Patient 2: SL Multiple Myeloma: Osteopenic Patient 3: BV Sclerotic Plasma Cell Neoplasms Diffuse: Sclerotic Multiple Myeloma Patient 4: HM Solitary: Sclerotic Plasmacytoma Multifocal: POEMS Patient 5: OJ (Plasmocytoma) Patient 6: BP (Mixed lytic-sclerotic) 10

11 Lytic Lesions of MM: Patient 1 - GW GW is a 71 y.o. female who presents to the EW with mild pain and an inability to walk. Labs indicate M-protein by electrophoresis. Pathologic fracture Multiple lytic lesions without sclerotic margins 11 Courtesy of Dr. Ferris Hall

12 Lytic MM: GW, Additional Radiographs Lateral skull film with classic punched out lytic lesions of various sizes Courtesy of Dr. Ferris Hall 12

13 DDx Multiple Punched-Out Lytic Lesions of Bone with Nonsclerotic Margins Common: Arthritis (eg, gout, rheumatoid, osteoarthritis) Brown tumors of hyperparathyroidism Langerhans Cell Histiocytosis Metastases Multiple Myeloma 13

14 Lytic MM Patient 2: Disease Progression SL was diagnosed in 1971 at age 28, initially with an isolated plasmacytoma. 10% of MM patients have an indolent course. June 1976 April 1985 All films this slide courtesy of Dr. Ferris Hall 14

15 Complications of Bone Destruction Additional Lesions Lytic lesions may cause: hypercalcemia pathologic fractures loss of height cord compression osteoporosis Pathologic Fracture 15 Courtesy of Dr. Ferris Hall

16 Osteopenia in MM Evidence for diffuse bone loss in 60% of multiple myeloma patients In 5% of patients bone loss occurs without focal lytic lesions Bisphosphonates often used for treatment of bone disease in MM. Use of palmidronate is associated with: pathologic fractures need for irradiation/surgery of bone spinal cord compression Prevention of hypercalcemia bone pain. 16

17 Osteopenic MM: Patient 3 - BV History: BV is a 54 y.o. female diagnosed with MM following a fall onto her hip, which lead to the discovery of lytic lesions in the pubic bone, leukopenia, anemia, and an monoclonal IgG lambda spike. A confirming bone marrow biopsy showed greater than 30% plasma cells. Compression Fracture Lateral thoracic spine illustrates diffuse osteopenia 17 PACS, BIDMC

18 Osteosclerotic MM 3-4% plasma cell neoplasms are sclerotic Sclerotic plasma cell neoplasms can be divided into: Solitary: Sclerotic plasmacytoma Diffuse: Sclerotic MM Multifocal: POEMS 85% sclerotic myeloma patients present with polyneuropathy More indolent course Affects younger patients Lambda > Kappa chains 18

19 Diffuse Osteosclerotic MM: Patient 4 - HM PACS, BIDMC History: HM is 77 y.o. woman who presented with DOE and pancytopenia. Initial work-up for lymphoproliferative disease prompted a CXR, CT, bone scan, skeletal survey and electrophoresis. Bone superscan with symmetrically diffuse increase of tracer uptake and diminished renal activity Lateral spine radiograph of diffuse sclerosis PACS, BIDMC 19

20 POEMS Polyneuropathy predominantly sensorimotor Organomegally liver, spleen or lymph nodes Endocrinopathy impotence, amenorrhea, gynecomastia, IGT Monoclonal gammopathy myeloma in >50%, MGUS or others Skin Changes hyperpigmentation, thickening, hirsutism Rare! Affected patients may not have all findings Pathogenesis remains unknown Skeletal findings usually on axial and proximal appedicular skeleton and are usually sclerotic or infrequently mixed lytic-sclerotic 20

21 Sclerotic Plasmacytoma POEMS Pt. 5: OJ History: OJ is a 42 y.o. male who presented with back pain, endocrinopathy, parasthesias & leg weakness. IgG was slightly, Bx diagnosed a plasmacytoma. MRI was performed to evaluate CC. T1W MRI: lesion with a dark margin T2W fat suppressed MRI: lesion with dark signal margin & high intensity central aspect. PACS, BIDMC PACS, BIDMC CT: well defined lytic lesion with sclerotic rim. No cortical destruction or bony expansion. PET fusion: Homogenous focus of intense FDG uptake 21

22 Mixed Lytic-sclerotic POEMS Patient 6: BP BP is a 27 y.o. male who presents with gynecomasti a, impotence & papilledema Plain film of the pelvis: multiple foci of sclerosis Courtesy of Dr. Ferris Hall Round lytic lesion within sclerotic focus 22

23 Mixed Lyic-sclerotic POEMS Patient PB s Axial CT of the pelvis at the level of the lytic lesion seen on plain film Courtesy of Dr. Ferris Hall 23

24 Summary Plasma cell neoplasms are often first diagnosed radiologically Plain film & potentially MRI or PET findings influence tumor prognosis and therapy decisions Skeletal surveys may be supplemented by additional imaging modalities in the future for lesion detection and follow-up 24

25 References Aggarwal S. Goulatia RK. Sood A. Prasad K. Ahuja GK. Mitchell MJ. Kumar A. POEMS syndrome: a rare variety of plasma cell dyscrasia. AJR. American Journal of Roentgenology. 155(2):339-41, 1990 Aug. Baur A. Stabler A. Nagel D. Lamerz R. Bartl R. Hiller E. Wendtner C. Bachner F. Reiser M. Magnetic resonance imaging as a supplement for the clinical staging system of Durie and Salmon?. Cancer. 95(6): , 2002 Sep 15. Croucher PI. Apperley JF. Bone disease in multiple myeloma. British Journal of Haematology. 103(4):902-10, 1998 Dec. Edelman RR. Kaufman H. Kolodny GM. Case report 350: Multiple myeloma--blastic type. Skeletal Radiology. 15(2):160-3, Glass DA 2nd. Patel MS. Karsenty G. A new insight into the formation of osteolytic lesions in multiple myeloma. New England Journal of Medicine. 349(26): , 2003 Dec 25. Jadvar H. Conti PS. Diagnostic utility of FDG PET in multiple myeloma. Skeletal Radiology. 31(12):690-4, 2002 Dec. Hall FM. Gore SM. Osteosclerotic myeloma variants. Skeletal Radiology. 17(2):101-5, Kyle, RA. Clinical and laboratory manifestations of multiple myeloma. UpToDate. 2004, Jan 24. Lecouvet FE. Malghem J. Michaux L. Maldague B. Ferrant A. Michaux JL. Vande Berg BC. Skeletal survey in advanced multiple myeloma: radiographic versus MR imaging survey. British Journal of Haematology. 106(1):35-9, 1999 Jul. Longo, DL. Plasma Cell Disorders. Harrisons Online. accessed 2004, July 20. Pathweb. Diseases of Bone, Multiple Myeloma. Reeder, Maurice M. Reeder and Felson's Gamuts in Radiology: Comprehensive Lists of Roentgen 25 differential diagnosis, 3 rd ed. Springer-Verlag, New York, 1993.

26 Acknowledgements Ferris Hall, MD Mary Hochman, MD Stephanie DiPerna, MD Pamela Lepkowski Larry Barbaras our Webmaster 26