A Diagnostic Chest XRay: Multiple Myeloma

Daniela Marinho Tridente, VI FCMSCSP October 2013 A Diagnostic Chest XRay: Multiple Myeloma Daniela Marinho Tridente, VI FCMSCSP

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

The patient in question 63 years old male No priors Not in use of any medication No family history 3

His chief complaint Right infrascapular pain and pleuritic pain 4

Daniela Marinho Tridente, VI FCMSCSP A chest x ray was requested, as to evaluate for possible fractures, bone lesions or pleural reaction

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

First relevant findings Multiple rightsided rib fractures Destructive rib lesion with soft tissue component at the right eighth rib laterally Multiple lytic lucencies in the right scapula PACS, BIDMC PA chest x ray 7

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 Comparison was made to prior chest xrays dated July 2007 and none of the findings were considered preexisting.

Daniela Marinho Tridente, VI FCMSCSP 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 That being so, our patient had a skeletal survey done as well as a Chest CT

Skeletal Survey: skull Let s pause for a minute and look for any abnormalities PACS, BIDMC Skull x ray, lateral view 12

Skeletal Survey: skull (findings) Multiple rounded lucencies in the skull, non-specific but highly compatible with myeloma PACS, BIDMC Skull x ray, lateral view 13

Skeletal Survey: left femur Let s pause for a minute and look for any abnormalities PACS, BIDMC Left femur PA x ray 14

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 Left femur PA x ray 15

Daniela Marinho Tridente, VI FCMSCSP Additionally, osteopenia was noted on the cervical and thoracic spines

Daniela Marinho Tridente, VI FCMSCSP Let s move on and have a look at the Chest CT

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 Sagital view, chest CT 18

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

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 Let s consider the differential diagnosis of lytic lesions

DDX for Lytic Lesions Here are some of the most common well-defined bone tumors and tumorlike 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/en/p4bc6176e56228/bone-tumor-well-defined-osteolytic-tumors-and-tumor-like-lesions.html 22

Daniela Marinho Tridente, VI FCMSCSP One of the ways to consider the differential diagnosis of lytic lesions is through the use of the mnemonic FEGNOMASHIC

FEGNOMASHIC http://www.radiologyassistant.nl/en/p4bc6176e56228/bone-tumor-well-defined-osteolytic-tumors-and-tumor-like-lesions.html 24

Daniela Marinho Tridente, VI FCMSCSP Considering that our patient had no priors and had negative screening tests for the most common primary cancer sites

Daniela Marinho Tridente, VI FCMSCSP that leaves us with Multiple Myeloma!

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

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 28

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 29

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

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

The Durie Salmon Staging System (1975) From myeloma.org 32

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

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 34

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 Let s consider some of the most commonly used imaging techniques

Daniela Marinho Tridente, 6th year FCMSCSP Plain Radiography Full skeletal survey (frontal and lateral view of skull, cervical, thoracic and lumbar spine, coneddown 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 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

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 Features and Radiological Techniques; 2011 39

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 40

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

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 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-laboratorymanifestations-and-diagnosis-of-multiplemyeloma?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 tumorlike lesions, The Radiology Assistant, http://www.radiologyassistant.nl/en/p4bc6176e56228/bone-tumor-well-definedosteolytic-tumors-and-tumor-like-lesions.html. Acessed October 16th, 2013 43

Acknowledgments Claire Odom Ronald L. Eisenberg, MD Jawad S. Hussain, MD 44