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Multiple Myeloma: Clinical Review and Diagnostic Imaging¹

¹ From the Department of Radiology (E.J.C.A., R.W., R.S.) and the Myeloma Institute (A.B.T.F., B.B.), University of Arkansas for Medical Sciences, 4301 W Markham, Slot 596, Little Rock, AR 72205. Received April 22, 2002; revision requested June 19; revision received March 4, 2003; accepted March 17. Address correspondence to E.J.C.A. (e-mail: angtuacoedgardoj@uams.edu).

View larger version (159K): [in a new window]   Figure 1a. Multiple plasmacytomas with cord compression. (a) Sagittal T1-weighted spin-echo (repetition time msec/echo time msec, 400/15) (left) and short tau inversion-recovery (STIR; repetition time msec/echo time msec/inversion time msec, 2,000/150/20) (right) magnetic resonance (MR) images of thoracic spine show scattered focal lesions involving vertebral bodies and posterior elements of thoracic spine. Both (b) transverse (600/15) and sagittal (a, left) T1-weighted spin-echo MR images show cord compression by a focal expansile mass (arrow) at the T10 spinous process.

View larger version (109K): [in a new window]   Figure 1b. Multiple plasmacytomas with cord compression. (a) Sagittal T1-weighted spin-echo (repetition time msec/echo time msec, 400/15) (left) and short tau inversion-recovery (STIR; repetition time msec/echo time msec/inversion time msec, 2,000/150/20) (right) magnetic resonance (MR) images of thoracic spine show scattered focal lesions involving vertebral bodies and posterior elements of thoracic spine. Both (b) transverse (600/15) and sagittal (a, left) T1-weighted spin-echo MR images show cord compression by a focal expansile mass (arrow) at the T10 spinous process.

View larger version (168K): [in a new window]   Figure 2. Multiple compression fractures on CT and MR images. Comparative images from sagittal reformatted CT data set (left) and sagittal STIR MR image (2,000/150/20) (right) of thoracic spine show multiple compression fractures of thoracic vertebral bodies, with severe thoracic kyphosis and marked osteolysis of the T1 vertebral body (arrow).

View larger version (155K): [in a new window]   Figure 3. Lytic expansile mass of C5. Transverse CT image at level of C5 shows expansile soft-tissue mass along right side of C5 vertebral body, with associated bone destruction.

View larger version (79K): [in a new window]   Figure 4. One-month comparative FDG PET images show good response to therapy. Left: Initial image shows increased metabolic activity in spine and pelvis. Note separate focal mass (arrow) in left iliac region. Right: Posttreatment (1-month follow-up) study shows decrease in overall metabolic activity in spine and pelvis, with resolution of left iliac mass and residual disease (arrowhead) in left sacrum. Decrease in metabolic activity indicates good response to chemotherapeutic agents.

View larger version (84K): [in a new window]   Figure 5a. Skull involvement of MM. (a) Craniovertebral junction disease. Unenhanced sagittal T1-weighted spin-echo MR images (450/15) of the head in two patients. Left: Clivus shows diffuse hypointensity with nonexpansile distal mass (arrow). Right: Focal expansile mass of dens (arrowhead) causes compression of cervicomedullary junction. (b) Multiple calvarial diploic lesions. Coronal fat-suppressed contrast-enhanced T1-weighted spin-echo MR image (550/15) of the head shows multiple focal areas of enhancement (arrowheads) of the diploë with an expansile mass (arrow) in left lateral frontal diploë.

View larger version (165K): [in a new window]   Figure 5b. Skull involvement of MM. (a) Craniovertebral junction disease. Unenhanced sagittal T1-weighted spin-echo MR images (450/15) of the head in two patients. Left: Clivus shows diffuse hypointensity with nonexpansile distal mass (arrow). Right: Focal expansile mass of dens (arrowhead) causes compression of cervicomedullary junction. (b) Multiple calvarial diploic lesions. Coronal fat-suppressed contrast-enhanced T1-weighted spin-echo MR image (550/15) of the head shows multiple focal areas of enhancement (arrowheads) of the diploë with an expansile mass (arrow) in left lateral frontal diploë.

View larger version (114K): [in a new window]   Figure 6a. MR imaging patterns in MM. Multiple midline sagittal MR images of thoracic or lumbar spine. (a-c) Left: T1-weighted spin-echo images (400/15). Middle: STIR images (2,000/150/20). Right: Gadolinium-enhanced fat-suppressed T1-weighted spin-echo images (500/15). (a) Normal MR pattern in lumbar spine. Note primarily fatty marrow (normal MR pattern) with diffuse hyperintensity on T1-weighted spin-echo image, diffuse hypointensity on STIR image, and no marrow enhancement on gadolinium-enhanced image. Note homogeneity of marrow signal intensity for all imaging sequences. (b) Diffuse marrow involvement in lumbar spine. Note primarily cellular marrow demonstrating reversal of normal MR pattern, with diffuse hypointensity on T1-weighted spin-echo image, diffuse hyperintensity on STIR image, and marked enhancement on gadolinium-enhanced image. There is associated fracture of the T12 vertebral body. (c) Diffuse heterogeneous marrow involvement in lumbar spine. Note heterogeneity of marrow signal intensity through all observed vertebral bodies, with mixed areas of hypointensity and hyperintensity on T1-weighted spin-echo, STIR, and gadolinium-enhanced images. Note reversal of signal intensity on T1-weighted and STIR images. MR imaging patterns in MM. (d, e) Left: T1-weighted spin-echo images (400/15). Middle: STIR images (2,000/150/20). Right: Gadolinium-enhanced fat-suppressed T1-weighted spin-echo images (500/15). (d) Diffuse speckled marrow involvement in thoracic spine. Note nodular abnormalities in entire spine are better seen on STIR and gadolinium-enhanced images. Speckled, or salt-and-pepper, appearance is better appreciated on STIR and gadolinium-enhanced images, again with posterior-element lesions better seen on these images. (e) Focal disease in thoracic spine. Note several focal lesions at T3 and T4 spinous processes and T12 vertebral body. The smaller spinous process lesions at T4 (arrows) can be seen only on STIR and gadolinium-enhanced images.

View larger version (117K): [in a new window]   Figure 6b. MR imaging patterns in MM. Multiple midline sagittal MR images of thoracic or lumbar spine. (a-c) Left: T1-weighted spin-echo images (400/15). Middle: STIR images (2,000/150/20). Right: Gadolinium-enhanced fat-suppressed T1-weighted spin-echo images (500/15). (a) Normal MR pattern in lumbar spine. Note primarily fatty marrow (normal MR pattern) with diffuse hyperintensity on T1-weighted spin-echo image, diffuse hypointensity on STIR image, and no marrow enhancement on gadolinium-enhanced image. Note homogeneity of marrow signal intensity for all imaging sequences. (b) Diffuse marrow involvement in lumbar spine. Note primarily cellular marrow demonstrating reversal of normal MR pattern, with diffuse hypointensity on T1-weighted spin-echo image, diffuse hyperintensity on STIR image, and marked enhancement on gadolinium-enhanced image. There is associated fracture of the T12 vertebral body. (c) Diffuse heterogeneous marrow involvement in lumbar spine. Note heterogeneity of marrow signal intensity through all observed vertebral bodies, with mixed areas of hypointensity and hyperintensity on T1-weighted spin-echo, STIR, and gadolinium-enhanced images. Note reversal of signal intensity on T1-weighted and STIR images. MR imaging patterns in MM. (d, e) Left: T1-weighted spin-echo images (400/15). Middle: STIR images (2,000/150/20). Right: Gadolinium-enhanced fat-suppressed T1-weighted spin-echo images (500/15). (d) Diffuse speckled marrow involvement in thoracic spine. Note nodular abnormalities in entire spine are better seen on STIR and gadolinium-enhanced images. Speckled, or salt-and-pepper, appearance is better appreciated on STIR and gadolinium-enhanced images, again with posterior-element lesions better seen on these images. (e) Focal disease in thoracic spine. Note several focal lesions at T3 and T4 spinous processes and T12 vertebral body. The smaller spinous process lesions at T4 (arrows) can be seen only on STIR and gadolinium-enhanced images.

View larger version (114K): [in a new window]   Figure 6c. MR imaging patterns in MM. Multiple midline sagittal MR images of thoracic or lumbar spine. (a-c) Left: T1-weighted spin-echo images (400/15). Middle: STIR images (2,000/150/20). Right: Gadolinium-enhanced fat-suppressed T1-weighted spin-echo images (500/15). (a) Normal MR pattern in lumbar spine. Note primarily fatty marrow (normal MR pattern) with diffuse hyperintensity on T1-weighted spin-echo image, diffuse hypointensity on STIR image, and no marrow enhancement on gadolinium-enhanced image. Note homogeneity of marrow signal intensity for all imaging sequences. (b) Diffuse marrow involvement in lumbar spine. Note primarily cellular marrow demonstrating reversal of normal MR pattern, with diffuse hypointensity on T1-weighted spin-echo image, diffuse hyperintensity on STIR image, and marked enhancement on gadolinium-enhanced image. There is associated fracture of the T12 vertebral body. (c) Diffuse heterogeneous marrow involvement in lumbar spine. Note heterogeneity of marrow signal intensity through all observed vertebral bodies, with mixed areas of hypointensity and hyperintensity on T1-weighted spin-echo, STIR, and gadolinium-enhanced images. Note reversal of signal intensity on T1-weighted and STIR images. MR imaging patterns in MM. (d, e) Left: T1-weighted spin-echo images (400/15). Middle: STIR images (2,000/150/20). Right: Gadolinium-enhanced fat-suppressed T1-weighted spin-echo images (500/15). (d) Diffuse speckled marrow involvement in thoracic spine. Note nodular abnormalities in entire spine are better seen on STIR and gadolinium-enhanced images. Speckled, or salt-and-pepper, appearance is better appreciated on STIR and gadolinium-enhanced images, again with posterior-element lesions better seen on these images. (e) Focal disease in thoracic spine. Note several focal lesions at T3 and T4 spinous processes and T12 vertebral body. The smaller spinous process lesions at T4 (arrows) can be seen only on STIR and gadolinium-enhanced images.

View larger version (122K): [in a new window]   Figure 6d. MR imaging patterns in MM. Multiple midline sagittal MR images of thoracic or lumbar spine. (a-c) Left: T1-weighted spin-echo images (400/15). Middle: STIR images (2,000/150/20). Right: Gadolinium-enhanced fat-suppressed T1-weighted spin-echo images (500/15). (a) Normal MR pattern in lumbar spine. Note primarily fatty marrow (normal MR pattern) with diffuse hyperintensity on T1-weighted spin-echo image, diffuse hypointensity on STIR image, and no marrow enhancement on gadolinium-enhanced image. Note homogeneity of marrow signal intensity for all imaging sequences. (b) Diffuse marrow involvement in lumbar spine. Note primarily cellular marrow demonstrating reversal of normal MR pattern, with diffuse hypointensity on T1-weighted spin-echo image, diffuse hyperintensity on STIR image, and marked enhancement on gadolinium-enhanced image. There is associated fracture of the T12 vertebral body. (c) Diffuse heterogeneous marrow involvement in lumbar spine. Note heterogeneity of marrow signal intensity through all observed vertebral bodies, with mixed areas of hypointensity and hyperintensity on T1-weighted spin-echo, STIR, and gadolinium-enhanced images. Note reversal of signal intensity on T1-weighted and STIR images. MR imaging patterns in MM. (d, e) Left: T1-weighted spin-echo images (400/15). Middle: STIR images (2,000/150/20). Right: Gadolinium-enhanced fat-suppressed T1-weighted spin-echo images (500/15). (d) Diffuse speckled marrow involvement in thoracic spine. Note nodular abnormalities in entire spine are better seen on STIR and gadolinium-enhanced images. Speckled, or salt-and-pepper, appearance is better appreciated on STIR and gadolinium-enhanced images, again with posterior-element lesions better seen on these images. (e) Focal disease in thoracic spine. Note several focal lesions at T3 and T4 spinous processes and T12 vertebral body. The smaller spinous process lesions at T4 (arrows) can be seen only on STIR and gadolinium-enhanced images.

View larger version (129K): [in a new window]   Figure 6e. MR imaging patterns in MM. Multiple midline sagittal MR images of thoracic or lumbar spine. (a-c) Left: T1-weighted spin-echo images (400/15). Middle: STIR images (2,000/150/20). Right: Gadolinium-enhanced fat-suppressed T1-weighted spin-echo images (500/15). (a) Normal MR pattern in lumbar spine. Note primarily fatty marrow (normal MR pattern) with diffuse hyperintensity on T1-weighted spin-echo image, diffuse hypointensity on STIR image, and no marrow enhancement on gadolinium-enhanced image. Note homogeneity of marrow signal intensity for all imaging sequences. (b) Diffuse marrow involvement in lumbar spine. Note primarily cellular marrow demonstrating reversal of normal MR pattern, with diffuse hypointensity on T1-weighted spin-echo image, diffuse hyperintensity on STIR image, and marked enhancement on gadolinium-enhanced image. There is associated fracture of the T12 vertebral body. (c) Diffuse heterogeneous marrow involvement in lumbar spine. Note heterogeneity of marrow signal intensity through all observed vertebral bodies, with mixed areas of hypointensity and hyperintensity on T1-weighted spin-echo, STIR, and gadolinium-enhanced images. Note reversal of signal intensity on T1-weighted and STIR images. MR imaging patterns in MM. (d, e) Left: T1-weighted spin-echo images (400/15). Middle: STIR images (2,000/150/20). Right: Gadolinium-enhanced fat-suppressed T1-weighted spin-echo images (500/15). (d) Diffuse speckled marrow involvement in thoracic spine. Note nodular abnormalities in entire spine are better seen on STIR and gadolinium-enhanced images. Speckled, or salt-and-pepper, appearance is better appreciated on STIR and gadolinium-enhanced images, again with posterior-element lesions better seen on these images. (e) Focal disease in thoracic spine. Note several focal lesions at T3 and T4 spinous processes and T12 vertebral body. The smaller spinous process lesions at T4 (arrows) can be seen only on STIR and gadolinium-enhanced images.

View larger version (157K): [in a new window]   Figure 7. Diffuse disease with multifocal lesions. Noncontiguous coronal STIR MR images (2,000/150/20) demonstrate diffuse overall hyperintensity of marrow as compared with signal intensity of adjacent muscles. Focal lesions involving right posterior ilium (curved arrow), right and left ischium (arrowheads), and L4 and L5 vertebral bodies with extraosseous mass at right side of L5 (straight arrows) are noted against background of hyperintense marrow.

View larger version (177K): [in a new window]   Figure 8. Complete resolution of diffuse and focal lesions. Left: Pretreatment sagittal (top) and coronal (bottom) STIR MR images (2,000/150/20) of lumbar spine and pelvis show diffuse disease with focal lesions (straight arrows) in pelvis. Right: Follow-up sagittal (top) and coronal (bottom) STIR MR images (2,000/150/20) of lumbar spine and pelvis show complete resolution of both diffuse and focal lesions. Note normal MR appearance of diffuse hypointensity without focal lesions. Superior end-plate fracture at L4 (curved arrow) has developed.

View larger version (141K): [in a new window]   Figure 9. Plasmacytoma with associated compression fracture of C7. Sagittal T1-weighted (left; 600/15) and STIR (right; 2,000/150/20) MR images of cervical spine show focal lesion (arrows) involving C7 vertebral body, with associated fracture. There is protrusion of the plasmacytoma into adjacent spinal canal.

View larger version (142K): [in a new window]   Figure 10. Leptomeningeal spread in MM. Contrast-enhanced sagittal (left) and transverse (right) T1-weighted spin-echo (450/15) MR images of lumbar spine show abnormal enhancement of nerve roots (arrowhead) and surface of conus medullaris (arrow). Transverse image shows distinct nodular enhancement of the cauda equina, indicative of leptomeningeal spread of tumor.

View larger version (87K): [in a new window]   Figure 11. Extramedullary spread in MM. Left: Transverse T2-weighted spin-echo MR image (2,000/80) in a patient with clinical findings of relapse show a mass (curved arrow) in the left pararenal space. A separate mass (straight arrow) is in the right pararenal space. Right: On transverse T2-weighted (2,000/80) section obtained at a lower level, right pararenal mass is shown extending into adjacent right neural foramen and epidural space (arrowhead). Associated dural sac compression is noted. Biopsy of both masses revealed malignant plasma cells.

View larger version (145K): [in a new window]   Figure 12. MR-directed CT-assisted biopsy. Left: Sagittal contrast-enhanced fat-suppressed T1-weighted spin-echo (600/15) MR image shows two enhancing lesions at T3 (arrow) and T9 (arrowhead). Right: Transverse CT image obtained with patient in prone position during CT-assisted biopsy of the T9 lesion shows biopsy needle (arrow) entering the lytic lesion of T9 vertebral body by using a transpedicular approach.