대한흉부영상의학회 Korean Society of Thoracic Radiology

Discussion

Diagnosis With Brief Discussion

Diagnosis

Multiple myeloma

Radiologic Findings

Chest radiograph shows destruction of the posterior arc of the right fifth rib associated with a soft tissue mass. CT scans show rib destruction with soft tissue mass in the posterior arc of the right fifth and ninth ribs, Of which soft tissue masses protrude into the thorax and compress the lung. Whole body bone scan shows increased uptake in the posterior arc of Rt. 5th, 9th and Lt. 1st ribs, left parietal bone of skull, C4, T6, T7, and left proximal femur.

Brief Review

Thoracic involvement in multiple myeloma is common. Skeletal or pleuropulmonary abnormalities were 46% in one review of 958 patients and radiologic abnormalities were in 25% at the time of diagnosis. The most common manifestation of thoracic disease is neoplastic infiltration of the skeleton. The most frequently affected site is the ribs showing focal expansion with extension and proliferation of tumor in the adjacent chest wall, although involvement of the vertebrae and sternum. The radiographic findings usually consist of one or more well-defined osteolytic lesions, osteoporosis, fractures, or a combination of lesions. In the involved rib, a smooth homogenous soft issue mass protruding into thorax and compressing the lung is a typical radiologic appearance. The tumor masses can grow to a larger size, sometimes almost completely opacifying a hemithorax. However, a similar appearance can be seen in association with a primary pulmonary disease such as pulmonary carcinoma or fungal infection that invade the chest wall, with primary or metastatic chest wall neoplasm, and with other primary chest wall disease such as osteomyelitis. Pleuropulmonary involvement is much less common. Rarely, malignant pleural effusion has been reported, sometimes combined with pleural thickening and nodularity. Pulmonary parenchymal or airway involvement is also umcommon, showing one or more localized masses with lobulated contour and homogenous density, relatively diffuse parenchymal infiltration or endobronchial or endotracheal tumor with atelectasis and obstructive pneumonitis. Other intrathoracic abnormalities include multiple pulmonary nodules and mediastinal lymph node enlargement. In older patients, particularly men, the association of a destructive lesion of one or more ribs with a soft tissue mass protruding into the thorax and indenting the lung is highly suggestive of myeloma.

References

1. Kintzer JS Jr, Rosenow EC, Kyle RA. Thoracic and pulmonary abnormalities in multiple myeloma. A review of 958 cases. Arch Intern Med. 1978; 138(5): 727-30
2. Fraser RS, Muller NL, Colman N, Pare PD. Diagnosis of disease of the chest. 4th ed. Philadelphia: Saunders, 1999; 1269-1330
3. Fraser RS, Muller NL, Colman N, Pare PD. Diagnosis of disease of the chest. 4th ed. Philadelphia: Saunders, 1999; 3011-3038

Keywords

Rib, Malignant tumor,