Guidelines for the use of imaging in the management of myeloma

Baseline bone marrow ADC value of diffusion-weighted MRI: a potential independent predictor for progression and death in patients with newly diagnosed multiple myeloma

OBJECTIVES

To illuminate the prognostic value of ADC (apparent diffusion coefficient), an important quantitative parameter of diffusion-weighted MRI, for multiple myeloma (MM).

METHODS

A prospective single-center study which enrolled 114 consecutive newly diagnosed MM patients with baseline whole-body diffusion-weighted MRI (WB DW-MRI) results was conducted. Baseline clinical and MRI parameters were analyzed with univariate and multivariate approaches to identify independent risk factors for progression-free survival (PFS) and overall survival (OS).

RESULTS

Five different DW-MRI patterns were seen, and the mean ADC value of the representative background bone marrow was 0.4662 ± 0.1939 × 10^-3 mm²/s. After a mean follow-up of 50.2 months (range, 15.7-75.8 months), twenty-four patients died and seven were lost to follow-up. The mean ADC value of the representative background bone marrow was showed to be an independent risk factor for both PFS (HR 4.664; 95% confidence interval (CI) 1.138-19.121; p = 0.032) and OS (HR 14.130; 95% CI 1.544-129.299; p = 0.019). Normal/salt-and-pepper pattern on DW-MRI was associated with PFS using univariate analysis (p = 0.035) but lost the significance with multivariate Cox regression.

CONCLUSIONS

Mean ADC value of the representative background bone marrow predicts both PFS and OS which suggests the role of baseline DW-MRI for risk stratification in newly diagnosed MM patients.

KEY POINTS

• Whole-body diffusion-weighted MRI (WB DW-MRI) might be helpful to improve the current risk stratification systems for newly diagnosed multiple myeloma (MM). • Morphological parameters as MRI pattern and focal lesion-associated parameters have been reported to be related to survival. However, important functional parameters such as apparent diffusion coefficient (ADC) values were not incorporated into the current risk stratification model. • This study is one of the first endeavors to delineate the correlation of baseline ADC values and survival in MM patients. It is revealed that the mean ADC value of the representative background bone marrow (L3-S1 and iliac bone) was an independent risk factor for both PFS and OS.

Multiple myeloma of young adult presented with paraplegia, rare case report in Saudi Arabia

Multiple myeloma is the second most common hematologic malignancy. It is characterized by the neoplastic proliferation of plasma cells in the bone marrow, leading to excessive production of monoclonal immunoglobulin. The mean age at diagnosis is 65 years. There are only a few cases of Multiple Myeloma arising in young population reported in the literature. We present a case of 33-years-old male presented with complete bilateral lower limbs paralysis and loss of sensation which were gradual in onset and accompanied by upper and lower back pain for 1 month. MRI of the whole spine show multiple infiltrative bone marrow high signal in T2 and STIR sequences involve C4 and the upper dorsal vertebral bodies and the spinous process of D4 with left para-spinal and large posterior epidural mass compress the spinal cord. CT guidance obtains three samples from the mass and placed in formalin in separate containers. Histopathology examination revealed neoplastic growth composed of Sheet of diffuse atypical plasma cells infiltrating fibro collagenous and adipose tissue. Although Multiple myeloma is a disease of elderly; it still could present in young age group. Histopathology examination is the gold standard for diagnosis.

Anaplastic plasmacytoma: a rare tumor presenting as a pathological fracture in a younger adult

Solitary plasmacytoma is the rarest type of plasma cell neoplasm, and the anaplastic form is even more uncommon. Plasmacytoma most commonly originates in bone and predominantly affects older patients. We describe the case of a 35-year-old woman with solitary osseous anaplastic plasmacytoma that presented initially with a pathological fracture following minor trauma. The patient was immunocompetent and had no predisposing conditions for a plasma cell tumor. Left lower extremity radiographs revealed an oblique fracture of the distal femur, and CT imaging indicated a primary osseous lesion at the fracture site. MRI confirmed the diagnosis of pathological fracture. Initial surgical pathology of the lesion was concerning because it could have been an osteosarcoma. Further immunostaining demonstrated CD138 positivity and kappa light chain restriction, confirming the diagnosis of plasmacytoma. In addition, the presence of marked anaplastic cellular changes confirmed the anaplastic variant. Further workup showed no evidence of multiple myeloma. This case is unusual given the age and gender of the patient. Awareness of the anaplastic variant of plasmacytoma is important to avoid erroneous diagnoses.

Cutaneous Vasculitis: An Unusual Presentation of a Biclonal Nodal Plasma Cell Dyscrasia

We describe an unusual case of a biclonal nodal plasma cell dyscrasia, presenting with a vasculitic rash, end-organ damage, and cytopenias. Serum protein electrophoresis demonstrated a biclonal kappa-restricted paraprotein, with a negative skeletal survey and no bone marrow disease. Fluorodeoxyglucose-PET-CT (FDG-PET-CT) revealed nodal involvement, which was not appreciable clinically, and facilitated biopsy, confirming the diagnosis of a nodal plasmacytoma. Complete biochemical response and resolution of the vasculitic rash were achieved with bortezomib-based therapy.

Whole-body computed tomography versus conventional skeletal survey in patients with multiple myeloma: a study of the International Myeloma Working Group

For decades, conventional skeletal survey (CSS) has been the standard imaging technique for multiple myeloma (MM). However, recently whole-body computed tomography (WBCT) has been implemented into the diagnostic criteria of MM. This analysis compares sensitivity and prognostic significance of WBCT and CSS in patients with smoldering MM (SMM) and MM. Fifty-four of 212 patients (25.5%) had a negative CSS and a positive WBCT for osteolytic lesions (P<0.0001). Of 66 patients with SMM based on CSS, 12 (22.2%) had osteolytic lesions on WBCT. In comparison, WBCT failed to detect some bone destructions in the appendicular skeleton possibly due to limitations of the field of view. Presence of lytic bone lesions in WBCT was of borderline prognostic significance (P=0.051) for SMM patients, with a median time to progression of 38 versus 82 months for those without bone destructions. In conclusion, WBCT identifies significantly more sites of bone destruction than CSS. More than 20% of patients with SMM according to CSS have in fact active MM detectable with WBCT. On the basis of this and other studies, WBCT (either computed tomography (CT) alone or as part of a positron emission tomography-CT protocol) should be considered the current standard for the detection of osteolytic lesions in MM.

Guidelines for the use of imaging in the management of patients with myeloma

The role of imaging in myeloma has gained increasing importance over the past few years. The recently revised definition of myeloma from the International Myeloma Working Group (IMWG) includes cross sectional imaging as a method to define bone disease and also incorporates its use in the disease definition for patients with suspected smouldering myeloma. The National Institute for Health and Care Excellence myeloma guidelines also recommend cross sectional imaging for patients with suspected myeloma. There is also increasing use of imaging in disease assessments and the International Myeloma Working Group has recently incorporated imaging in defining new response categories of minimal residual disease negativity, with or without imaging-based evidence of disease. Plain X-rays have previously been the standard imaging modality included in a myeloma work up at presentation but evidence is mounting for use of cross-sectional modalities such as computed tomography (CT), magnetic resonance imaging (MRI) and 18 fluoro-deoxyglucose (18 F-FDG) positron emission tomography (PET)/CT. Funding and therefore availability of newer imaging techniques remains a barrier. Here, we propose an evidence-based approach to the use and technical application of the latest imaging modalities at diagnosis and in the follow-up of patients with myeloma and plasmacytoma.

Whole body magnetic resonance imaging in newly diagnosed multiple myeloma: early changes in lesional signal fat fraction predict disease response

Cross-sectional imaging techniques are being increasingly used for disease evaluation in patients with multiple myeloma. Whole body magnetic resonance imaging (WB-MRI) scanning is superior to plain radiography in baseline assessment of patients but changes following treatment have not been systematically explored. We carried out paired WB-MRI scans in 21 newly diagnosed patients prior to, and 8-weeks after, starting chemotherapy, and analysed stringently selected focal lesions (FLs) for parametric changes. A total of 323 FLs were evaluated, median 20 per patient. At 8 weeks, there was a reduction in estimated tumour volume (eTV), and an increase in signal fat fraction (sFF) and apparent diffusion coefficient (ADC) in the group as a whole (P < 0·001). Patients who achieved complete/very good partial response (CR/VGPR) to induction had a significantly greater increase in sFF compared to those achieving ≤ partial response (PR; P = 0·001). When analysed on a per-patient basis, all patients achieving CR/VGPR had a significant sFF increase in their FL's, in contrast to patients achieving ≤PR. sFF changes in patients reaching maximal response within 100 days (fast responders) were greater compared to slow responders (P = 0·001). Receiver Operator Characteristic analysis indicated that sFF changes at 8 weeks were the best biomarker (area under the Curve 0·95) for an inferior response (≤PR). We conclude that early lesional sFF changes may provide important information on depth of response, and are worthy of further prospective study.

Fully automated classification of bone marrow infiltration in low-dose CT of patients with multiple myeloma based on probabilistic density model and supervised learning

This paper presents a fully automated method for the identification of bone marrow infiltration in femurs in low-dose CT of patients with multiple myeloma. We automatically find the femurs and the bone marrow within them. In the next step, we create a probabilistic, spatially dependent density model of normal tissue. At test time, we detect unexpectedly high density voxels which may be related to bone marrow infiltration, as outliers to this model. Based on a set of global, aggregated features representing all detections from one femur, we classify the subjects as being either healthy or not. This method was validated on a dataset of 127 subjects with ground truth created from a consensus of two expert radiologists, obtaining an AUC of 0.996 for the task of distinguishing healthy controls and patients with bone marrow infiltration. To the best of our knowledge, no other automatic image-based method for this task has been published before.

Apparent diffusion coefficient maps integrated in whole-body MRI examination for the evaluation of tumor response to chemotherapy in patients with multiple myeloma

RATIONALE AND OBJECTIVES

To determine the diagnostic value of apparent diffusion coefficient (ADC) maps in the assessment of response to chemotherapy in patients with multiple myeloma (MM).

MATERIALS AND METHODS

Fourteen patients (seven women) with MM underwent whole-body magnetic resonance imaging (WB-MRI) study on a 1.5T scanner, before and after chemotherapy. DWI with background body signal suppression (DWIBS) sequences (b values: 0, 500, and 1000 mm(2)/sec) were qualitatively analyzed, along with T1 turbo spine echo and short tau inversion recovery T2-weighted images, to evaluate bone lesions. On ADC maps, regions of interest were manually drawn along contours of lesions. The ADC values percentage variation (ΔADC) before (MR1) and after (MR2) chemotherapy were calculated and compared between responders (11 of 14) and nonresponders (3 of 14). The percentage of plasma cells by the means of the bone marrow aspirate was evaluated as parameter for response to chemotherapy.

RESULTS

Twenty-four lesions, hyperintense on DWIBS as compared to normal bone marrow, were evaluated. In responder group, the mean ADC values were 0.63 ± 0.24 × 10(-3) mm(2)/s on MR1 and 1.04 ± 0.46 × 10(-3) mm(2)/s on MR2; partial or complete signal intensity decrease during follow-up on DWIBS was found along with a reduction of plasma cells infiltration in the bone marrow. The mean ADC values for nonresponders were 0.61 ± 0.05 × 10(-3) mm(2)/s on MR1 and 0.69 ± 0.09 × 10(-3) mm(2)/s on MR2. The mean variation of ΔADC in responders (Δ = 66%) was significantly different (P < .05) than in nonresponders (Δ = 15%).

CONCLUSIONS

WB-MRI with DWIBS sequences, by evaluating posttreatment changes of ADC values, might represent a complementary diagnostic tool in the assessment of response to chemotherapy in MM patients.

Non Secretory Multiple Myeloma With Extensive Extramedullary Plasmacytoma: A Diagnostic Dilemma

Multiple myeloma (MM) is characterized by progressive proliferation of malignant plasma cells, usually initiating in the bone marrow. MM can affect any organ; a total of 7 - 18% of patients with MM demonstrate extramedullary involvement at diagnosis. Non-secretory multiple myeloma (NSMM) is a rare variant that accounts for 1 - 5% of all cases of multiple myeloma. The disease is characterized by the absence of monoclonal gammopathy in serum and urine electrophoresis. Our case report highlights the diagnostic challenge of a case of NSMM with extensive extramedullary involvement in a young female patient who initially presented with right shoulder pain and bilateral breasts lumps. Skeletal survey showed multiple lytic bony lesions. The initial diagnosis was primary breast carcinoma with osseous metastases. No monoclonal gammopathy was found in the serum or urine electrophoresis. Bone marrow and breast biopsies revealed marked plasmacytosis. The diagnosis was delayed for a month in view of the lack of clinical suspicion of multiple myeloma in a young patient and scant biochemical expression of non-secretory type of multiple myeloma.

Quantitative Analysis of MR Imaging to Assess Treatment Response for Patients with Multiple Myeloma by Using Dynamic Intensity Entropy Transformation: A Preliminary Study

PURPOSE

To develop a quantitative measure of bone marrow changes in magnetic resonance (MR) images and investigate its capability for assessment of treatment response for patients with multiple myeloma (MM).

MATERIALS AND METHODS

This study was retrospective, institutional review board approved, and HIPAA compliant. Informed consent was waived. Patients (n = 64; mean age, 58.8 years [age range, 27-75 years]) who were diagnosed with MM and underwent autologous bone marrow stem cell transplantation (BMT) were evaluated. A pair of spinal MR examinations performed before and after BMT was collected from each patient's records. A three-dimensional dynamic intensity entropy transformation (DIET) method was developed to transform MR T1-weighted signal voxel by voxel to a quantitative entropy enhancement value (qEEV), from which predictor variables were derived to train a linear discriminant analysis classifier by using a leave-one-out method. The output of the linear discriminant analysis provided a qEEV-based response index for quantitative assessment of treatment response. The performance of quantitative response index for the discrimination of responder and nonresponder patients was evaluated by receiver operating characteristic curve analysis.

RESULTS

Among the 46 and 18 clinically diagnosed responder and nonresponder patients, the quantitative response index at a chosen decision threshold correctly identified 42 responder and 17 nonresponder patients. The agreement between the DIET method and the clinical outcome reached 0.922 (59 of 64; κ = 0.816; area under the receiver operating characteristic curve, 0.886 ± 0.042).

CONCLUSION

This study demonstrated the feasibility of quantitative response index to differentiate responder and nonresponder patients and had substantial agreement with clinical outcomes, which indicated that this quantitative measure has the potential to be an image biomarker to assess MM treatment response.

Oral lesion as unusual first manifestation of multiple myeloma: case reports and review of the literature

Extramedullary plasmacytoma (EMP) and solitary bone plasmacytoma (SBP) represent a disease continuum through a multistage process of cell differentiation, survival, proliferation, and dissemination, strictly related to multiple myeloma (MM), the second most common hematological malignancy. Herein, we report two cases of recurrent oral plasmacytoma progressed to MM, in which the first clinical sign of a more widespread disease was limited to the mouth. Based on our experience, we recommend a strict workup for the differential diagnosis between EMP, SBP, and MM for patients with oral plasmacytoma, including radiological exam of the skeleton, magnetic resonance imaging (MRI) of the bone, and positive emission tomography (FDG-PET). MRI and possibly PET can all be used to more sensitively detect EM plasmacytoma sites.

Diagnostic and Prognostic Implications of Spine Magnetic Resonance Imaging at Diagnosis in Patients with Multiple Myeloma

Purpose

The aim of this study is to determine the diagnostic and prognostic role of baseline spinal magnetic resonance imaging (MRI) in patients with multiple myeloma.

Materials and Methods

We enrolled patients newly diagnosed with multiple myeloma from 2004-2011 at a single center. Abnormal MRI findings that were not detected in radiographs have been analyzed and categorized as malignant compression fractures or extramedullary plasmacytoma. The bone marrow (BM) infiltration patterns on MRI have been classified into five categories.

Results

A total of 113 patients with a median age of 65 years (range, 40 to 89 years) were enrolled in the study. Malignant compression fractures not detected in the bone survey were found in 26 patients (23.0%), including three patients (2.6%) with no related symptoms or signs. Extramedullary plasmacytoma was detected in 22 patients (19.5%), including 15 (13.3%) with epidural extension of the tumor. Of these 22 patients, 11 (50.0%) had no relevant symptoms or signs. The presence of malignant compression fractures did not influence overall survival; whereas non-epidural extramedullary plasmacytoma was associated with poor overall survival in the multivariate analysis (hazard ratio, 3.205; 95% confidence interval [CI], 1.430 to 9.845; p=0.042). During the follow-up for a median of 21 months (range, 1 to 91 months), overall survival with the mixed BM infiltrative pattern (median, 24.0 months; 95% CI, 22.9 to 25.1 months) was shorter than those with other patterns (median 56 months; 95% CI, 48.9 to 63.1 months; p=0.030).

Conclusion

These results indicate that spine MRI at the time of diagnosis is useful for detecting skeletal lesions and predicting the prognosis in patients with multiple myeloma.

Quality of life in patients with multiple myeloma treated with percutaneous vertebroplasty

OBJECTIVE: To determine the quality of life in patients with multiple myeloma treated with vertebroplasty. Multiple myeloma has a prevalence of 1% in all neoplastic diseases and 10% of hematological malignancies. Bone pain is the initial symptom in most cases. METHODS: A series of cases study was conducted. Patients were assessed by the Karnofsky scale to measure its functionality, the WHO analgesic scale to assess the type of analgesic and visual analog scale (VAS) and the Oswestry questionnaire for pain. RESULTS: Of 24 patients, 10 were cases (vertebroplasty) (41.7%) and 14 were controls (conservative) (58.3%), 13 (54.2%) were female and 11 (45.8%) male, with an average age of 60 years (SD = 12) and 63 kg of average weight (SD = 12), mean height of 1.59 cm (SD = 9) and mean body mass index of 24.8 (SD = 3.7). Survival was obtained from the time of diagnosis to death, and 2 (8.3%) patients died within the first 2 years and 1 (4.2%) after 3 years. CONCLUSIONS: Patients with MM who have vertebral fractures are excellent candidates to undergo vertebroplasty, because this represents a greater benefit in their quality of life, which has a direct impact on their level of functionality, giving them greater self-sufficiency and reducing their pain because of the benefits of the thermogenic effect of vertebroplasty.

Diagnostic value of whole-body low-dose computed tomography (WBLDCT) in bone lesions detection in patients with multiple myeloma (MM)

PURPOSE

To assess the role of whole-body low-dose computed tomography (WBLDCT) in the diagnosis and staging of patients with suspicion of multiple myeloma (MM).

MATERIALS AND METHODS

A total of 138 patients (76 male and 62 female; mean age 63.5 years, range 50-81 years), with early MM, underwent WBLDCT protocol study, performed on 16-slice scanner (Brilliance, Philips Medical System, Eindhoven, The Netherlands): tube voltage 120 kV; tube current time product 40 mAs. Diagnosis of osteolytic lesions was performed on the basis of axial and multiplanar reformatted images, whereas the assessment of spinal misalignment and fracture was done by using multiplanar reformatted images. The overall dose delivered to each patient was 4.2 mSv. Every patient gave personal informed consent, as required by our institution guidelines.

RESULTS

The diagnosis was established either by histopathology or imaging follow-up (size increase of over a period time). In all 138 patients, image resolution was diagnostic, enabling correct classification of multiple myeloma patients. WBLDCT showed a total of 328 pathologic bone findings in 81/138 patients. CT scanning resulted in complete evaluation of the bone lesions in these areas of the skeleton: skull (42), humerus (15), femur (20), ribs (7), scapulae (13), pelvis (35), clavicle (13), sternum (10), cervical (39), dorsal (65), lombar (48) and sacral rachis (21). In 40/81 bone involvement detected by CT was the only CRAB criterion present. Furthermore, WBLDCT demonstrated pleuro-pulmonary lesions in 20 patients (11 infective, 9 as MM localizations) and 1 renal neoplasia.

CONCLUSION

WBLDCT, detecting bone marrow localizations and demonstrating extra-osseous findings, with a fast scanning time and high resolution images, is a reliable imaging-based tool for a proper management of MM patients.

(18)F-FDG-PET/CT imaging in an IL-6- and MYC-driven mouse model of human multiple myeloma affords objective evaluation of plasma cell tumor progression and therapeutic response to the proteasome inhibitor ixazomib

(18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) and computed tomography (CT) are useful imaging modalities for evaluating tumor progression and treatment responses in genetically engineered mouse models of solid human cancers, but the potential of integrated FDG-PET/CT for assessing tumor development and new interventions in transgenic mouse models of human blood cancers such as multiple myeloma (MM) has not been demonstrated. Here we use BALB/c mice that contain the newly developed iMyc(ΔEμ) gene insertion and the widely expressed H2-L(d)-IL6 transgene to demonstrate that FDG-PET/CT affords an excellent research tool for assessing interleukin-6- and MYC-driven plasma cell tumor (PCT) development in a serial, reproducible and stage- and lesion-specific manner. We also show that FDG-PET/CT permits determination of objective drug responses in PCT-bearing mice treated with the investigational proteasome inhibitor ixazomib (MLN2238), the biologically active form of ixazomib citrate (MLN9708), that is currently in phase 3 clinical trials in MM. Overall survival of 5 of 6 ixazomib-treated mice doubled compared with mice left untreated. One outlier mouse presented with primary refractory disease. Our findings demonstrate the utility of FDG-PET/CT for preclinical MM research and suggest that this method will play an important role in the design and testing of new approaches to treat myeloma.

Value of whole body MRI and dynamic contrast enhanced MRI in the diagnosis, follow-up and evaluation of disease activity and extent in multiple myeloma

PURPOSE

To evaluate the significance of dynamic contrast enhanced MRI (DCE-MRI) and whole body MRI (WB-MRI) in the diagnosis, prognosis and assessment of therapy for patients with monoclonal gammopathy of undetermined significance (MGUS) and multiple myeloma (MM).

MATERIALS AND METHODS

The retrospective study includes 219 patients providing 463 WB-MRI and DCE-MRI investigations for the subgroups MGUS (n=70), MM active disease (n=126; this includes 70 patients with new diagnosis of MM, according to the International Staging System (ISS): 41.4% ISS stage I, 20.0% ISS stage II, 7.1% ISS stage III, 31.4% insufficient for staging; and 56 patients with '(re-)active disease': 16.07% relapse, 32.14% progressive disease and 51.79% stable disease) and MM remission (n=23; 60.87% complete remission, 17.39% very good partial remission and 21.74% partial remission). Investigations of patients with hereditary multiple exostoses (n=5), neurofibromatosis (n=7) and healthy persons (n=9) were added as control subjects (n=21). WB-MRI evaluation was done by evaluating thirteen skeletal regions, providing a 'skeletal score'. DCE-MRI images of the spine, were analyzed with regions-of-interest and time-intensity-curves (TIC).

RESULTS

All TIC parameters can significantly differentiate between the predefined subgroups (p<0.001). One hundred days after autologous stem cell transplantation a 75% decrease of the slope wash-in value (p<0.001) can be seen. A cubic regression trend between 'skeletal score' and slope wash-in (adj.R(2)=0.412) could demonstrate a significant increase bone marrow perfusion if MM affects more than 10 skeletal regions (p<0.001), associated with a poorer prognosis (p<0.001).

CONCLUSION

DCE-MRI evaluation of the spine is useful for diagnosis of MM, follow-up after stem cell transplantation and evaluation of disease activity. A combined evaluation with WB-MRI and DCE-MRI provides additional micro-vascular information on the morphologic lesions and could help categorize patients with MM in two different groups to offer useful therapeutic and prognostic advise.

Assessing response of myeloma bone disease with diffusion-weighted MRI

OBJECTIVES

To measure apparent diffusion coefficient (ADC) values in patients with active myeloma and remission and to determine whether changes differ in those responding/progressing on treatment. The relationship between changes in marrow fat and ADC was also explored.

METHODS

20 patients were recruited. T(1 )weighted, T(2) weighted, short tau inversion-recovery, diffusion-weighted and two-point Dixon MRI of the lumbar spine and pelvis were performed at baseline, 4-6 weeks and 20 weeks.

RESULTS

ADC values of active disease (mean 761.2 ± 255×10(-6) mm(2) s(-1)) were significantly higher (p=0.047) than marrow in remission (mean 601.8 ± 459×10(-6) mm(2) s(-1)). Changes in ADC in responders showed a significant increase at 4-6 weeks (p=0.005) but no significant change between baseline and 20 weeks (p=0.733). ADCs in progressing and stable patients did not change significantly between either time point. Pearson's correlation coefficient between change in fat fraction and change in the number of pixels with an ADC of ≤655×10(-6) mm(2) s(-1) was 0.924, indicating a significant correlation (p<0.001).

CONCLUSION

ADC values in active myeloma are significantly higher than marrow in remission, indicating the potential for diffusion-weighted MRI to quantify the transition from active disease to remission and vice versa. This study confirms significant changes in ADC in patients responding to treatment and indirect evidence from two-point Dixon MRI suggests that these changes are influenced by changes in marrow fat.

ADVANCES IN KNOWLEDGE

ADC of active myeloma is significantly higher than marrow in remission; the direction of ADC changes on treatment is dependent on the timing of measurements and is influenced by changes in marrow fat.

Assessment of whole body MRI and sestamibi technetium-99m bone marrow scan in prediction of multiple myeloma disease progression and outcome: a prospective comparative study

OBJECTIVES

This study aims primarily to determine whether whole body MRI (WB-MRI) and Sestamibi Technetium-99m-bone marrow (MIBI) scans in the same patients produce the same estimate of disease load and location, and secondly, to study possible association between the bone disease detected by these scans and the effect on disease outcome and survival. Bone disease occurs in about 90% of multiple myeloma (MM) patients. There are no data comparing the new diagnostic modalities with WB-MRI and MIBI in MM.

DESIGN

A prospective comparative study between WB-MRI and MIBI scans in assessing bone disease and outcome of MM.

PARTICIPANTS AND METHODS

Sixty-two consecutive patients with confirmed MM underwent simultaneous WB-MRI (both axial T1 and turbo spin echo short tau inversion recovery (STIR)) and MIBI scans at a single institution from January 2010 to January 2011, and their survival status was determined in January 2012. The median age was 62 years (range 37-88) with a male-to-female ratio of 33 : 29.

RESULTS

In vertebrae and long bones, MRI scan detected more disease compared with MIBI scan (p<0.001) but there was less difference in the skull (p=0.09). In the ribcage, the MIBI scan detected more lytic lesions of the ribs compared with MRI scan (p<0.001). Thirteen of the 62 patients died during the 24-month follow-up. Increased disease detected in all bones by both scans was associated with increased mortality risk (MIBI p=0.001; MRI-STIR p=0.044; but not MRI-T1 p=0.44). In all combined bone groups, the mean MIBI scan results provided a better prediction of mortality than MRI scan over the follow-up period (MRI-T1 vs MIBI p=0.019; MRI-STIR vs MIBI p=0.047).

CONCLUSIONS

Although WB-MRI detected more MM bone disease, MIBI scan predicted overall disease outcome and mortality better than MRI scan. Further studies to define optimum use of these imaging techniques are warranted.

TRIAL REGISTRATION NUMBER

The study was registered prospectively in the Australian and New Zealand Clinical Trials Registry at http://www.ANZCTR.org.au under No: ACTRN12609000761268.

The role of imaging techniques in the management of multiple myeloma

Bone disease is the major feature of multiple myeloma (MM). Imaging is required for correct staging, in the follow-up after treatment and, as recently highlighted, is predictor of prognosis. In the near future, whole-body X-Ray may be replaced by more sensitive techniques, such as whole-body low-dose computerized tomography (CT). Magnetic resonance imaging (MRI) is the gold standard method for assessing bone marrow infiltration of the spine, predicting the risk of vertebral fracture and distinguishing between benign and malignant osteoporosis. Positron emission tomography (PET) with CT (PET/CT) provides important information about the extent of whole-body disease, including soft tissue masses, and is the best tool to distinguish between active or inactive disease after therapy. Both MRI and PET/CT are predictors of clinical outcome. A prospective use of these newer imaging techniques in both clinical trials and clinical practice may help optimize MM management in the near future.

Diagnostic performance of whole-body MRI for the detection of persistent or relapsing disease in multiple myeloma after stem cell transplantation

OBJECTIVES

To compare the diagnostic performance of whole-body MRI (WBMRI) with haematological parameters for detecting persistent or relapsing disease in patients with multiple myeloma after stem cell transplantation.

METHODS

Sixty-six WBMRI acquisitions were performed in 33 patients with multiple myeloma at two time points after stem cell transplantation. Extent of disease and inter-test dynamics of intra- and extramedullary myeloma manifestations were compared (kappa statistics) with Uniform Response Criteria, comprising haematological parameters.

RESULTS

Using data from 66 sequential WBMRI acquisitions in 33 patients, 10 patients (30.3 %) were classified as having progressive disease and 23 (69.7 %) as being in remission. Eight (80 %) of the ten patients with progressive disease revealed intramedullary lesions, and two patients (20 %) had intra- and extramedullary lesions. WBMRI and laboratory tests were concordant in 26/33 (78.8 %) patients. We found an agreement of 51.2 %, 95 % confidence interval 19.8 %-82.6 %, between results from WBMRI and haematological parameters. WBMRI had a sensitivity of 63.6 %, specificity of 86.4 %, PPV of 70.0 %, NPV of 82.6 % and accuracy of 78.8 % for detection of remission.

CONCLUSIONS

WBMRI allows the detection and exact localisation of intra- and extramedullary myeloma manifestations after stem cell transplantation, but shows only moderate agreement with routinely performed laboratory tests for determination of remission.

Rheumatic manifestations of primary and metastatic bone tumors and paraneoplastic bone disease

Bone tumors can show a wide range of nonspecific rheumatic manifestations. The presence of unexplained or atypical chronic bone pain, an enlarging bone mass, neurovascular compression syndromes, or pathologic fractures should alert us to the possibility of a bone tumor causing these symptoms. These patients must undergo a complete physical examination; adequate imaging; and, if needed, a biopsy to confirm their diagnosis and offer them an opportune treatment. In addition, bone tumors and other malignancies can present remote clinical manifestations and unusual laboratory findings (eg, HOA, hypophosphatemia, hyperphosphaturia, and hypercalcemia) that may be the first and early manifestation of an occult cancer. These findings should motivate a cancer screening according to age, sex, and personal history. Cancer therapies also have a big impact on bone health, increasing the risk of osteoporosis, osteomalacia, and/or osteonecrosis. Rheumatologists should be aware of possible long-term adverse events of cancer treatment to avoid future complications.

Multiple myeloma: a review of imaging features and radiological techniques

The recently updated Durie/Salmon PLUS staging system published in 2006 highlights the many advances that have been made in the imaging of multiple myeloma, a common malignancy of plasma cells. In this article, we shall focus primarily on the more sensitive and specific whole-body imaging techniques, including whole-body computed tomography, whole-body magnetic resonance imaging, and positron emission computed tomography. We shall also discuss new and emerging imaging techniques and future developments in the radiological assessment of multiple myeloma.

Renal failure due to primary amyloidosis: a case report and literature review

CONTEXT

Primary amyloidosis, also known as AL amyloidosis, is commonly caused by clonal expansion of plasma cells in the bone marrow, thereby segregating light chains of clonal immunoglobulin that settle in tissues in the form of insoluble amyloid fibrils. The aim of this study was to report a case of primary amyloidosis with renal failure, diagnosed in Hospital São João, Porto, Portugal, focusing on the diagnostic difficulties and presenting a literature review.

CASE REPORT

A 68-year-old Caucasian man was admitted to the Internal Medicine Department of the hospital with a condition of anasarca and nephrotic syndrome. After performing a renal biopsy that tested positive using Congo red and immunohistochemistry, lambda light chain amyloidosis was diagnosed. This evolved into terminal renal disease, which led to hemodialysis and several episodes of urinary and catheter infections. He was started on chemotherapy, consisting of bortezomib 0.7 mg/m(2) and dexamethasone 40 mg in six cycles. This led to clinical improvement, stabilization of the illness and good tolerance of the treatment.

CONCLUSION

Amyloidosis is a rare entity that is difficult to diagnose. This is because of the unspecific early clinical manifestations of the disease. The hypothesis of amyloidosis is only considered when specific organ failure occurs. This case consisted of primary amyloidosis with involvement of the kidneys as an initial presentation of the disease and its difficulties were shown, going from the clinical approach to the final diagnosis.

State-of-the-Art Management of Complications of Myeloma and Its Treatment

Multiple myeloma is an incurable disease, although patient survival has increased with the availability of novel agents. Both multiple myeloma and its therapies often affect the renal, immune, skeletal, hematologic, and nervous systems. The resulting organ dysfunctions often impair the quality of life of affected patients, complicate and limit subsequent therapies, and may result in significant mortality. Research on the treatment of complications of multiple myeloma has been limited; hence, preventative and management strategies for patients with these complications are heterogeneous and often based on anecdotal experience. In this paper, we review the effects of myeloma and the novel therapies on organ systems and suggest management strategies.

Presentation and risk stratification--improving prognosis for patients with multiple myeloma

Major improvement milestones in the treatment of patients with multiple myeloma (MM) include the introduction of the melphalan/prednisone combination in the 1960s; high-dose chemotherapy supported by autologous stem cell transplant in the 1980s; and the more recent introduction of the novel agents, thalidomide, lenalidomide, bortezomib, and pegylated liposomal doxorubicin. While, historically, age and eligibility for autologous stem cell transplantation were the primary basis for treatment selection, cytogenetics and other risk stratification methods are increasingly being used to guide treatment, especially with the newer agents. This trend reflects our improved understanding of the numerous genetic and biological abnormalities that mark this complex disease. In the absence of prospective, randomised studies assessing the value of risk stratification in guiding treatment decisions, and the use of the newest therapies, results of a number of studies provide a rationale for this approach. Currently available data indicate that the use of novel therapies in both the induction and maintenance settings, accompanied by risk stratification, may improve prognosis for patients with MM. Large, prospective randomised studies are needed to confirm these early pilot studies.

Current concepts in the evaluation of multiple myeloma with MR imaging and FDG PET/CT

Multiple myeloma is a heterogeneous group of plasma cell neoplasms that primarily involve bone marrow but also may occur in the soft tissue. Although the disease varies in its manifestations and its course, it is eventually fatal in all cases. Over the past 2 decades, significant advances have been made in our understanding of the genetics and pathogenesis of multiple myeloma and in its treatment. The use of magnetic resonance (MR) imaging and fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography (PET) with computed tomography (CT) has improved sensitivity for the detection of this disease. PET aids in the identification of active multiple myeloma on the basis of FDG uptake, and MR imaging helps identify multiple myeloma from its infiltration of normal fat within the bone marrow, which occurs in characteristic patterns that correlate with the disease stage. The increased sensitivity of these advanced cross-sectional imaging techniques has led to further refinement of the classic Durie and Salmon staging system. In addition, these imaging techniques allow a more reliable assessment of the disease response to treatment with current regimens, which may include autologous stem cell transplantation as well as various medications. In lesions that respond to chemotherapeutic agents, the replacement of previously infiltrated marrow by fat is seen at MR imaging and decreased FDG uptake is seen at FDG PET; however, a lengthy and intensive regimen may be necessary before the MR imaging appearance of marrow normalizes. Lytic lesions seen at CT almost always persist even after successful treatment. To provide an accurate assessment, radiologists must be familiar not only with the appearances of multiple myeloma and its mimics but also with common treatment-related findings.

The prognostic value of F-18 fluorodeoxyglucose bone marrow uptake in patients with recent diagnosis of multiple myeloma: a comparative study with Tc-99m sestamibi

PURPOSE

We assessed the prognostic value of F-18 fluorodeoxyglucose (FDG) uptake in the bone marrow of patients with multiple myeloma (MM) in comparison with Tc-99m methoxy-isobutyl-isonitrile (MIBI).

METHODS

The extent and intensity of FDG and MIBI uptake in the bone marrow of 18 patients with a recent diagnosis of MM were assessed by visual score and by calculating the mean SUV (mSUV) for FDG and the femora/thigh ratio (TG/BKG, [Target/Background ratio]) for MIBI images. These parameters were correlated with clinical indexes of disease using hemoglobin and beta-2-microglobulin levels and plasma cell infiltrate (PCI) percentage. The mean values of the visual score, mSUV, and TG/BKG levels were compared in patients deceased after a relatively short follow-up (n = 9; group A) and in patients with a longer survival or were alive at the end of the study (n = 9; group B).

RESULTS

Significant correlations of mSUV and TG/BKG values with PCI percentages and beta-2-microglobulin were found (P < 0.05). The extent of FDG and MIBI bone marrow uptake was greater in patients of group A (P < 0.01). Higher values of mSUV (P < 0.01) and TG/BKG (P < 0.05) were also observed in patients of group A. These results were consistent with the differences (not statistically significant) in hemoglobin, albumin, beta-2-microglobulin levels, and PCI percentages observed in the 2 groups.

CONCLUSION

Our study demonstrates that an increase of FDG bone marrow uptake may predict a more aggressive disease, as much as MIBI uptake. Therefore, an additional analysis of FDG bone marrow images should be performed in patients undergoing PET studies during the initial staging of MM.

Image quality in low-dose multidetector computed tomography: a pilot study to assess feasibility and dose optimization in whole-body bone imaging

OBJECTIVE

To study the impact of dose parameters on image quality at whole-body low-dose multidetector computed tomography (CT) in an attempt to derive parameters that allow diagnostic quality images of the skeletal system without incurring significant radiation dose in patients referred for investigation of plasma cell dyscrasias.

METHODS

By using a single cadaver, 14 different whole-body low-dose CT protocols were individually assessed by 2 radiologists, blinded to acquisition parameters (kVp and mAs, reconstruction algorithm, dose reduction software). Combinations of kVps that range from 80-140 kVp, and tube current time product from 14-125 mAs were individually scored by using a Likert scale from 1-5 in 4 separate anatomical areas (skull base, thoracic spine, pelvis, and distal femora). Correlation between readers scores and effective doses were obtained by using correlation coefficient statistical analysis, statistical significance was considered P < .01. Interobserver agreement was assessed by using a Bland and Altman plot. Interobserver agreement in each of the 4 anatomical areas was assessed by using kappa statistics. A single set of parameters was then selected for use in future clinical trials in a cohort of patients referred for investigation of monoclonal gammopathy, including multiple myeloma.

RESULTS

Several sets of exposure parameters allowed low-dose whole-body CT to be performed with effective doses similar to skeletal survey while preserving diagnostic image quality. Individual reader's and average combined scores showed a strong inverse correlation with effective dose (reader 1, r = -0.78, P = .0001; reader 2, r = -0.75, P = .0003); average combined scores r = -0.81, P < .0001). Bland and Altman plot of overall scores shows reasonable interobserver agreement, with a mean difference of 1.055.

CONCLUSION

Whole-body low-dose CT can be used to obtain adequate CT image quality to assess normal osseous detail while delivering effective doses similar to those associated with conventional radiographic skeletal survey.

Multiple myeloma

Advances in the imaging and treatment of multiple myeloma have occurred over the past decade. This article summarises the current status and highlights how an understanding of both is necessary for optimum management.

Multiple myeloma: changes in serum C-terminal telopeptide of collagen type I and bone-specific alkaline phosphatase can be used in daily practice to detect imminent osteolysis

Objective: Monitoring of bone disease in multiple myeloma is becoming increasingly important because bone-protecting treatment with bisphosphonate is becoming restricted after the awareness of osteonecrosis of the jaw. Despite the potential of biochemical markers of bone remodeling to monitor dynamic bone turnover, they are not used in everyday practice. Here, we investigate their usefulness to detect imminent progressive osteolysis in relapsing patients with multiple myeloma. Methods: In an unselected cohort of 93 patients, we measured the bone resorption markers C-terminal telopeptide of collagen type I (CTX-I), C-terminal cross-linked telopeptide of type-I collagen generated by MMPs (ICTP), N-terminal cross-linked telopeptide of type-I collagen (NTX-I), and the bone formation marker bone-specific alkaline phosphatase (bALP) monthly for 2 yr. Retrospectively, we identified 40 cases where patients had progressive disease. We investigated how the bone markers developed prior to disease progression. Results: We observed that CTX-I and bALP changed significantly before progressive disease were recognized. More interestingly, these changes differed depending on whether concurrent progressive osteolysis was present. In patients with progressive osteolysis, there was a large increase in bone resorption which was not compensated by increased bone formation. In contrasts, patients with stable bone disease had only a slight increase in bone resorption which was compensated by concurrent increased bone formation. By calculating a patient-specific CTX-I/bALP ratio, we quantified the risk a patient experiences if the ratio increases. Conclusion: By analyzing patient-specific changes in the ratio of CTX-I/bALP, we might tailor treatment with bone-protecting agents in the individual patient.

[Pelvic and spinal MR follow-up of multiple myeloma patients after high-dose chemotherapy and autologous peripheral blood stem cell transplant]

PURPOSE

To evaluate the changes of bone marrow lesions on pelvic and spinal MR in patients with multiple myeloma after high-dose chemotherapy and autologous peripheral blood stem cell transplant.

PATIENTS AND METHODS

Pelvic and spinal MR examinations were obtained at presentation (myeloma diagnosis) and 1 year after transplant in 20 patients that were part of a group of 39 patients enrolled in a prospective study. The type of marrow replacement (classified in stages with stage 0: normal; stage 1: salt and pepper; stage 2: focal infiltration; stage 3: diffuse infiltration), the number and size of marrow lesions and the number of vertebral compression fractures were recorded. We have compared the findings prior to and following transplant, with correlation to the response to treatment and the use of biphosphonates.

RESULTS

The type of marrow replacement was improved following transplant in 65% of patients (not statistically significant). The number and size of nodules > 20 mm showed significant reduction (p = 0.0224 and p = 0.0237 respectively). Lesions on MR improved in 50% of patients with good response and 75% of patients with poor response to treatment. Patients receiving biphosphonates showed more vertebral compression fractures.

CONCLUSION

The evolution of marrow replacing lesions on MR is discordant compared to the biological and clinical response to treatment. Pelvic and spinal MR evaluation at the time of diagnosis does not appear to be a good predictive factor of response to treatment. Biphosphonates do not appear to prevent new vertebral compression fractures. Pelvic and spinal MR provides interesting data in the follow-up of patients with myeloma following autologous transplant, especially in the local evolution of marrow replacing lesions, but our results do not justify its use in routine clinical practice.