Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Daniela Marinho Tridente, VI FCMSCSP Gillian Lieberman, MD October 2013 A Diagnostic Chest XRay: Multiple Myeloma Daniela Marinho Tridente, VI FCMSCSP Gillian Lieberman, MD Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD Our Learning Agenda Introduction of our patient His imaging data and findings Differential diagnosis Multiple Myeloma Diagnostic approach of MM Imaging Techniques on MM Some take home points 2 Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD The patient in question 63 years old male No priors Not in use of any medication No family history 3 Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD His chief complaint Right infrascapular pain and pleuritic pain 4 Daniela Marinho Tridente, VI FCMSCSP Gillian Lieberman, MD A chest x ray was requested, as to evaluate for possible fractures, bone lesions or pleural reaction Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD Update #1: Learning Agenda Introduction of our patient His imaging data and findings Differential diagnosis Multiple Myeloma Diagnostic approach of MM Imaging Techniques on MM Some take home points 6 Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD First relevant findings Multiple rightsided rib fractures Destructive rib lesion with soft tissue component at the right eighth rib laterally Multiple lytic lucencies in the right scapula PACS, BIDMC PA chest x ray 7 Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD Additional view: CXR The lucencies mentioned in the PA are better seen at the concurrent rib series performed on the same day PACS, BIDMC Unilateral rib series and chest PA x ray 8 Daniela Marinho Tridente, VI FCMSCSP Gillian Lieberman, MD Comparison was made to prior chest xrays dated July 2007 and none of the findings were considered preexisting. Daniela Marinho Tridente, VI FCMSCSP Gillian Lieberman, MD Following up… Additional scans were recommended by the radiologist, to correlate multiple myeloma or metastases since the patient had no priors. Daniela Marinho Tridente, VI FCMSCSP Gillian Lieberman, MD That being so, our patient had a skeletal survey done as well as a Chest CT Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD Skeletal Survey: skull Let’s pause for a minute and look for any abnormalities… PACS, BIDMC Skull x ray, lateral view 12 Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD Skeletal Survey: skull (findings) Multiple rounded lucencies in the skull, non-specific but highly compatible with myeloma PACS, BIDMC Skull x ray, lateral view 13 Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD Skeletal Survey: left femur Let’s pause for a minute and look for any abnormalities… PACS, BIDMC Left femur PA x ray 14 Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD Skeletal Survey: left femur (findings) A rounded 6.5mm lucency is seen in the distal left femur adjacent to the lateral cortex of the distal diaphysis and could represent a small myelomatous lesion PACS, BIDMC Left femur PA x ray 15 Daniela Marinho Tridente, VI FCMSCSP Gillian Lieberman, MD Additionally, osteopenia was noted on the cervical and thoracic spines Daniela Marinho Tridente, VI FCMSCSP Gillian Lieberman, MD Let’s move on and have a look at the Chest CT… Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD Chest CT (findings) Diffuse demineralization and lytic lesions affect nearly the entire chest cage, consistent with multiple myeloma A compression deformity of the T9 vertebral body, with approximately 50% loss of height PACS, BIDMC Sagital view, chest CT 18 Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD More on the chest CT A 3.5 x 1.8 cm expansile lytic lesion is present in the lateral, right eighth rib with associated soft tissue mass in the chest wall that causes cortical destruction and pathologic fracture PACS, BIDMC Axial view, chest CT 19 Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD Update #2: Learning Agenda Introduction of our patient His imaging data and findings Differential diagnosis Multiple Myeloma Diagnostic approach of MM Imaging Techniques on MM Some take home points 20 Daniela Marinho Tridente, VI FCMSCSP Gillian Lieberman, MD Let’s consider the differential diagnosis of lytic lesions… Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD DDX for Lytic Lesions Here are some of the most common well-defined bone tumors and tumorlike lesions FD: fibrous dysplasia EG: eosinophilic granuloma NOF: non-ossifying fibroma SBC: simple bone cyst ABC: aneurysmal bone cyst CMF: chondromyxoid fibroma Giant CT: giant cell tumour 22 http://www.radiologyassistant.nl/en/p4bc6176e56228/bone-tumor-well-defined-osteolytic-tumors-and-tumor-like-lesions.html Daniela Marinho Tridente, VI FCMSCSP Gillian Lieberman, MD One of the ways to consider the differential diagnosis of lytic lesions is through the use of the mnemonic “FEGNOMASHIC” Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD “FEGNOMASHIC” 24 http://www.radiologyassistant.nl/en/p4bc6176e56228/bone-tumor-well-defined-osteolytic-tumors-and-tumor-like-lesions.html Daniela Marinho Tridente, VI FCMSCSP Gillian Lieberman, MD Considering that our patient had no priors and had negative screening tests for the most common primary cancer sites… Daniela Marinho Tridente, VI FCMSCSP Gillian Lieberman, MD … that leaves us with Multiple Myeloma! Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD Update #3: Learning Agenda Introduction of our patient His imaging data and findings Differential diagnosis Multiple Myeloma Diagnostic approach of MM Imaging Techniques on MM Some take home points 27 Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD Let’s talk about MM Neoplastic disorder of plasma B cells Characteristic bone marrow infiltration and overproduction of monoclonal immunoglobulins Accounts for 10% of all haematological malignancies (and 1% of all cancers) Predominantly affects patients in the seventh decade High mortality and morbidity 28 Healy et al, “Multiple Myeloma: A Review of Imaging Features and Radiological Techniques”, 2011 Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD Standard Investigations for MM Complete blood count Serum biochemistry Serum and urine eletrophoresis Bone marrow aspirate and biopsy (GOLD STANDARD FOR DIAGNOSIS 29 Healy et al, “Multiple Myeloma: A Review of Imaging Features and Radiological Techniques”, 2011 Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD Update #4: Learning Agenda Introduction of our patient His imaging data and findings Differential diagnosis Multiple Myeloma Diagnostic approach of MM Imaging Techniques on MM Some take home points 30 Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD Diagnostic Criteria (All 3 are required for diagnosis) Monoclonal plasma cells in the bone marrow > 10% and/or presence of a biopsy-proven plasmacytoma Monoclonal protein present in the serum and/or urine Myeloma-related organ dysfunction (1 or more) ** [C] Calcium elevation in the blood {S. Calcium >10.5 mg/l or upper limit of normal} [R] Renal insufficiency {S. Creatinine > 2 mg/dl} [A] Anemia {Hemoglobin < 10 g/dl or 2 g < normal} [B] Lytic bone lesions or osteoporosis 31 Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD The Durie Salmon Staging System (1975) 32 From myeloma.org Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD The Durie Salmon PLUS New staging system, published in 2006 later staging system used skeletal survey as its only radiological criterion Effort to standardize treatment approaches and better stage the disease = improved system Integrates the more sensitive imaging techniques (MRI, CT, PET/CT…) 33 Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD Role of Radiological Imaging in MM Initial staging of disease Detection and characterization of complications Evaluation of patient’s response to treatment 34 Healy et al, “Multiple Myeloma: A Review of Imaging Features and Radiological Techniques”, 2011 Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD Update #5: Learning Agenda Introduction of our patient His imaging data and findings Differential diagnosis Multiple Myeloma Diagnostic approach of MM Imaging Techniques on MM Some take home points 35 Daniela Marinho Tridente, VI FCMSCSP Gillian Lieberman, MD Let’s consider some of the most commonly used imaging techniques… Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD Plain Radiography Full skeletal survey (frontal and lateral view of skull, cervical, thoracic and lumbar spine, coneddown frontal view of the dens axis, frontal views of rib cage, humeri, femora, knees and pelvis) Clear association between extent of disease (number of lytic lesions at presentation) and tumor load at diagnosis Almost 80% of patients will have radiological evidence of skeletal involvement Disadvantages: high false-negative rate (significant underestimation in diagnosis) 37 Healy et al, “Multiple Myeloma: A Review of Imaging Features and Radiological Techniques”, 2011 Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD Computed Tomography (CT) Great for assessing punched-out lytic lesions, expansile lesions with soft tissue masses, diffuse osteopenia and fractures (as presented earlier) Whole-body CT is not used for screening purposes due to high radiation exposure – low dose CT techniques are being developed as an alternative to plain films and since it does not require iodine containing contrast agents (contraindicated in patients with MM due to risk of renal impairment and cast nephropathy) it appears as an attractive screening option 38 Healy et al, “Multiple Myeloma: A Review of Imaging Features and Radiological Techniques”, 2011 Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD Multiple “punched-out” lytic lesions throughout lumbar spine and pelvis Volume rendering 3-dimensional reconstruction of lumbar spine and pelvis (companion patient #1) From Healy et al, Multiple Myeloma: a Review of Imaging Features and Radiological Techniques; 2011 39 Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD Whole-body MRI Favoured imaging method for evaluating disease within the bone marrow Excellent correlation with survival outcomes (due to Durie-Salmon PLUS) Focal MRI used for narrowing the differential diagnosis in a solitary lytic lesion 40 Healy et al, “Multiple Myeloma: A Review of Imaging Features and Radiological Techniques”, 2011 Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD Update #5: Learning Agenda Introduction of our patient His imaging data and findings Differential diagnosis Multiple Myeloma Diagnostic approach of MM Imaging Techniques on MM Some take home points 41 Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD Conclusions Faced with osteolytic lesions in any patients over the age of 40 years old, MM and metastases are a must when considering possible differential diagnosis; There is no single better imaging method to evaluate MM; as the new techniques become more available and less expensive, a combined view of them all is the best way to better access MM. 42 Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD References B. G. M. Durie and S. E. Salmon, “A clinical staging system for multiple myeloma. Correlation of measured myeloma cell mass with presenting clinical features, response to treatment, and survival,” Cancer, vol. 36, no. 3, pp. 842–854, 1975. B. G. M. Durie, “The role of anatomic and functional staging in myeloma: description of Durie/Salmon plus staging system,” European Journal of Cancer, vol. 42, no. 11, pp. 1539–1543, 2006. Healy et al, “Multiple Myeloma: A Review of Imaging Features and Radiological Techniques”, Bone Marrow Research, vol. 2011, 2011. Angtuaco et al, “Multiple Myeloma: Clinical Review and Diagnostic Imaging”, Radiology, vol. 231, pp. 11-23, 2004. B.G.M. Durie, “Myeloma Management Guidelines”, from myeloma.org, acessed on October 18th, 2013 Rajkumar, SV, “Clinical features, laboratory manifestations and diagnosis of multiple myeloma”, UpToDate. http://www.uptodate.com/contents/clinical-features-laboratorymanifestations-and-diagnosis-of-multiplemyeloma?source=outline_link&view=text&anchor=H22#H22. Acessed on October 17th, 2013 Woude, HJ and Smithuis, R. “Bone Tumor: well-defined osteolytic tumors and tumorlike lesions”, The Radiology Assistant, http://www.radiologyassistant.nl/en/p4bc6176e56228/bone-tumor-well-definedosteolytic-tumors-and-tumor-like-lesions.html. Acessed October 16th, 2013 43 Daniela Marinho Tridente, 6th year FCMSCSP Gillian Lieberman, MD Acknowledgments Claire Odom Gillian Lieberman, MD Ronald L. Eisenberg, MD Jawad S. Hussain, MD 44