Imaging gives a clue on pattern recognition for differential diagnosis. Therefore imaging alone may not be sufficient for the diagnosis of MM. Hematopathologic and Histopathologic correlation are important key for differentiation and definitive diagnosis.

1. MULTIPLE MYELOMA
DR MATHAN RAJ
(Radiologist)
DR AB KADIR RIFAEI RASHID KHAIRI
(Anatomical Pathologist)

2. CPC

3. Case 1
• 66 years old lady with history of spine fracture treated surgically by ortho. Noted high
preop and post op TWC count : 38 and 41, respectively associated with anemia. FBP
showed neutrophilia and left shift (leukemoid reaction) and the presence of a few
atypical lymphocytes and plasmacytoid cells.
• Additional Clinical notes and Lab findings : History of cervical carcinoma in >10 years
ago. No ascites, hepatosplenomegaly or lymphadenopathy
• Serum calcium is high : 3 , Urea : 9.0
• Infective screening : non reactive
• Transpedicular biopsy of vertebral body: Hypercellular with > 50% CD138+ plasma
cells. Kappa almost 0% Lambda 1%. CPC conclusion- Not interpretable and could
not rule out light chain restriction. Loss of antigenecity most likely due to
decalcification procedure.
• Serum & Urine protein electrophoresis : IgA kappa paraproteinemia
• BMAT : Aspirate 9% plasma cells ; Trephine >50% CD138 + plasma cells
• Kappa light chain restriction confirmed
• Skeletal survey Xray showed lesion confined to T10. No other bony lesion or
osteopenia ???

4. Full blood picture

5. Transpedicular biopsy of vertebral body

6. cont.

7. SUMMARY OF CT SCAN REPORT
• Osteolytic lesions in bilateral neck of femur and left ilium
• Collapse and pathological compression fracture of T10
vertebra with soft tissue component involving the whole
of T10 vertebra body , bilateral T10 pedicles, right T10
superior articular process, extending into epidural space
and displacing & compressing onto the spinal cord. No
longitudinal high signal in the cord proximallly or distally
to T10 level to suggest infarct/ischemia or longitudinal
myelitis
• Bulky iliacus, iliopsoas and rectus femoris muscles with
intramuscular hypodense lesion.

8. Osteolytic lesion in left ileum with hypodense
lesion in the surrounding muscles

9. Osteolytic lesions in bilateral neck of femur

10. Osteolytic lesions in bilateral neck of femur

11. Bulky iliacus, iliopsoas and rectus femoris muscles with
intramuscular hypodense lesion.

12. Collapse and pathological compression fracture of T10 vertebra with soft tissue component involving the
whole of T10 vertebra body , bilateral T10 pedicles, right T10 superior articular process, extending into
epidural space and displacing & compressing onto the spinal cord. No longitudinal high signal in the cord
proximallly or distally to T10 level to suggest infarct/ischemia or longitudinal myelitis

13. Differential diagnosis
• Multiple myeloma
• Metastases
• Lymphoma
• Leukemia
• Infection /intramuscular abscess
/intramuscular hematoma/Extrapulmonary
TB

14. Osteolytic lesion DDX

15. Multiple myeloma
• Incidence
– Most common primary bone marrow malignancy
in adults
– Accounts for 1% of all malignant diseases and 10
% of hematologic malignancies
– Occurs between the ages of 40-80 years
• Location
– Axial skeleton is most commonly affected
(vertebra, skull, ribs, shoulder girdle, pelvis ) and
long bones

16. Multiple myeloma
• Types
– Multiple myeloma (multiple lesions)- axial
skeleton
– Solitary plasmacytoma –Common in vertebral
body, pelvis & femur

17. Multiple myeloma
• Radiographic features
a. Diffuse pattern -Numerous well circumscribed lytic bone
lesions, punched out lucencies e.g. pepperpot skull or
raindrop skull with endosteal scalloping
b. Diffuse pattern- widespread osteopenia
c. Vertebral compression fractures /vertebra plana
d. Expansile osteolytic lesion with or without extraosseous
soft tissue component.
• Plamacytoma
– Discrete solitary tumors of neoplastic monoclonal plasma
cells either bone or soft tissue –solitary bone
plasmacytoma(70%) or extramedullary
plasmacytoma(30%)
– Tends to be large and expansile

18. Skeletal Survey
• Essential not only for the diagnosis of MM
but also pre-empting potential
complication.
• Lateral skull
• Frontal chest radiograph
• Cervical-thoracolumbar spine
• Shoulders
• Pelvis
• Femur

19. Cross- sectional imaging(CT, MRI, PET-CT )
• Extramedullary non-osseous disease cannot be
visualized on conventional radiography.
• Greater sensitivity for osseous lesions with cross
sectional imaging compared to conventional
imaging
• PET-CT (FDG)-growing role in identifying the
distribution of the disease. 18F-FDG uptake by the
myeloma lesions corresponds to areas of bone
lysis seen on CT
• PET-CT –provides functional information
(metabolic activity) for monitoring treatment
response (metabolically active or not)

20. Multiple myeloma
• Differential diagnosis
– Main DDX is widespread bony metastases
– Others would be Lymphoma, leukemia
• Lymphoma
– Secondary is commoner than primary
– Secondary is usually lytic or permeative
– Primary can be lytic, sclerotic or permeative

21. Multiple myeloma

22. Multiple myeloma

23. Multiple myeloma

24. Multiple myeloma

25. Multiple myeloma

26. Multiple myeloma
MRI of the thoracic spine demonstrates extensive patchy
regions of bone marrow replacement (normal fatty marrow is
bright on both T1 and T2 - abnormal marrow is dark)

27. Multiple myeloma

28. Multiple Myeloma

29. Metastasis
• Skeletal metastases accounts for 70 % of all
malignant bone tumors
• More with lung cancer, breast cancer, renal cell
carcinoma and prostate cancer (80% of all skeletal
metastases)
• Adult male:
– Prostate, lung, kidney
• Adult female
– Breast, lung, kidney
• Children
– Neuroblastoma, lymphoma, leukemia,
medulloblastoma, sarcoma, Wilm’s tumor

30. Metastasis
• Location:
– Vertebra , especially posterior vertebral body
extending into pedicles
– Pelvis
– Proximal femur
– Proximal humerus
– Skull

31. Metastasis
• Lytic metastases
– Kidney
– Lung
– Thyroid
– Breast
• Sclerotic metastases
– Brain, Bronchus, Breast, Bladder, Bowel, Lymphoma &Prostate
• Mixed lytic sclerotic metastases
– Breast carcinoma
– Lung carcinoma
– Carcinoma of the cervix
– Testicular tumors
– Prostate carcinoma
• Metastases may be diffuse, focal or expansile

32. Metastasis

33. Metastasis

34. Metastasis

35. Metastasis
1. Osteoblasti
c
metastases
2. Lymphoma

36. Metastasis

37. Diagnostic criteria of Multiple Myeloma (IMWG)
• Plasma cell myeloma
Clonal bone marrow plasma cells ≥10% or biopsy -proven bony or
extramedullary plasmacytoma and ≥ 1 of the following myeloma defining events
:
– End-organ damage attributable to the plasma cell proferative disorder :
• Hypercalcemia
• Renal insufficiency
• Anemia
• Bone lesions ≥ 1 osetolytic lesion on skeletal radiography, CT or
PET –CT
– ≥ 1 of the following biomarkers of malignancy :
• Clonal bone marrow plasma cell percentage ≥60%
• An involved to uninvolved serum free light chain ratio ≥100
• > 1 focal lesion on MRI
• Smouldering (asymptomatic) plasma cell myeloma
Both criteria must be met :
-Serum M protein (IgG & IgA) ≥30g/L or urinary M protein ≥ 500 mg/24
hours and/or clonal bone marrow plasma cells percentage of 10-60%
-Absence of myeloma defining events or amyloidosis

38. In conclusion
• Imaging gives a clue on pattern
recognition for differential diagnosis.
Therefore imaging alone may not be
sufficient for the diagnosis of MM.
• Hematopathologic and Histopathologic
correlation are important key for
differentiation and definitive diagnosis.

39. THANK YOU FOR YOUR ATTENTION