Multiple myeloma associated with diffuse osteosclerotic bone lesions: a clinical entity distinct from osteosclerotic myeloma (POEMS syndrome)

Non-POEMS osteosclerotic multiple myeloma: Clinical characteristics and differential diagnosis

Osteosclerosis in multiple myeloma (MM) is typically associated with rare POEMS syndrome, characterized by polyneuropathy (P), organomegaly (O), endocrinopathy (E), M-protein (M), and skin changes (S). However, osteosclerosis in multiple myeloma (MM) without POEMS syndrome, defined as non-POEMS Osteosclerotic MM, is exceedingly rare. We report a 70-year-old man with rib pain, remarkably high bone mineral density and diffuse osteosclerosis. The diagnosis of non-POEMS osteosclerotic MM was confirmed by biopsy and aspiration of bone marrow through surgery. A literature review spanning from 1990 identified 12 cases of similar non-POEMS osteosclerotic MM, including 5 males and 7 females with a mean age of 59.7 ± 10.6 years. The non-POEMS osteosclerotic MM can be divided into two subtypes, the osteosclerotic lesion subtype and the diffuse osteosclerosis subtype. Absence of polyneuropathy and organomegaly are the main factors that differentiate non-POEMS osteosclerotic MM from POEMS. A hyperactive osteoblastic process might be the etiology of diffuse osteosclerosis. Further research is needed to understand its etiology and pathophysiology.

Recent Advances in the Treatment and Supportive Care of POEMS Syndrome

POEMS is a rare clonal plasma cell disorder characterized by multi-systemic features that include demyelinating peripheral neuropathy, organomegaly, endocrinopathy, presence of monoclonal proteins (M-protein), and skin changes. Even though the pathophysiology is poorly understood, recent studies suggest that both clonal and polyclonal plasmacytosis leading to the production of pro-inflammatory cytokines and angiogenic mediators play the central role. These mediators including vascular endothelial growth factor (VEGF) are the driving forces of the syndrome. The diagnosis of POEMS is not always straight forward and often the diagnosis is delayed. It is based on fulfilling mandatory criteria of polyradiculoneuropathy and monoclonal protein and the presence of one major criterion (Castleman disease, sclerotic bone lesions, or elevated VEGF), and at least one minor criterion. Due to the presence of neuropathy, it can be confused with chronic inflammatory demyelinating polyradiculopathy (CIDP), and if thrombocytosis and splenomegaly are present, it can be confused with myeloproliferative neoplasms. Due to the rarity of the syndrome, clear guidelines for treatment are still lacking. Immediate treatment targeting the underlying plasma cell proliferation results in a dramatic response in most patients. The key is early diagnosis and immediate anti-plasma cell directed therapy for the best clinical outcomes. For patients with disseminated disease as defined by bone marrow involvement or more than three osteosclerotic bone lesions, high-dose chemotherapy with autologous hematopoietic stem cell transplant (ASCT) yields durable responses and is the preferred treatment in eligible patients. For patients with localized bony disease, radiotherapy has proven to be very effective. Lenalidomide and dexamethasone is a proven therapy in patients ineligible for ASCT. In this review article, we tackle the diagnostic approach and discuss the latest treatment modalities of this rare debilitating disease.

Multiple myeloma: a review of atypical imaging features and other distinct plasma cell disorders that demonstrate similar imaging features

Multiple osteolytic lesions are a well-recognized and typical imaging feature of multiple myeloma as well as several other plasma cell disorders. Given the high volume of imaging studies obtained of multiple myeloma patients, radiologists will likely encounter a subset of multiple myeloma patients with less common or "atypical" findings during their practice. These atypical findings include osteosclerotic lesions, extramedullary lesions, and amyloid deposition. Similar imaging findings that are considered atypical for multiple myeloma can also be detected in other plasma cell disorders that are distinct from multiple myeloma. For instance, POEMS syndrome is a distinct plasma cell disorder from multiple myeloma, but also can present with osteosclerotic lesions. This article reviews the atypical findings associated with multiple myeloma and also reviews other plasma cell disorders that can have a similar spectrum of imaging findings. Special attention is paid to the musculoskeletal imaging findings.

[Skeletal changes in plasma cell dyscrasias]

BACKGROUND

Plasma cell dyscrasias are a spectrum of diseases characterized by clonal plasma cell proliferation. Important entities within this group are monoclonal gammopathy of unknown significance, smoldering multiple myeloma, and symptomatic multiple myeloma.

PURPOSE

The goal of this review is to illustrate plasma cell dyscrasia imaging findings of bone and bone marrow as seen on whole-body computed tomography (CT) and magnetic resonance imaging (MRI) and to discuss the relevance of imaging for management of patients with plasma cell dyscrasias.

MATERIALS AND METHODS

Selective literature search with analysis of dedicated original research articles and reviews and discussion of clinical guidelines.

RESULTS

Diagnostic classification of plasma cell dyscrasias is based on the SLiM-CRAB criteria. CT primarily represents imaging of mineralized bone to show osseous end organ damage by detecting osteodestruction. MRI is primarily used for bone marrow imaging to detect diffuse or focal bone marrow infiltration, even in the absence of bone destruction. Different patterns of bone marrow infiltration can be distinguished. Treatment response is associated with characteristic imaging signs of lesion regression.

CONCLUSION

Imaging plays a prominent role in treatment stratification of patients with plasma cell dyscrasia at first diagnosis and during follow-up.

Young patient with arterial thrombosis and skin changes as the onset manifestations: POEMS syndrome

POEMS syndrome is a rare multi-systemic disease characterized by polyneuropathy, organomegaly, endocrinopathy, monoclonal protein and skin changes. Arterial thrombosis is a distinctively unusual feature in patients with POEMS syndrome. We report a 33-year-old man with intermittent amaurosis of left eye and skin changes as the onset manifestations, who was finally confirmed as having POEMS syndrome. Most notably, this was a young man without high risk factors of arterial thrombosis and no monoclonal protein was detected until the repeated measurement later. This case evokes the need to consider the diagnosis of POEMS syndrome for young patients with symptoms of arterial thrombosis but no high risk factors of thrombosis.

High bone mass in adults

A finding of high bone mineral density (BMD) from routine dual-energy X-ray absorptiometry (DXA) screening is not uncommon. No consensus exists about the definition of high BMD, and T-score and/or Z-score cutoffs of ≥+2.5 or ≥+4 have been suggested. The many disorders that can result in high BMD are usually classified based on whether the BMD changes are focal vs. generalized or acquired vs. constitutional. In over half the cases, careful interpretation of the DXA report and images identifies the cause as an artefact (e.g., degenerative spinal disease, vascular calcifications, or syndesmophytes) or focal lesion (e.g., sclerotic bone metastasis or Paget's disease). Generalized acquired high BMD may be secondary to a diverse range of disorders such as fluorosis, diffuse bone sclerosis related to renal osteodystrophy, hematological diseases, and hepatitis C. Identification of the cause may require additional investigations such as imaging studies, serum tryptase assay, or serological tests for the hepatitis C virus. Finally, high BMD is a feature of many genetic diseases, most notably osteopetrosis and the disorders caused by mutations in the sclerostin gene SOST (sclerosing bone dysplasia and van Buchem disease) or in the LRP5 gene encoding the low-density lipoprotein receptor-related protein 5 (which is the Wnt co-receptor).

Multiple myeloma presenting in association with gastric phytobezoar

We present a rare case of a patient with delayed gastric emptying, gastric phytobezoar formation, and osteosclerotic bone lesions as an atypical association with multiple myeloma. Associated gastric features in myeloma, which include diffuse infiltration, gastric plasmacytomas, or delayed gastric emptying, are rare and have a poor prognosis.

Idiopathic Acquired Osteosclerosis in a Middle-Aged Woman With Systemic Lupus Erythematosus

Widely distributed osteosclerosis is an unusual radiographic finding with multiple causes. A 42-year-old premenopausal Spanish woman gradually acquired dense bone diffusely affecting her axial skeleton and focally affecting her proximal long bones. Systemic lupus erythematosus (SLE) diagnosed in adolescence had been well controlled. She had not fractured or received antiresorptive therapy, and she was hepatitis C virus antibody negative. Family members had low bone mass. Lumbar spine bone mineral density (BMD) measured by dual-photon absorptiometry (DPA) at age 17 years, while receiving glucocorticoids, was 79% the average value of age-matched controls. From ages 30 to 37 years, dual-energy X-ray absorptiometry (DXA) BMD Z-scores steadily increased in her lumbar spine from +3.8 to +7.9, and in her femoral neck from -1.4 to -0.7. Serum calcium and phosphorus levels were consistently normal, 25-hydroxyvitamin D (25OHD) <20 ng/mL, and parathyroid hormone (PTH) sometimes slightly increased. Her reduced estimated glomerular filtration rate (eGFR) was 38 to 55 mL/min. Hypocalciuria likely reflected positive mineral balance. During increasing BMD, turnover markers (serum bone-specific alkaline phosphatase [ALP], procollagen type 1 N propeptide [P1NP], osteocalcin [OCN], and carboxy-terminal cross-linking telopeptide of type 1 collagen [CTx], and urinary amino-terminal cross-linking telopeptide of type 1 collagen [NTx and CTx]) were 1.6- to 2.8-fold above the reference limits. Those of bone formation seemed increased more than those of resorption. FGF-23 was slightly elevated, perhaps from kidney disease. Serum osteoprotegerin (OPG) and TGFβ1 levels were normal, but sclerostin (SOST) and receptor activator of nuclear factor kappa-B ligand (RANKL) were elevated. Serum multiplex biomarker profiling confirmed a high level of SOST and RANKL, whereas Dickkopf-1 (DKK-1) seemed low. Matrix metalloproteinases-3 (MMP-3) and -7 (MMP-7) were elevated. Iliac crest biopsy revealed tetracycline labels, no distinction between thick trabeculae and cortical bone, absence of peritrabecular fibrosis, few osteoclasts, and no mastocytosis. Then, for the past 3 years, BMD Z-scores steadily decreased. Skeletal fluorosis, mastocytosis, myelofibrosis, hepatitis C-associated osteosclerosis, multiple myeloma, and aberrant phosphate homeostasis did not explain her osteosclerosis. Mutation analysis of the LRP5, LRP4, SOST, and osteopetrosis genes was negative. Microarray showed no notable copy number variation. Perhaps her osteosclerosis reflected an interval of autoimmune-mediated resistance to SOST and/or RANKL. © 2016 American Society for Bone and Mineral Research.

Vertebral lesion distribution in multiple myeloma--assessed by reduced-dose whole-body MDCT

OBJECTIVE

To observe the distribution and potential distribution patterns of osteolytic and sclerotic vertebral involvement in a representative collective of multiple myeloma patients.

MATERIALS AND METHODS

A total of 66 consecutive patients with a diagnosis of multiple myeloma at initial diagnosis or during follow-up were examined by multidetector reduced-dose computed tomography to evaluate the distribution of bone lesions along the spine with focus on size, location, and lesion character. Confirmation of diagnosis was performed by comparison to follow-up computed tomography or magnetic resonance tomography. If >50% of all detected malignant lesions occurred in one spinal segment, the distribution pattern was called cervical, thoracic, lumbar, or sacral, otherwise a "mixed" pattern was classified.

RESULTS

Of a total number of 933 osseous spine lesions, 632 (67.7%) were classified as malignant (98.9% of them osteolytic) and 293 (31.5%) as benign. The distribution pattern analysis yielded two patients (3.8%) with a cervical, 26 (50%) with a thoracic, 4 (7.7%) with a lumbar, one (1.9%) with a sacral pattern, and 19 cases (36.6%) showed a mixed distribution pattern. Segment-wise, the mean lesion size was 6.52 ± 2.76 mm (cervical), 8.97 ± 5.43 mm (thoracic), 11.97 ± 7.11 mm (lumbar), and 17.5 ± 16.465 (sacral), whilst, related to the vertebra size, the lesion/vertebra size ratio is decreasing through the whole spine beginning from the top.

CONCLUSIONS

Multiple myeloma bone lesions occur preferably and are larger in the thoracic and lumbar spine. Moreover, a specific distribution pattern is present in about 60%.

International Myeloma Working Group updated criteria for the diagnosis of multiple myeloma

This International Myeloma Working Group consensus updates the disease definition of multiple myeloma to include validated biomarkers in addition to existing requirements of attributable CRAB features (hypercalcaemia, renal failure, anaemia, and bone lesions). These changes are based on the identification of biomarkers associated with near inevitable development of CRAB features in patients who would otherwise be regarded as having smouldering multiple myeloma. A delay in application of the label of multiple myeloma and postponement of therapy could be detrimental to these patients. In addition to this change, we clarify and update the underlying laboratory and radiographic variables that fulfil the criteria for the presence of myeloma-defining CRAB features, and the histological and monoclonal protein requirements for the disease diagnosis. Finally, we provide specific metrics that new biomarkers should meet for inclusion in the disease definition. The International Myeloma Working Group recommends the implementation of these criteria in routine practice and in future clinical trials, and recommends that future studies analyse any differences in outcome that might occur as a result of the new disease definition.

[Multiple myeloma with diffuse osteosclerosis: distinct from POEMS syndrome]

Diffuse osteosclerotic lesions are a very uncommon radiologic presentation in multiple myeloma. These lesions affect the axial skeleton and proximal limbs; they may be accompanied by osteolytic lesions in the course of the disease. In fact, in cases of diffuse osteosclerosis, the diagnosis of multiple myeloma is reached only after ruling out other, more common diseases. We present an exceptional case of multiple myeloma with diffuse osteosclerosis and highlight the differences between this entity and POEMS syndrome.

Multiple Myeloma With Mixed Lytic and Blastic Bone Lesions With Lymphadenopathy: Rare Manifestation of a Common Disease-Case Presentation and Literature Review

Multiple myeloma - a neoplastic proliferation of plasma cell is the second most common blood cancer. Multiple myeloma is characterized by neoplastic proliferation of the plasma cells. These cells infiltrate variety of organs. Infiltration by immature neoplastic cells and overproduction of monoclonal immunoglobulin chain is responsible for clinical manifestations of multiple myeloma. The most common clinical presentation of multiple myeloma is an asymptomatic person having anemia and elevated globulin in laboratory testing. Multiple myeloma is diagnosed by triad of > 10% marrow infiltration by plasma cells, serum/urine monoclonal protein and end organ damages. One of the common end organ damage is lytic bone lesions resulting from imbalance between osteolytic and osteoblastic activities. Lymphadenopathy and osteoblastic lesions are rare presentations of multiple myeloma - lymphadenopathy in 1% of cases with IgA subtype and osteoblastic lesions in IgE myeloma and lambda light chains. Osteoblastic multiple myeloma is a distinct entity from POEMS syndrome. IgG myeloma with kappa chain predominance is not described yet with osteoblastic lesions and lymphadenopathy. We present a rare case of IgG myeloma with kappa chain predominance that had both lymphadenopathy and osteoblastic lesions.

Development of POEMS syndrome after an initial manifestation of solitary plasmacytoma

A 44-year-old male was admitted for numbness in the left arm. CT showed a tumor impacting on the spinal cord with an adjacent thoracic vertebral osteosclerotic lesion. The histopathology of the tumor showed diffuse proliferation of atypical plasma cells with expressed vascular endothelial growth factor (VEGF), which is a known etiological factor in POEMS syndrome. Though serum VEGF (sVEGF) level was elevated, a diagnosis of solitary plasmacytoma with an osteosclerotic lesion was made as the patient presented no polyneuropathy, organomegaly, endocrinopathy, or skin changes. The patient experienced muscle weakness of the lower limbs and skin pigmentation/hemangioma one year after irradiation of the osteosclerotic lesion. Laboratory tests revealed hypothyroidism, hyperglycemia, serum monoclonal gammopathy, further elevation of sVEGF, and increased atypical bone marrow plasma cells. CT imaging showed splenomegaly, and a nerve conduction test revealed demyelinating motor peripheral neuropathy. The patient was therefore diagnosed with POEMS syndrome. Plasmacytoma is very rare as an initial manifestation of POEMS syndrome. Patients presenting with plasmacytoma with an osteosclerotic lesion should be carefully observed and evaluated for the expression of sVEGF and development of POEMS syndrome, as most bone plasmacytomas in POEMS syndrome patients are reported to be osteosclerotic. This is to our knowledge the first case of osteosclerotic plasmacytoma that progressed to POEMS syndrome, with an increase of sVEGF.

Comparison among immunologically different subtypes of 595 untreated multiple myeloma patients in northern China

BACKGROUND

Generally, characteristics of heterogeneous multiple myeloma (MM) have been described as a whole. Actually, isolated immunologic subtypes of MM may be associated with prognostic significance.

PATIENTS AND METHODS

The aim of this retrospective single-center study was to determine the characteristics of immunologically different subtypes among 595 evaluable cases with previously untreated MM in northern China.

RESULTS

The major distribution of MM subtypes were immunoglobulin (Ig)G, 47.9%; IgA, 23.3%; and light-chain, 21.0%. Nonsecretory, IgD, and biclonal subtypes were rarely seen, comprising only 7.7%. The male-to-female ratio was 1:7, and the median age was 59 years. In the IgG subtype, more patients presented with elevated M protein, fulfilling the major diagnostic criteria determined by Durie, and infection occurred more frequently; however, the prognosis was favorable. In the IgA subtype, in which survival was significantly poorer, the extent of anemia was more severe, and nonhyperdiploid abnormality may be its adverse indicator. In the light-chain subtype, the mean level of serum IL-6 was the highest, and more patients presented with advanced renal dysfunction, bone destruction, and thrombocytopenia. However, more light-chain patients were staged at International Staging System I, partially resulting in the favorable median survival of 51 months (almost equivalent to 50 months with the IgG subtype). Another rare subtype with unfavorable outcome was IgD myeloma, in which the median age was 50 years, and the serum calcium level was significantly decreased. Intriguingly, we also noted that more patients presented hypocalcemia than hypercalcemia (37.7% vs. 15.7%) in the current series. Multivariate analysis revealed that independent adverse indicators included age > 50 years, Durie-Salmon stage III, and increased values of C-reactive protein and beta2-microglobulin.

CONCLUSION

The median duration of survival in MM reached 36.0 months. Distinctions among immunologically different subtypes can predict prognostic significance, namely, favorable in IgG and light-chain subtypes but significantly poorer in IgA and IgD subtypes.

Role of osteoblast suppression in multiple myeloma

Multiple myeloma is the most common form of plasma cell dyscrasia and virtually all cases of myeloma exhibit osteolytic lesions, which result in bone pain, pathological fractures, spinal cord compression, and hypercalcaemia. Malignant plasma cells disrupt the delicate balance between bone formation and bone resorption, which ultimately leads to the debilitating osteolytic lesions. This review focuses principally on mechanisms of osteoblast inhibition by malignant plasma cells with emphasis placed on our experimental findings, which support a model for abnormal Wnt signaling in osteoblast suppression. We describe how excessive amounts of soluble Wnt inhibitors secreted by malignant plasma cells in multiple myeloma could promote osteolytic lesions, tumor growth, suppress hematopoiesis, prevent proper engraftment, and expansion of transplanted stem cells. Finally, we detail current therapies shown to disrupt the interaction between the myeloma cell and the microenvironment, leading to activation of osteoblasts.

POEMS Syndrome – A Case for More Aggressive Treatment

Introduction: Patients with POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal or M-protein and skin changes) syndrome exhibit a wide range of clinical manifestations and are often seen by a variety of specialists prior to diagnosis. Clinical Picture: We describe a case of POEMS syndrome that first presented with significant neuropathy but progressed to develop further manifestations of the condition, including marked gastrointestinal symptoms. Treatment: The patient was commenced on localised radiotherapy and chemotherapy in addition to immunomodulatory therapy for the neuropathy. 437specialties. This case is also unique for its marked gastrointestinal manifestation. To our knowledge, this is the second reported case in the literature with this feature. Key words: Demyelinating polyneuropathy, Gastrointestinal

Angiogenetic Factors and Biochemical Markers of Bone Metabolism in POEMS Syndrome Treated with High-Dose Therapy and Autologous Stem Cell Support

The cause of the polyneuropathy, organomegaly, endocrinopathy, monoclonal plasma cell disorder and skin changes (POEMS) syndrome is currently unknown, but increased levels of vascular endothelial growth factor (VEGF) appear to play a pathogenetic role. Osteosclerotic bone lesions are a characteristic finding in POEMS, but there are no data about the specific role of various molecules that control bone remodeling in patients with POEMS. Serum levels of angiogenic cytokines (VEGF, angiogenin, angiopoietin-2, and basic fibroblast growth factor) along with a series of bone remodeling indices (C-telopeptide of type I collagen, bone-alkaline phosphatase [bALP], osteocalcin [OC], soluble receptor activator of nuclear factor-kappaB ligand [RANKL], osteoprotegerin [OPG], and macrophage inflammatory protein-1alpha) were measured in 2 patients with POEMS before and after high-dose therapy (HDT) with autologous stem cell transplantation and in age- and sex-matched controls. Increased VEGF levels before HDT were reduced significantly after treatment, although levels of the other angiogenetic factors did not differ from that of controls and were less influenced by HDT. Serum RANKL levels were increased before HDT, whereas OPG levels were within the levels of healthy controls, resulting in an abnormal soluble RANKL to OPG ratio. Levels of bone resorption markers (C-telopeptide of type I collagen) were very low or undetectable before HDT, although bALP and OC levels were similar to that of controls. After HDT, soluble RANKL levels decreased, OPG remained rather stable, bone resorption markers increased to levels of normal individuals, bALP levels were rather unchanged, and OC levels increased. Decreasing VEGF levels parallel clinical improvement, and the restoration of normal bone metabolism follows HDT.

Multiple myeloma: clinical features and indications for therapy

Multiple myeloma is a malignant plasma-cell proliferative disease with an expected 15,270 new cases and 11,070 deaths in the USA in 2004 alone. This accounts for 1% of all malignancies and slightly more than 10% of all hematologic malignancies in Caucasians and 20% in African Americans. The diagnosis is based on the presence of bone pain, anemia, and plasma-cell infiltrate in the bone marrow or within bone lesions. It is essential that the spectrum of plasma-cell proliferative disorders be recognized: monoclonal gammopathy of undetermined significance (MGUS), smoldering (asymptomatic) multiple myeloma (SMM), and active (symptomatic) MM. These distinctions affect important management decisions. Other related disorders include primary systemic amyloidosis, POEMS syndrome, and acquired Fanconi syndrome.

Imaging techniques used in the diagnosis, staging, and follow-up of patients with myeloma

Radiologists play a central role in the diagnosis, initial staging, follow-up, and restaging of patients with myeloma. This review article attempts to familiarize the reader with all the various types of myeloma, their imaging appearances and useful imaging strategies. The staging system for myeloma patients has been updated and now includes findings from advanced imaging modalities. Radiologists have a vast array of imaging modalities at their disposal to aid them in diagnosis, staging, and follow-up. Currently, conventional radiographic skeletal surveys, magnetic resonance imaging, and F-18 FDG PET/CT examinations are the most useful instruments.

Audit of bone marrow aspirates and trephine biopsies in multiple myeloma - a single centre study

We compared 79 simultaneous marrow aspirates and trephine biopsies from multiple myeloma patients for sensitivity, concordance, quality and clinical relevance. A total of 60 examinations had been performed for initial diagnosis, i.e. in cases of suspected myeloma and 19 at follow-up. Of which, 45 (57%) of trephine biopsies were less than 1.6 cm before processing and 33 (42%) were crushed and/or fragmented. Overall, only 19/79 (24%) of trephine biopsy specimens were of at least 1.6 cm length prior to processing and not disrupted. On the other hand, 75% of aspirates were particulate and satisfactory. Mean time between receipt of a trephine biopsy specimen and issuance of a histopathological report was 9 days. Although 40% of trephine biopsies yielded information that could not be reliably obtained from a bone marrow aspirate such information was in all cases clinically irrelevant or obtainable by non-invasive means. In all cases where myeloma was detected in a trephine biopsy it was also detected in a simultaneous bone marrow aspirate, if particulate. However, there were four (5%) cases in which myeloma was detected in such aspirates but not in simultaneously taken trephine biopsies. In cases (n=19) where repeat aspirates/trephine biopsies were taken for surveillance, concordance was found between reported changes in plasma cell ratio. Our data failed to demonstrate any added benefit from routinely performing trephine biopsies after a particulate specimen had been aspirated for the diagnosis or surveillance of myeloma. Furthermore, they suggest that particulate aspirates may be at least as sensitive as trephine biopsies for detecting myeloma.

Endothelins in bone cancer metastases

Most evidence indicates that osteoblastic bone metastases are due to tumor-produced factors that stimulate the osteoblast. This review supports a causal role for ET-1. Based on our results, we propose a model to explain the tumor cell and bone interactions that are responsible for the osteoblastic response (Figure 2). Tumor cells housed in bone produce factors, such as ET-1, stimulate osteoblast activity. This results in the abundant and disorganized new bone formation that is characteristic of osteoblastic metastases. The effects of ET-1 to stimulate bone formation are mediated by ETA receptors on the osteoblast. ETA receptor inhibition successfully blocked osteoblastic bone metastases in a mouse model. These receptor antagonists are currently in clinical trials for advanced prostate cancer and bone metastases (Stephenson, 2001; Carducci et al., 2002; 2003). Therefore, the molecular mechanisms responsible for osteoblastic metastases are complex and involve bi-directional interactions between tumor cells and bone. Elucidation of the interactions at a molecular level can identify therapeutic targets for osteoblastic metastases. Although ET-1 and ETA receptors are potential targets for this devastating complication of cancer (Remuzzi et al., 2003), they are certainly not the only ones. The rapid pace of metastasis research, will not only expand our therapeutic armamentarium against bone metastases, but will also provide insight into achieving the ultimate goal: the prevention of cancer metastases to bone.

Multiple myeloma presenting with widespread osteosclerotic lesions

Sclerotic lesions are rare in malignant monoclonal gammopathies, although they are occasionally associated with POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy and skin changes). In most cases, osseous lesions in POEMS syndrome present as an isolated sclerotic deposit or a combination of both lytic and sclerotic lesions. Diffuse osteosclerosis is extremely rare and may lead to the diagnosis of multiple myeloma, classically known to present as lytic lesions in the skeleton, with or without diffuse osteoporosis. We report a 74-year-old woman with widespread and substantial osteosclerotic lesions, associated with IgA-lambda myeloma, and with no other criteria for POEMS syndrome, and who was rapidly diagnosed with compression of the spinal cord. Detailed knowledge of imaging features in myeloma emphasises the need to consider plasma cell neoplasm in the differential diagnosis of any pattern of bone sclerosis. Although exceptional, multiple myeloma must be borne in mind in the presence of diffuse bone sclerosis.

Review of 1027 patients with newly diagnosed multiple myeloma

OBJECTIVE

To determine the clinical and laboratory features of newly diagnosed multiple myeloma.

PATIENTS AND METHODS

Records of all patients in whom multiple myeloma was initially diagnosed at the Mayo Clinic in Rochester, Minn, from January 1, 1985, to December 31, 1998, were reviewed.

RESULTS

Of the 1027 study patients, 2% were younger than 40 years, and 38% were 70 years or older. The median age was 66 years. Anemia was present initially in 73% of patients, hypercalcemia (calcium level > or = 11 mg/dL) in 13%, and a serum creatinine level of 2 mg/dL or more in 19%. The beta2-microglobulin level was increased in 75%. Serum protein electrophoresis revealed a localized band in 82% of patients, and immunoelectrophoresis or immunofixation showed a monoclonal protein in 93%. A monoclonal light chain was found in the urine in 78%. Nonsecretory myeloma was recognized in 3% of patients, whereas light-chain myeloma was present in 20%. Conventional radiographs showed an abnormality in 79%. The plasma cell labeling index was 1% or more in 34% of patients. Multivariate analysis revealed that age, plasma cell labeling index, low platelet count, serum albumin value, and the log of the creatinine value were the most important prognostic factors.

CONCLUSION

The median duration of survival was 33 months and did not improve from 1985 through 1998.

Rheumatologic features of hematologic disorders

This review focuses on the various rheumatologic manifestations of hematologic diseases and is based on the English literature published over the past year. Interrelationships between leukemia, lymphoma, POEMS syndrome, multiple myeloma, hemophilia, and rheumatic manifestations are discussed. Other less common associated conditions dealt with include the RS3PE syndrome, large granular lymphocyte syndrome, and interferon-related arthritis. Finally, therapeutic measures, such as bone marrow transplantation and the use of granulocyte colony-stimulating factor, are reviewed.