Prognostic significance of magnetic resonance imaging in patients with asymptomatic multiple myeloma

PURPOSE

To assess the prognostic significance of magnetic resonance (MR) imaging in patients with newly diagnosed asymptomatic multiple myeloma.

PATIENTS AND METHODS

Thirty-eight consecutive patients with asymptomatic myeloma of low tumor mass and negative skeletal surveys underwent MR imaging of the thoracic and lumbosacral spine. The presence and patterns of marrow involvement were correlated with standard laboratory parameters and time to disease progression.

RESULTS

Nineteen patients (50%) had evidence of marrow involvement at spinal MR imaging. MR patterns of marrow involvement were classified as diffuse (five patients), variegated (nine), and focal (five). Patients with abnormal MR imaging studies required therapy after a median of 16 months, versus 43 months for those with normal MR studies (P < .01).

CONCLUSION

Abnormal marrow patterns were present in half of patients with asymptomatic myeloma. An abnormal MR study of the spine identified asymptomatic patients who were likely to require treatment earlier than those with a normal MR study. A normal MR pattern provided additional justification to defer institution of chemotherapy. However, MR imaging remains an investigational tool to stage patients with multiple myeloma until more data are accumulated.

Multiple myeloma: MR patterns of response to treatment

PURPOSE

To assess changes in the magnetic resonance (MR) appearance of the spine in patients with multiple myeloma who responded to chemotherapy.

MATERIALS AND METHODS

Twenty patients with multiple myeloma underwent MR imaging of the spine before and after chemotherapy. Sagittal T1-weighted images were obtained before and after administration of contrast material. MR patterns of marrow involvement before treatment were classified as focal, diffuse, or variegated. The changes seen on MR images after treatment were analyzed and correlated with the clinical response as defined with standard criteria.

RESULTS

Patterns of complete response included resolution of marrow abnormality or persistent abnormality without enhancement or with peripheral rim enhancement. Conversion of a diffuse to a variegated or focal pattern and a decrease in the amount of marrow abnormality with persistent enhancement were observed in patients who showed a partial response. Ten patients sustained new or progressive compression fractures after successful therapy.

CONCLUSION

Recognition of spinal MR patterns of response to treatment supported the occurrence of remission in patients with multiple myeloma. MR findings may help clarify response to therapy in patients with equivocal clinical changes or nonsecretory myeloma.

Acute airway obstruction and necrotizing tracheobronchitis from invasive mycosis

Necrotizing tracheobronchitis and acute airway obstruction from invasive mycosis developed in a patient who had undergone bone marrow transplantation. The infectious process obstructed the airway and disintegrated the walls of the right mainstem bronchus and pulmonary artery. The airway was cleared using rigid bronchoscopy to extract the detritus. The patient died of hemorrhage after rupture of the pulmonary artery through the right mainstem bronchus.

Extraosseous multiple myeloma: imaging features

Multiple myeloma is a disseminated malignant neoplasm usually derived from a single clone of plasma cells. Patients with myeloma have diverse signs such as anemia, hypercalcemia, uremia, pathologic fractures, and recurrent infections. Extraosseous manifestations are found in less than 5% of patients with multiple myeloma. They can arise in any tissue, and their presence has been associated with more aggressive disease. The purpose of this essay is to illustrate the imaging findings of extraosseous myeloma and heighten awareness of this unusual manifestation of multiple myeloma.

Waldenström macroglobulinemia: MR imaging of the spine and CT of the abdomen and pelvis

Twenty-three consecutive patients with Waldenström macroglobulinemia were studied with magnetic resonance (MR) imaging of the spine and computed tomography (CT) of the abdomen and pelvis. MR imaging studies included sagittal T1-weighted and gradient-recalled-echo sequences performed with and without contrast material enhancement. Marrow involvement was identified with MR imaging in 21 of 23 (91%) patients. Diffuse involvement was noted in 13 patients (56%), and a variegated pattern in eight (35%). CT demonstrated enlarged nodes in 10 of 23 (43%) patients. Correlation of MR imaging patterns and presence of adenopathy at CT with standard laboratory values for Waldenström macroglobulinemia revealed an association of the diffuse MR imaging pattern of marrow involvement and the presence of enlarged nodes at CT with more advanced disease. MR imaging of the spine and CT are reliable means of evaluation of disease status in Waldenström macroglobulinemia. They may be employed as additional means in the staging of Waldenström macroglobulinemia and may be helpful in the follow-up of patients with this rare hematologic malignancy.

Magnetic resonance imaging in the staging of solitary plasmacytoma of bone

PURPOSE

To assess prospectively the role of magnetic resonance (MR) imaging in the staging of patients with a solitary bone plasmacytoma (SBP).

PATIENTS AND METHODS

Twelve consecutive patients with an apparent SBP underwent MR imaging of both the primary tumor and the thoracic and lumbosacral spine to seek additional foci of marrow involvement that might have been undetected by standard skeletal survey. All patients received megavoltage irradiation (total dose, 40 Gy) to the primary lesion.

RESULTS

MR imaging of the thoracic and lumbosacral spine showed additional foci of marrow replacement in four of 12 patients, with signal characteristics identical to those of the primary tumor. In all four patients, the abnormal protein persisted at greater than 50% of the pretreatment value following radiation treatment. In contrast, the myeloma protein disappeared or was reduced by greater than 50% in five of the six patients with secretory disease and without additional marrow abnormalities. One of four patients progressed to multiple myeloma 10 months after diagnosis with new lesions on conventional radiographs in the same areas as detected previously by MR imaging.

CONCLUSION

Four of 12 patients considered to have a SBP by standard criteria may have been understaged, because MR imaging showed additional marrow abnormalities consistent with myeloma. MR imaging of the spine may contribute to the initial staging of SBP, especially since some patients may be cured with radiotherapy.

Treatment of primary neoplasms of the trachea. The role of radiation therapy

BACKGROUND

Primary tracheal tumors are a rare malignancy. Before 1960, most patients had a biopsy, followed by external orthovoltage irradiation or radon seed implantation. Advances in surgery and in radiation therapy during the past three decades have allowed more patients to undergo definitive treatment.

METHODS

Between 1957 and 1988, 22 patients with primary tracheal malignancy were treated with curative intent at The University of Texas M.D. Anderson Cancer Center. Five patients underwent primary surgical resection (Group 1), 5 patients had surgical resection and adjuvant irradiation (Group 2), and 12 patients had primary irradiation (Group 3).

RESULTS

Median survival times were 26 months for all patients; 16 months for Group 1; 61 months for Group 2; and 26 months for Group 3. Local control was attained in 1 of 5 patients in Group 1, 4 of 5 patients in Group 2, and 4 of 12 patients in Group 3. Among those treated with primary radiation therapy, local control was attained by three of four patients who received 60 Gy or higher and one of eight patients who received less than 60 Gy. Results of chi-square test (P = 0.03) were statistically significant. Severe complications, including treatment-related deaths, occurred in 2 of 5 patients in Group 1, 2 of 5 patients in Group 2, and 3 of 12 patients in Group 3.

CONCLUSION

Radiation therapy has a role in the treatment of patients with tracheal malignancy, either as postoperative adjuvant therapy or as sole therapy for those who refuse surgery or have medically inoperable disease. Alternative methods for increasing the local administration of radiation therapy, such as endotracheal brachytherapy, should be investigated for improvement in local control.

Multiple myeloma: spinal MR imaging in patients with untreated newly diagnosed disease

Spinal magnetic resonance (MR) imaging was performed in 29 patients with newly diagnosed, untreated multiple myeloma. Nineteen (66%) patients were asymptomatic. Sagittal pre- and postcontrast T1-weighted spin-echo images and gradient-recalled-echo images of the thoracic and lumbosacral spine were obtained. Marrow involvement was identified in 20 (69%) patients. There were three MR patterns: focal lesions in nine patients (31%), diffuse involvement in seven (24%), and an inhomogeneous pattern of tiny lesions on a background of normal marrow in four (14%). A statistically significant correlation between MR imaging patterns of marrow involvement and serum hemoglobin values (one-way, P = .0899; Kruskal-Wallis, P = .0620) and between MR imaging patterns and percentage of marrow plasmacytosis (Kruskal-Wallis, P = .0314) was noted, with patterns of diffuse and focal marrow involvement associated with more abnormal values. Spinal MR imaging in patients with early myeloma may reveal marrow involvement in both symptomatic and asymptomatic patients. Some correlation was found between MR imaging patterns and laboratory indexes of disease.

Mediastinal metastases of infradiaphragmatic malignancies

Mediastinal lymph node metastases from infradiaphragmatic malignancies are reported to be a rare occurrence. The results of previous studies have been based on the evaluation of chest radiographs. In this study we retrospectively reviewed the chest and abdominal computed tomography examinations of 50 such patients. Of these, 25 had renal cell carcinoma and the remainder, other genitourinary or gastrointestinal carcinomas. The major nodal groups involved in the mediastinum were the right paratracheal in 41 cases, subcarinal in 31, paraesophageal in 26, and aortopulmonary in 25. Hilar nodes were involved in 21 cases. In the abdomen, para-aortic and or retrocrural adenopathy was present in 29 cases. Of 21 patients with pulmonary metastases, only 12 cases were associated with ipsilateral hilar lymphadenopathy. Supraclavicular lymphadenopathy occurred in only 8 patients. These results suggest that spread of infradiaphragmatic malignancies to the mediastinum occurs primarily by extension from the retrocrural and para-aortic nodes into the thoracic duct and then by antegrade flow in the thoracic duct and its collaterals, with retrograde flow from these channels to the mediastinal nodes.

Multiple myeloma: appearance at MR imaging

Magnetic resonance (MR) imaging examinations of the lumbar spine and clinical and laboratory findings in 32 patients with multiple myeloma were reviewed. On T1-weighted images, signal intensity (SI) of the vertebrae approximated that of muscle in 14 cases and was intermediate (between the SIs of muscle and fat) in 18. Definite foci of decreased SI were seen in eight cases (25%), and foci of increased SI, representing fatty infiltration, were seen in 12 (38%). On T2-weighted images, SI approximated that of muscle in 17 cases and was intermediate in 15. Definite foci of increased SI were seen in 17 (53%). Of 38 vertebral compression fractures (including 18 in nine additional patients), foci of abnormal SI consistent with tumor on either T1- or T2-weighted images were seen in 19 cases (50%). There was no correlation between MR imaging findings and laboratory or bone marrow findings. Foci of presumed tumor were better or exclusively shown on T2-weighted images in 11 of 17 patients (65%) with identifiable focal disease. Other suggestions of multiple myeloma on T1-weighted images may be the absence of fatty replacement or a generalized decrease in SI.

Edatrexate improves the antitumor effects of cyclophosphamide and cisplatin against non-small cell lung cancer

The authors treated 32 patients with Stage IIIB or IV non-small cell lung cancer (NSCLC) with an outpatient regimen of edatrexate (10-ethyl-10-deaza-aminopterin) (10-EdAM) on days 1 and 8, cyclophosphamide on day 1, and cisplatin on day 1, repeated every 3 weeks with dose modification. The 22 men and 10 women (median age, 57 years of age) had no prior chemotherapy and a Zubrod performance status less than or equal to 2. A schedule with initial doses of 80 mg/m2, 800 mg/m2, and 80 mg/m2, respectively, yielded a 47% major response rate with two complete responses (95% confidence interval [CI], 25% to 70%), but it also yielded significant stomatitis and myelosuppression. A schedule with reduced starting doses (70 mg/m2, 700 mg/m2, and 70 mg/m2) was better tolerated, but dropped the major response rate to 27% with no complete responses (95% CI, 11% to 52%). Median survival time was 39 weeks for all 30 evaluable patients without a significant difference between the treatment groups (which were comparable in patient characteristics). Major response, however, was associated with longer survival time than minor response or no change (P = 0.024) or progressive disease (P = 0.001) (median survival times, 55, 39, and 27 weeks, respectively). When the doses delivered were compared, patients treated with the reduced dose schedule received less mean 10-EdAM per course (P = 0.01), although the doses of cyclophosphamide and cisplatin were comparable to the original dose schedule for the second course and thereafter. These results suggest that this three-drug regimen may have synergistic antitumor effects, with a steep dose-response relationship, particularly with 10-EdAM. With amelioration of the dose-limiting stomatitis of 10-EdAM, it seems possible to maximize the antitumor effects of this regimen.

Mammographic and CT findings after breast reconstruction with a rectus abdominis musculocutaneous flap

This essay illustrates the radiologic appearance of the reconstructed breast and the abdominal wall after breast reconstruction with a transverse rectus abdominis musculocutaneous (TRAM) flap. The findings are based on a retrospective study of 42 mammograms, 17 abdominal CT scans, and two CT scans each of the chest and pelvis of patients who underwent this procedure.

Radiation-induced malignant pleural mesothelioma

Malignant pleural mesothelioma is a rare and usually fatal disease. Its association with asbestosis is well recognized. The authors report a case of malignant pleural mesothelioma that developed 30 years after the patient underwent radiotherapy for breast cancer. This appears to be the first such case reported in the radiology literature.

Malignant pleural mesothelioma: CT manifestations in 50 cases

Malignant pleural mesothelioma, a rare and usually fatal neoplasm that is associated with asbestos exposure, is being encountered with increasing frequency. Pretreatment CT findings from 50 patients with malignant pleural mesothelioma are illustrated. Pleural thickening was found in 46 (92%) of the 50 patients, thickening of the pleural surfaces of the interlobar fissures in 43 (86%), pleural calcifications in 10 (20%), and pleural effusions in 37 (74%). The volume of the involved hemithorax varied appreciably. Contractions of the involved hemithorax was noted in 21 (42%) of 50 patients and contralateral mediastinal shift in seven (14%). Disease beyond the parietal pleura was found in the chest wall (nine patients), mediastinum, lymph nodes, and diaphragm.

Primary malignant tumors of the trachea. A radiologic and clinical study

Fifty-four cases (55 foci) of primary tracheal malignancies were reviewed retrospectively. Radiologic material was available in 32 cases (33 tracheal foci). The most frequent primary malignant tumor of the trachea was squamous cell carcinoma (54.5%), followed by adenoid cystic carcinoma (18%) and adenocarcinoma (9%). The radiologic appearance of the tumors could be divided into intraluminal, wall-thickening, and exophytic forms. Wall-thickening and exophytic forms in this study accounted for 62% of the tumors. This indicates that malignant tumors of the trachea tend to extraluminal invasion. Tomography and computed tomography are the most helpful methods of radiologic examination for tracheal tumors. Bronchoscopy and radiologic examination are complementary procedures. The chief advantage of imaging is the demonstration of tracheal wall thickening and extraluminal changes. Hemoptysis, dyspnea, and cough were the most common symptoms. Four cases (7%) in our series presented as thyroid tumors due to direct extension into the thyroid gland. Fifteen of the 54 cases (28%) were associated with other carcinomas of the head and neck and the lung.

Phase II study of 10-ethyl-10-deaza-aminopterin (10-EdAM; CGP 30 694) for stage IIIB or IV non-small cell lung cancer

Thirty-one patients with stage IIIB or IV non-small cell lung cancer (NSCLC) were treated with intravenous 10-EdAM on a weekly basis. The starting dose was 80 mg/m2, with subsequent doses adjusted depending on evidence of toxicity. There were 20 men and 11 women with a median age of 58 years (range, 33-75). Response was evaluated in 30 patients, 5 with evaluable but not measurable tumors and 25 with measurable indicator lesions. There were no complete remissions; 3 patients achieved partial remission. Nine patients had a minor response, 6 showed no change, and 12 had progressive disease. Median survival for all 31 patients was 43 weeks (range, 12-65+). During the first 3-week period, the 10-EdAM dose was reduced or withheld in 19 patients (because of stomatitis in 12, SGPT elevation in 3, skin rash in 2, and granulocytopenia in 2), escalated in 11 patients, and unchanged in 1 patient. A mean of 34-88 mg/m2 of 10-EdAM (median, 50) was given per week during the first 5-week period. Myelotoxicity was infrequent and there was no significant nephrotoxicity. Considering the modest side effects of this treatment and the conservative dose-modification schedule which mandated substantial dose reductions, we conclude that 10-EdAM is a promising antitumor agent for NSCLC.

Thoracic lymphoma

Mediastinal adenopathy is a common manifestation of HD in a usually predictable pattern involving anterior and middle mediastinal nodes with or without disease in the hili. Hilar adenopathy is uncommon without detectable mediastinal disease and the lung is virtually never involved alone. In NHL the pattern of disease is more unpredictable. Lung manifestations include direct extension from involved nodes, nodules with or without cavitation, atelectasis secondary to endobronchial or nodal obstruction and rarely an interstitial pattern. Pleural effusions are not uncommon, but solid pleural masses are less frequent. Invasion of the pericardium is not often seen, although masses are commonly seen along the pericardium. Invasion of the chest wall occurs particularly with involvement of internal mammary nodes. Occasionally, posterior nodes will invade the adjacent vertebrae and spinal canal. The chest wall may be invaded by enlarged axillary nodes. Isolated chest wall soft-tissue masses are not common and are usually a manifestation of NHL, especially large cell lymphoma. Although the chest radiograph should detect most intrathoracic disease. CT has been found a necessary adjunct in patients with HD for accurate staging and therapy, especially if radiotherapy is planned. CT has been found helpful in NHL for staging, especially for the pleura and chest wall. MR imaging has not been found to contribute additional useful information except in selected cases.

Detection of hepatic metastases in breast cancer: the role of nonenhanced and enhanced CT scanning

Nonenhanced and enhanced CT was compared in 88 patients with breast cancer and hepatic metastasis. Twenty-five patients had bolus, sequential dynamic CT, and 63 patients were scanned more slowly after a bolus or during drip infusion. Metastatic lesions were more conspicuous on nonenhanced CT and became isodense or nearly isodense after contrast medium administration in 28% of the patients scanned dynamically and in 29% of those scanned more slowly. Although breast cancer has not generally been considered a common origin of hypervascular metastases, we recommend that it be treated as such and that both enhanced and nonenhanced CT of the liver be obtained when patients are screened for metastasis.