Waldenström macroglobulinemia: MR imaging of the spine and CT of the abdomen and pelvis

Multimodality imaging of indolent B cell lymphoma from diagnosis to transformation: what every radiologist should know

Indolent B cell lymphomas are a group of lymphoid malignancies characterized by their potential to undergo histologic transformation to aggressive lymphomas. While different subtypes of indolent B cell lymphomas demonstrate specific clinical and imaging features, histologic transformation can be suspected on cross-sectional imaging when disproportionate lymph node enlargement or new focal lesions in extranodal organs are seen. On PET/CT, transformed indolent lymphoma may show new or increased nodal FDG avidity or new FDG-avid lesions in different organs. In this article, we will (1) review the imaging features of different subtypes of indolent B cell lymphomas, (2) discuss the imaging features of histologic transformation, and (3) propose a diagnostic algorithm for transformed indolent lymphoma. The purpose of this review is to familiarize radiologists with the spectrum of clinical and imaging features of indolent B cell lymphomas and to define the role of imaging in raising concern for transformation and in guiding biopsy for confirmation.

Imaging of Spinal Manifestations of Hematological Disorders

Imaging manifestations of hematological diseases and their potential complications are broad, and there may be significant overlap in features of various disease processes. Knowledge of appropriate choice of imaging test, pertinent imaging patterns, and pathophysiology of disease can help the reader increase specificity in the diagnosis and treatment of the patient. Most importantly, we encourage readers of this review to engage their radiologists during the diagnostic, treatment, and management phases of care delivery.

Multimodality imaging of osseous involvement In haematological malignancies

The purpose of this article is to provide a comprehensive review of the imaging features of osseous involvement in haematological malignancies. Osseous involvement can be seen in various haematological malignancies including lymphomas, plasma cell neoplasms, leukaemias and myeloproliferative neoplasms. Imaging plays a crucial role in initial diagnosis, staging and in the assessment of treatment response in these patients.

Are you sure this is Waldenström macroglobulinemia?

Waldenström macroglobulinemia (WM) is a rare lymphoproliferative disorder characterized by the presence of lymphoplasmacytic cells in the BM and IgM monoclonal protein in the serum. The origin of the malignant clone is thought to be a B cell arrested after somatic hypermutation in the germinal center and before terminal differentiation to plasma cells. In this review, recent advances in the genetic and epigenetic regulators of tumor progression are discussed. Risk factors include IgM-monoclonal gammopathy of undermined significance, familial disease, and immunological factors. The clinical manifestations of the disease include those related to clonal infiltration of the BM, lymph nodes, and, rarely, other sites such as pulmonary or CNS infiltration (Bing-Neel syndrome). Other manifestations are related to the IgM monoclonal protein, including hyperviscosity, cryoglobulinemia, protein-protein interactions, Ab-mediated disorders such as neuropathy, hemolytic anemia, and Schnitzler syndrome. IgM deposition in organs can lead to amyloidogenic manifestations in WM. The diagnostic workup for a patient with WM and rare presentations of WM are described herein. Prognosis of WM depends on 5 major factors in the International Staging System, including age, anemia, thrombocytopenia, β-2 microglobulin, and IgM level. The differential diagnosis of WM includes IgM-multiple myeloma, marginal zone lymphoma, mantle cell lymphoma, and follicular lymphoma.

The role of 18F-FDG PET/CT imaging in Waldenstrom macroglobulinemia

Disease assessment in WM is dependent on the quantification of the IgM monoclonal protein and percent involvement of the bone marrow. There is a need for imaging studies that objectively measure tumor load in these patients. In this study, we sought to examine the role of combined FDG-PET/CT imaging in the detection of tumor load and in the assessment of response to therapy. Thirty-five patients were enrolled on a prospective study using bortezomib and rituximab therapy and were included in this study because they completed a pre- and post-treatment FDG-PET/CT imaging at one facility (12 newly diagnosed and 23 relapsed/refractory). The use of combined FDG-PET/CT imaging showed positive findings in 83% of patients with WM, unlike prior studies using conventional imaging that indicate that only 20% of patients have lymphadenopathy or hepatosplenomegaly. Moreover, 43% of patients had abnormal bone marrow uptake on FDG-PET imaging that can potentially help in the assessment of their tumor load, especially with heterogenous sampling of the bone marrow. There was no statistical correlation between EORTC response criteria for FDG-PET/CT and response by monoclonal protein. This is the first study to examine the role of FDG-PET/CT imaging in WM. Future studies should examine the role of FDG-PET/CT in conjunction with monoclonal protein response in the assessment of progression-free survival in patients with WM.

IgM multiple myeloma: a diagnostic challenge in a patient with coexisting chronic lymphocytic leukaemia

As IgM multiple myeloma is a rare poorly characterised disease entity; there is only limited published data on its clinical, microscopic and immunophenotypic features. We report a 72-year-old man misdiagnosed as Waldenström's macroglobulinemia. Also the diagnosis was further complicated by coexisting chronic lymphocytic leukaemia. Following confirmation of IgM myeloma, in view of the patient's deteriorating clinical condition; he was entered into the UK Medical Research Council Myeloma IX trial where he had partial response to chemotherapy. This case highlights the value of detailed immunophenotypic evaluation when clinical and morphological markers are equivocal.

Radiological aid to clinical diagnosis of Schnitzler's syndrome: multimodality imaging approach

Schnitzler's syndrome is a rare combination of chronic urticaria, fever of unknown origin, disabling bone pain, and monoclonal gammopathy. We report a case with an unusual radiological manifestation as a solitary sclerotic lesion of the right iliac bone. Its main features on conventional radiography, computed tomography, and magnetic resonance imaging are described, and the main radiological differential diagnoses are discussed to help with the characterization of this syndrome, which requires a combination of clinical, laboratory, and radiological data. On the other hand, although our patient had an excellent clinical response to anakinra, the sclerotic lesion remained unchanged on follow-up X-ray examinations.

MR Imaging Evaluation of the Bone Marrow and Marrow Infiltrative Disorders of the Lumbar Spine

The use of MR imaging in assessing lumbar bone marrow first requires an understanding of the bone marrow's normal composition and the various imaging sequences available for use. One of the most useful sequences is the T1-weighted spin-echo sequence. This sequence may be combined with other sequences such as T2-weighted or diffusion-weighted sequences; techniques such as fat suppression, chemical shift imaging, and contrast-enhanced imaging are discussed. The varying features of normal lumbar marrow related to the normal physiologic changes that occur with aging and with changes in hematopoietic demand are important to understand and are described. The appearances of infiltrative marrow disease are explained on the basis of marrow composition and whether disease causes proliferation, replacement, or depletion of normal marrow components.

Abnormal bone remodelling and increased levels of macrophage inflammatory protein-1 alpha (MIP-1alpha) in Waldenström macroglobulinaemia

Serum levels of macrophage inflammatory protein-1 alpha (MIP-1alpha) and bone remodelling markers were evaluated in 38 patients with Waldenström macroglobulinaemia (WM) and correlated with clinical and laboratory variables. MIP-1alpha was elevated in WM; untreated patients had higher MIP-1alpha levels than patients in remission or with active disease after treatment. MIP-1alpha correlated with increased bone resorption, beta2-microglobulin and splenomegaly. Receptor activator of nuclear factor-kappaB ligand serum levels were elevated in WM patients; the subsequent increased bone resorption was balanced by a comparable elevation of osteoprotegerin production and bone formation. These findings may explain the absence of lytic lesions in WM patients and suggest a potential role of MIP-1alpha in WM.

IgM myeloma and Waldenstrom's macroglobulinemia: a distinct clinical feature, histology, immunophenotype, and chromosomal abnormality

Multiple myeloma represents a malignant proliferation of plasma cells derived from a single clone within the bone marrow. While the cause of myeloma is not known, interleukin 6 may play a role in driving myeloma cell proliferation. Waldenstrom's macroglobulinemia (WM) is a proliferative disease of B-lymphocytes. The cells have lymphoplasmacytoid features and secrete IgM. It is important to distinguish between IgM myeloma and WM as they have distinct clinical courses and prognoses, and treatment strategies are therefore different. The clinical characteristics of a patient diagnosed with IgM myeloma, and his excellent response to treatment are reported here.

Lymphoplasmacytoid lymphoma presenting as severe osteoporosis

We report four cases presenting with severe osteoporosis which on further investigation were found to have an underlying lymphoplasmacytoid lymphoma (LPL). Common secondary causes of osteoporosis were excluded in each case. Three of the cases responded to treatment with a biphosphonate. As these lymphomas share some common pathological and clinical features with multiple myeloma (MM) an association with osteoporosis is likely to represent more than a coincidental finding. The incidence of osteoporosis occurring with LPL will become clearer if routine imaging is carried out in patients at presentation. Issues relating to the treatment of the osteoporosis as well as the lymphoma arise in patients that present in this way. Based on the model of bone disease in MM, correlating serum levels of osteoclast activating cytokines such as interleukin-1 (IL-1), interleukin-6 (IL-6), and tumour necrosis factor (TNF) with the actual finding of bone disease provides a basis for future research into the pathogenesis and management of bone disease in these rare forms of low grade non-Hodgkin's lymphoma.

Lumbar spine imaging. Normal variants, imaging pitfalls, and artifacts

Accurate recognition and reporting of spine abnormalities on MRI requires knowledge of normal anatomy and its variants. This article deals with common normal variants, points out pitfalls which may be sources of errors in interpretation and describes imaging artifacts which are essential to be recognized and not mistaken for true pathologies.

Waldenström's macroglobulinemia: clinical features, complications, and management

PURPOSE

To review the clinical features, complications, and treatment of Waldenström's macroglobulinemia, a low-grade lymphoproliferative disorder that produces monoclonal immunoglobulin (Ig) M.

METHODS

A review of published reports was facilitated by the use of a MEDLINE computer search and by manual search of the Index Medicus.

RESULTS

The clinical manifestations associated with Waldenström's macroglobulinemia can be classified according to those related to direct tumor infiltration, to the amount and specific properties of circulating IgM, and to the deposition of IgM in various tissues. Asymptomatic patients should be followed without treatment. For symptomatic patients, standard treatment consists primarily of oral chlorambucil; nucleoside analogs, such as fludarabine and cladribine, are effective in one third of previously treated patients and in up to 80% of previously untreated patients. Preliminary evidence suggests that anti-CD20 monoclonal antibody may be active in about 30% of previously treated patients and that high-dose therapy with autologous stem-cell rescue is effective in most patients, including some with resistance to nucleoside analogs.

CONCLUSION

Waldenström's macroglobulinemia has a wide clinical spectrum that practicing physicians need to recognize early to reach the correct diagnosis. When therapy is indicated, oral chlorambucil is the standard primary treatment, but cladribine or fludarabine can be used when a rapid cytoreduction is desirable. Prospective randomized trials are required to elucidate the impact of nucleoside analogs on patients' survival. A nucleoside analog is the treatment of choice for patients who have been previously treated with an alkylating agent.

Waldenström's macroglobulinemia

Waldenström's macroglobulinemia is an unusual low-grade lymphoplasmacytic lymphoma characterized by the production of monoclonal IgM. The clinical manifestations associated with WM can be classified as those related to direct tumor infiltration, by the amount and specific properties of circulating IgM, and by the deposition of IgM in various tissues. Asymptomatic patients should be followed without treatment. The management of the disease relies on the administration of systemic chemotherapy to reduce tumor load and on the application of plasmapheresis to remove circulating IgM. Standard treatment consists of oral chlorambucil, which induces response in at least 50% of patients, resulting in a median survival of approximately 5 years. Nucleoside analogues (cladribine, fludarabine) are effective in most previously untreated patients. These agents are the treatment of choice for patients with disease resistant to alkylating agents. New treatment approaches include high-dose therapy with stem-cell support and administration of monoclonal anti-CD20 antibodies.

IgM myeloma: case report with immunophenotypic profile

Immunoglobulin (Ig)M myeloma is a distinct subtype of multiple myeloma (MM) displaying clinical and pathologic features of both MM and Waldenström's macroglobulinemia (WM). Although the immunophenotypic characteristics of classic MM and WM have been reported, the surface antigen expression of IgM myeloma has not been reported. We report a case of IgM myeloma and describe its immunophenotypic profile using flow cytometry. The cells showed a hybrid MM-WM phenotype, strongly expressing CD38 but lacking CD45 and DR, typical for plasma cells; however, pan-B cell antigens CD20 and FMC7 as well as weak monoclonal surface Ig also were positive, resembling B-cell lymphoproliferative malignancies. Discordant B-cell antigen expression was present, in that pan-B antigens CD19 and CD22 were absent. In addition, B-cell activation antigen CD23, early B-precursor antigen CD10, and pan-T antigen CD5 were not expressed. Although CD20 and weak surface Ig expression have been reported in MM, FMC7 positivity has not been seen. The data therefore suggest that IgM myeloma may have a unique phenotype with characteristics of both MM and WM.

Rheumatic manifestations of dysproteinemias and lymphoproliferative disorders

Rheumatic manifestations may be the presenting features of dysproteinemias and lymphoproliferative disorders. Disease or therapy-related complications may mimic a number of primary rheumatic syndromes. This article emphasizes clinical aspects pertaining to prompt diagnosis and therapy.

Bone scintigraphy and multimodality imaging in bone neoplasia: strategies for imaging in the new health care climate

The integration of multiple imaging modalities in the assessment of musculoskeletal neoplasia is complex. Although no two instances are identical, certain guidelines can be gleaned from our experience as well as that reported in the literature. Assessment of most soft tissue masses is best carried forth with a combination of conventional radiography and magnetic resonance imaging (MRI). Screening skeletal scintigraphy without localizing symptomatology that includes axial and appendicular skeleton is best carried out initially with bone scintigraphy. Screening the axial skeleton in the presence of clinical symptomatology or a strong suspicion of axial skeletal metastases or pathology is best implemented as a total spine screening examination with MRI and specialized pulsing sequences. Computed tomography is reserved primarily for assessment of cortical and juxtacortical lesions, fracture fragment positioning and/or configuration, and characterization of lesion matrix calcification or ossification when conventional radiographs are indeterminate. Although physical examination and conventional radiography still remain the initial medical algorithms used to evaluate possible musculoskeletal neoplasia, primary skeletal tumors may require multimodality imaging to segregate aggressive and nonaggressive processes. In this multimodality scenario, bone scintigraphy has a critical role in assisting with differentiation between malignant and benign neoplasms.