대한흉부영상의학회 Korean Society of Thoracic Radiology

Discussion

Diagnosis With Brief Discussion

Diagnosis

Extraosseous manifestation of multiple myeloma

Radiologic Findings

Figure 1. Initial chest AP shows subtle pleural nodularity in the both upper hemithorax.
Figure 2. Chest AP after 1 month shows bilateral pleural effusion with suspicious bilateral pleural nodularity.
Figure 3 -5. CT scans reveal multiple enhancing pleural nodules with bilateral pleural effusion and multiple homogeneously enhancing soft tissue masses at chest wall, paravertebral area, and retrosternal area.
Figure 6. Axial CT scan with lung window setting shows partial atelectasis at both lower lobes and no other abnormal finding in the lung parenchyma.
Figure 7. Coronal CT scan with bone window setting shows multifocal diffuse osteolytic lesions in the bony thorax.

In this case, multiple myeloma was diagnosed by bone marrow biopsy. Also, thoracocentesis was done and pleural myelomatous involvement was confirmed through pleural fluid cytology.

Figure 8. T1 enhanced brain MRIs show diffuse dural thickening with enhancement, extraosseous mass in the both orbit, and bone marrow signal change with enhancement in the skull.

Figure 9. T1WI and T1 enhancement with fat suppression of L-spine MRIs show diffuse low signal intensity of the bone marrow with multifocal enhancing bone lesions. Consistent with multiple myeloma.

Figure 8

Figure 9

Brief Review

Multiple myeloma is a malignancy of clonal plasma cell proliferation arising in the bone marrow. A minority of patients with multiple myeloma have imaging findings of extraosseous involvement. Recent studies suggest that clinically or radiologically detectable extraosseous manifestations occur in approximately 10–16% of patients with multiple myeloma. Extraosseous myeloma may affect any organ and can mimic other malignancies. Patients with extraosseous myeloma have significantly shorter overall survival and shorter progression-free survival.
The skeletal involvement of multiple myeloma shows lytic bone lesions, diffuse osteopenia and osteoporotic fractures. The predominant areas of skeletal bone involvement include the axial skeleton - vertebral bodies (49%), skull (35%), pelvis (34%), and ribs (33%) - as well as the proximal metaphysis of long bones, especially the femur and humerus.
Extraosseous myeloma can affect any organ, and its imaging findings are nonspecific. Common imaging features include soft-tissue masses with homogeneous density on CT, a lack of necrosis and calcification, low T2 signal on MRI because of high cellularity, and FDG uptake on FDG PET.
Extraosseous myeloma in the thorax occurs most commonly in the form of pulmonary parenchymal nodules, masses, or interstitial infiltration. The lung nodules appear as multiple scattered forms in both lungs. Pleural involvement can also be seen. CT image shows pleural thickening or irregular nodular pleural-based soft tissues with pleural effusion.

Please refer to

Case 355, Case 638, Case 998, Case 1014,

References

1. Hall, Matthew N., et al. "Imaging of extraosseous myeloma: CT, PET/CT, and MRI features." American Journal of Roentgenology 195.5 (2010): 1057-1065.
2. Ormond Filho, Alípio G., et al. "Whole-Body Imaging of Multiple Myeloma: Diagnostic Criteria." RadioGraphics 39.4 (2019): 1077-1097.
3. Seo, Jung Min, et al. "A pictorial review on extraosseous manifestations of multiple myelomas." Journal of the Korean Society of Radiology 64.6 (2011): 567-575.

Keywords

pleura, chest wall, myeloma,