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Multiple Myeloma
Pushpender Gupta, MBBS
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KEY FACTS

  • Terminology

    • Imaging

      • Clinical Issues

        • Diagnostic Checklist

          TERMINOLOGY

          • Definitions

            • Multiple myeloma (MM): Malignant neoplasm of plasma cells in bone marrow
              • Smoldering (asymptomatic) MM
                • Elevated M-protein in serum (IgG or IgA ≥ 3 g/dL) or Bence-Jones protein ≥ 500 mg/24 &/or bone marrow clonal plasma cells 10-60%, no end-organ damage, no bone lesions, no amyloidosis
              • Active (symptomatic) MM
                • 1 or more of the following: Myeloma-related organ dysfunction (CRAB criteria), bone marrow clonal plasma cells > 60%, > 1 focal lesion (≥ 5 mm) on MR
            • Diagnosis of myeloma
              • At least 10% clonal bone marrow plasma cells
              • Serum or urinary monoclonal protein
            • Myeloma-related organ dysfunction (CRAB criteria)
              • Increased serum calcium (> 11.5 mg/dL), renal insufficiency (creatinine > 2 mg/dL), anemia (hemoglobin < 10 g/dL), bone disease (lytic lesions, severe osteopenia, or pathological fracture)
            • Monoclonal gammopathy of undetermined significance (MGUS)
              • Elevated M-protein, bone marrow clonal plasma cells < 10%, no end-organ damage
            • Solitary plasmacytoma
              • Solitary bone or soft tissue lesion without marrow clonal plasma cell proliferation, no end-organ damage

          IMAGING

          • F-18 FDG PET/CT

            • Radiographic Findings

              • CT Findings

                • MR Findings

                  • Nuclear Medicine Findings

                    • Imaging Recommendations

                      DIFFERENTIAL DIAGNOSIS

                        PATHOLOGY

                        • General Features

                          • Staging, Grading, & Classification

                            • Microscopic Features

                              • Pathophysiology

                                CLINICAL ISSUES

                                • Presentation

                                  • Demographics

                                    • Natural History & Prognosis

                                      • Treatment

                                        DIAGNOSTIC CHECKLIST

                                        • Consider

                                          • Image Interpretation Pearls

                                            Selected References

                                            1. Mesguich C et al: State of the art imaging of multiple myeloma: comparative review of FDG PET/CT imaging in various clinical settings. Eur J Radiol. 83(12): 2203-23, 2014
                                            2. van de Donk NW et al: Diagnosis and risk stratification in multiple myeloma. Hematol Oncol Clin North Am. 28(5):791-813, 2014
                                            3. Koppula B et al: Imaging of multiple myeloma: usefulness of MRI and PET/CT. Semin Ultrasound CT MR. 34(6):566-77, 2013
                                            4. Padhani AR et al: Assessing the relation between bone marrow signal intensity and apparent diffusion coefficient in diffusion-weighted MRI. AJR Am J Roentgenol. 200(1):163-70, 2013
                                            5. Sebro R et al: Value of true whole-body FDG-PET/CT scanning protocol in oncology: optimization of its use based on primary diagnosis. Acta Radiol. Epub ahead of print, 2013
                                            6. Caldarella C et al: Is fluorine-18-fluorodeoxyglucose positron emission tomography useful in monitoring the response to treatment in patients with multiple myeloma? Int J Hematol. 96(6):685-91, 2012
                                            7. Fonti R et al: Metabolic tumor volume assessed by 18F-FDG PET/CT for the prediction of outcome in patients with multiple myeloma. J Nucl Med. 53(12):1829-35, 2012
                                            8. van Lammeren-Venema D et al: ¹⁸F-fluoro-deoxyglucose positron emission tomography in assessment of myeloma-related bone disease: a systematic review. Cancer. 118(8):1971-81, 2012
                                            9. Walker RC et al: Imaging of multiple myeloma and related plasma cell dyscrasias. J Nucl Med. 53(7):1091-101, 2012
                                            10. Zhang Y et al: Multiple metastasis-like bone lesions in scintigraphic imaging. J Biomed Biotechnol. 2012:957364, 2012
                                            11. Palumbo A et al: Multiple myeloma. N Engl J Med. 364(11):1046-60, 2011
                                            12. Sager S et al: The value of FDG PET/CT in the initial staging and bone marrow involvement of patients with multiple myeloma. Skeletal Radiol. 40(7):843-7, 2011
                                            13. Lütje S et al: Role of radiography, MRI and FDG-PET/CT in diagnosing, staging and therapeutical evaluation of patients with multiple myeloma. Ann Hematol. 88(12):1161-8, 2009
                                            14. Fonti R et al: 18F-FDG PET/CT, 99mTc-MIBI, and MRI in evaluation of patients with multiple myeloma. J Nucl Med. 49(2):195-200, 2008
                                            15. Pace L et al: Use of 99mTc-sestamibi scintigraphy in multiple myeloma. J Nucl Med. 47(3):555, 2006
                                            16. Bredella MA et al: Value of FDG PET in the assessment of patients with multiple myeloma. AJR Am J Roentgenol. 184(4):1199-204, 2005
                                            17. Alexandrakis MG et al: Correlation between the uptake of Tc-99m-sestaMIBI and prognostic factors in patients with multiple myeloma. Clin Lab Haematol. 24(3):155-9, 2002
                                            18. Durie BG et al: Whole-body (18)F-FDG PET identifies high-risk myeloma. J Nucl Med. 43(11):1457-63, 2002
                                            19. Van de Berg BC et al: Stage I multiple myeloma: value of MR imaging of the bone marrow in the determination of prognosis. Radiology. 201(1):243-6, 1996
                                            20. Bergsagel D: The incidence and epidemiology of plasma cell neoplasms. Stem Cells. 13 Suppl 2:1-9, 1995
                                            21. Moulopoulos LA et al: Extraosseous multiple myeloma: imaging features. AJR Am J Roentgenol. 161(5):1083-7, 1993
                                            22. Waxman AD et al: Radiographic and radionuclide imaging in multiple myeloma: the role of gallium scintigraphy: concise communication. J Nucl Med. 22(3):232-6, 1981
                                            23. Durie BG et al: A clinical staging system for multiple myeloma. Correlation of measured myeloma cell mass with presenting clinical features, response to treatment, and survival. Cancer. 36(3):842-54, 1975
                                            Related Anatomy
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                                            Related Differential Diagnoses
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                                            References
                                            Tables

                                            Tables

                                            KEY FACTS

                                            • Terminology

                                              • Imaging

                                                • Clinical Issues

                                                  • Diagnostic Checklist

                                                    TERMINOLOGY

                                                    • Definitions

                                                      • Multiple myeloma (MM): Malignant neoplasm of plasma cells in bone marrow
                                                        • Smoldering (asymptomatic) MM
                                                          • Elevated M-protein in serum (IgG or IgA ≥ 3 g/dL) or Bence-Jones protein ≥ 500 mg/24 &/or bone marrow clonal plasma cells 10-60%, no end-organ damage, no bone lesions, no amyloidosis
                                                        • Active (symptomatic) MM
                                                          • 1 or more of the following: Myeloma-related organ dysfunction (CRAB criteria), bone marrow clonal plasma cells > 60%, > 1 focal lesion (≥ 5 mm) on MR
                                                      • Diagnosis of myeloma
                                                        • At least 10% clonal bone marrow plasma cells
                                                        • Serum or urinary monoclonal protein
                                                      • Myeloma-related organ dysfunction (CRAB criteria)
                                                        • Increased serum calcium (> 11.5 mg/dL), renal insufficiency (creatinine > 2 mg/dL), anemia (hemoglobin < 10 g/dL), bone disease (lytic lesions, severe osteopenia, or pathological fracture)
                                                      • Monoclonal gammopathy of undetermined significance (MGUS)
                                                        • Elevated M-protein, bone marrow clonal plasma cells < 10%, no end-organ damage
                                                      • Solitary plasmacytoma
                                                        • Solitary bone or soft tissue lesion without marrow clonal plasma cell proliferation, no end-organ damage

                                                    IMAGING

                                                    • F-18 FDG PET/CT

                                                      • Radiographic Findings

                                                        • CT Findings

                                                          • MR Findings

                                                            • Nuclear Medicine Findings

                                                              • Imaging Recommendations

                                                                DIFFERENTIAL DIAGNOSIS

                                                                  PATHOLOGY

                                                                  • General Features

                                                                    • Staging, Grading, & Classification

                                                                      • Microscopic Features

                                                                        • Pathophysiology

                                                                          CLINICAL ISSUES

                                                                          • Presentation

                                                                            • Demographics

                                                                              • Natural History & Prognosis

                                                                                • Treatment

                                                                                  DIAGNOSTIC CHECKLIST

                                                                                  • Consider

                                                                                    • Image Interpretation Pearls

                                                                                      Selected References

                                                                                      1. Mesguich C et al: State of the art imaging of multiple myeloma: comparative review of FDG PET/CT imaging in various clinical settings. Eur J Radiol. 83(12): 2203-23, 2014
                                                                                      2. van de Donk NW et al: Diagnosis and risk stratification in multiple myeloma. Hematol Oncol Clin North Am. 28(5):791-813, 2014
                                                                                      3. Koppula B et al: Imaging of multiple myeloma: usefulness of MRI and PET/CT. Semin Ultrasound CT MR. 34(6):566-77, 2013
                                                                                      4. Padhani AR et al: Assessing the relation between bone marrow signal intensity and apparent diffusion coefficient in diffusion-weighted MRI. AJR Am J Roentgenol. 200(1):163-70, 2013
                                                                                      5. Sebro R et al: Value of true whole-body FDG-PET/CT scanning protocol in oncology: optimization of its use based on primary diagnosis. Acta Radiol. Epub ahead of print, 2013
                                                                                      6. Caldarella C et al: Is fluorine-18-fluorodeoxyglucose positron emission tomography useful in monitoring the response to treatment in patients with multiple myeloma? Int J Hematol. 96(6):685-91, 2012
                                                                                      7. Fonti R et al: Metabolic tumor volume assessed by 18F-FDG PET/CT for the prediction of outcome in patients with multiple myeloma. J Nucl Med. 53(12):1829-35, 2012
                                                                                      8. van Lammeren-Venema D et al: ¹⁸F-fluoro-deoxyglucose positron emission tomography in assessment of myeloma-related bone disease: a systematic review. Cancer. 118(8):1971-81, 2012
                                                                                      9. Walker RC et al: Imaging of multiple myeloma and related plasma cell dyscrasias. J Nucl Med. 53(7):1091-101, 2012
                                                                                      10. Zhang Y et al: Multiple metastasis-like bone lesions in scintigraphic imaging. J Biomed Biotechnol. 2012:957364, 2012
                                                                                      11. Palumbo A et al: Multiple myeloma. N Engl J Med. 364(11):1046-60, 2011
                                                                                      12. Sager S et al: The value of FDG PET/CT in the initial staging and bone marrow involvement of patients with multiple myeloma. Skeletal Radiol. 40(7):843-7, 2011
                                                                                      13. Lütje S et al: Role of radiography, MRI and FDG-PET/CT in diagnosing, staging and therapeutical evaluation of patients with multiple myeloma. Ann Hematol. 88(12):1161-8, 2009
                                                                                      14. Fonti R et al: 18F-FDG PET/CT, 99mTc-MIBI, and MRI in evaluation of patients with multiple myeloma. J Nucl Med. 49(2):195-200, 2008
                                                                                      15. Pace L et al: Use of 99mTc-sestamibi scintigraphy in multiple myeloma. J Nucl Med. 47(3):555, 2006
                                                                                      16. Bredella MA et al: Value of FDG PET in the assessment of patients with multiple myeloma. AJR Am J Roentgenol. 184(4):1199-204, 2005
                                                                                      17. Alexandrakis MG et al: Correlation between the uptake of Tc-99m-sestaMIBI and prognostic factors in patients with multiple myeloma. Clin Lab Haematol. 24(3):155-9, 2002
                                                                                      18. Durie BG et al: Whole-body (18)F-FDG PET identifies high-risk myeloma. J Nucl Med. 43(11):1457-63, 2002
                                                                                      19. Van de Berg BC et al: Stage I multiple myeloma: value of MR imaging of the bone marrow in the determination of prognosis. Radiology. 201(1):243-6, 1996
                                                                                      20. Bergsagel D: The incidence and epidemiology of plasma cell neoplasms. Stem Cells. 13 Suppl 2:1-9, 1995
                                                                                      21. Moulopoulos LA et al: Extraosseous multiple myeloma: imaging features. AJR Am J Roentgenol. 161(5):1083-7, 1993
                                                                                      22. Waxman AD et al: Radiographic and radionuclide imaging in multiple myeloma: the role of gallium scintigraphy: concise communication. J Nucl Med. 22(3):232-6, 1981
                                                                                      23. Durie BG et al: A clinical staging system for multiple myeloma. Correlation of measured myeloma cell mass with presenting clinical features, response to treatment, and survival. Cancer. 36(3):842-54, 1975