Abnormal radiological features in a multiple myeloma patient: a case report and radiological review of myelomas

Pathology Mimicking Orofacial Pain

A case of a 64-year-old woman is reported, who developed new-onset pain over a preexisting area of right mandibular fullness. Clinical examination, MRI, and fine-needle aspiration cytology confirmed the diagnosis of a benign parotid gland tumor-pleomorphic adenoma, which was treated by total parotidectomy with complete removal of the tumor. When evaluating a patient with orofacial pain, oral health care providers should be cognizant of all potential differential diagnoses, especially in the setting of red flags such as persistent or enlarging facial swelling/fullness.

Multiple myeloma with oral manifestations as maxillary ulceroproliferative lesion: A case report

ABSTRACT

Multiple Myeloma (MM) is the most common malignant neoplasm of bone and can manifest with different clinical features in oral cavity. MM lesions in skull and jaws have characteristic punched out lesions but are often confused with meningioma when they occur in skull as solitary lesions. We report a case of MM that reported in oral cavity for which prompt diagnosis was done, but there were symptoms that persisted for years and a skull lesion that was diagnosed and treated as meningioma before MM was diagnosed from the oral lesions. This is the first case where the patient has been actually treated for meningioma, and then diagnosed with MM after months. In that case, SBP or MM should be included in the differential diagnosis of a dural mass, particularly when a patient is complaining of neurological deficits. Also, the role of oral physician in the diagnosis of MM should be stressed in diagnosis and multidisciplinary management, thus facilitating better clinical outcomes.

Avaliação Radiográfica da Maxila e da Mandíbula de Pacientes Diagnosticados com Mieloma Múltiplo: Estudo Retrospectivo

Introdução: O mieloma múltiplo e caracterizado como uma neoplasia maligna plasmocitária com a proliferação anormal de plasmócitos clonais na medula óssea de etiologia desconhecida. Objetivo: Caracterizar os pacientes com mieloma múltiplo atendidos no Setor de Estômato-Odontologia e Prótese do INCA, por meio de dados sociodemográficos, clínicos, laboratoriais e radiográficos. Método: Estudo transversal retrospectivo de pacientes com diagnostico de mieloma múltiplo, no período de 2000 a 2018, que realizaram radiografia panorâmica no período do diagnóstico da doença. Os dados sociodemográficos e clinico-radiográficos da população em estudo foram coletados nos prontuários dos pacientes, armazenados em banco de dados, analisados de forma descritiva e submetidos ao teste não paramétrico X2 (qui-quadrado). Resultados: Na amostra final, foram totalizados 163 casos. A maioria era de homens (56,4%), brancos (55,8%), com idade ≤55 anos (54%), ensino fundamental incompleto (30,7%), não fumantes (54,6%) e não bebedores (54,6%). Havia lesões líticas em 46 pacientes (28,2%) com predileção pela mandíbula (82,6%; p=0,000). Houve maior frequência de margens parcialmente definidas (50,0%), não escleróticas (78,2%) e de aspecto unilocular (43,5%). Dos 46 pacientes que apresentaram lesão lítica maxilomandibular, 27 pacientes tinham >55 anos (p=0,042). Conclusão: Ha maior ocorrência de lesões ósseas na mandíbula quando comparada a maxila.

Rare Distribution of Sclerotic Bony Lesions in Multiple Myeloma: A Case Report

ABSTRACT

A 66-year-old man was referred to our hospital due to a newly discovered left chest wall mass, which was diagnosed as plasmacytoma on biopsy. The patient underwent 18F-FDG PET/CT scanning before treatment. PET imaging revealed intense FDG signal in osseous lesions, and the CT showed most of the lesions were osteoblastic. The osseous lesions were predominantly localized to the humerus, femur, tibia, and phalanx of toe.

Tumors of the Acromion Process—A Pictorial Review

Introduction  Acromion is essential for stabilizing the shoulder complex. Tumors of the acromion are rare. We report the largest series of acromion tumor and tumor-like lesion.

Materials and Methods  A retrospective review of the oncology and radiology database within our tertiary center for orthopaedic oncology was performed to identify all tumors of the acromion over the past 30 years and imaging was reviewed.

Results  We identified a total of 31 lesions arising in the acromion and chondrosarcoma was the commonest.

Conclusion  One needs to be aware of tumor and tumor-like lesions of acromion.

A Radiographic Assessment of Dental Morbidity in Patients with Multiple Myeloma Undergoing Autologous Stem Cell Transplant: A Retrospective Study

Aim:

To assess the dental and oral morbidity in multiple myeloma patients as expressed in dental radiographs before autologous stem cell transplant.

Materials and Methods:

A retrospective study involving 79 multiple myeloma patients was designed to collect data prior to their autologous stem cell transplant. Patients were seen at the oral medicine clinic at the University of Florida College of Dentistry during the years 2010–2013. Through available patient data and interpretation of radiographs, the following variables were recorded: age, gender, carious lesions, periodontal disease, and periapical radiolucency. In addition, the incidence of root fragment retention and the presence of punched-out osteolytic lesions were recorded. Cochran–Mantel–Haenszel (CMH) tests and logistic regression were performed for descriptive analysis and presentation of the data.

Results:

Seventy-nine multiple myeloma patients were recruited for this study. Ages ranged from 28 to 79 years (mean = 61, SD = 9.6), including 41 (51.9%) females and 38 (48.1%) males. The results demonstrated dental decay in 64.56% of patients, periodontal disease in 62.03%, apical rarefying osteitis in 13.92% of patients, and punched-out lesions in 24.05% of patients.

Conclusion:

Our study indicates high dental morbidity in multiple myeloma patients prior to autologous stem cell transplant. The elimination of foci of infection is highly recommended prior to autologous stem cell transplant for this high-risk population because of the potential risk of bacteremia/septicemia from oral bacteria associated with dental morbidity.

Radiographic patterns of multiple myeloma in the jawbones of patients treated with intravenous bisphosphonates

BACKGROUND

The purpose of this study was to evaluate whether intravenous (IV) bisphosphonate (BP) therapy can change the radiographic patterns of multiple myeloma (MM) in the jawbones.

METHODS

The authors evaluated panoramic radiographs obtained from 188 patients with MM for the presence of solitary osteolytic lesions, multiple osteolytic lesions, diffuse osteoporosis, diffuse sclerosis, lamina dura abnormalities, nonhealing alveolar sockets, and bone sequestration. The authors compared results obtained from patients treated with IV BPs with those obtained from patients who had never been exposed to BPs.

RESULTS

Multiple osteolytic lesions (P = .001), diffuse osteoporosis (P = .001), and diffuse sclerosis (P = .0036) occurred more often in the mandible in both groups. Solitary osteolytic lesions occurred less frequently in the BP group (P = .0078). Lamina dura abnormalities (P = .0006) and nonhealing alveolar sockets (P = .0021) were associated with BP treatment.

CONCLUSIONS

IV BP therapy changes the radiographic patterns of MM in the jawbones.

PRACTICAL IMPLICATIONS

The effect of BPs in the maxillofacial area is a matter of concern for health practitioners because this type of medication causes several alterations of the jawbones in patients with cancer.

Oral health status of patients with multiple myeloma

Objective

To describe the oral health status of patients with multiple myeloma and compare to a control group.

Materials and methods

The medical history of the studied subjects was obtained from the medical records and through interviews. Trained examiners evaluated the oral mucosa, teeth, periodontium and imaging aspects. The dental status was evaluated by the decayed, missing and filled teeth index. The presence of bone lesions was investigated with cone beam computer tomography images of the jaws.

Results

The most common oral mucosa features were paleness (31%) and coated tongue (14.3%) in the multiple myeloma group (N = 42); and coated (21.4%) and fissured tongue (10.7%) in the control group (N = 28). The mean DMFT index of patients with multiple myeloma was high, but not significantly different from controls (14.57 versus 19.69, p = 0.975). Hypodense lesions suggestive of multiple myeloma were observed in the jaws of 73.8% of the patients. Hypodense lesions related to teeth were detected in 33.3% of the patients and in 53.6% of the controls (p = 0.832).

Conclusions

The studied population of multiple myeloma patients presented many oral health issues that needed attention. Thus, oral care should be included in the routine treatment to improve the quality of the oral status in these patients.

Imaginological characterization of multiple myeloma lesions of the jaws through cone-beam computed tomography

PURPOSE

To establish an evaluation protocol for the identification and description of the variations in multiple myeloma (MM) lesions of the jaws, by means of cone-beam computed tomography (CBCT).

MATERIALS AND METHODS

Tomography exams from 33 MM patients were evaluated in this retrospective observational study. The reconstructions were analyzed simultaneously, according to the established protocol, with the following description criteria: anatomic location, size, margins, inner aspect, relationship with adjacent structures, and presence or absence of a punched-out aspect. The exams were further subdivided into groups of patients using, or not bisphosphonates.

RESULTS

There were osteolytic lesions in 100% of cases, most of which were extended to more than one anatomical region. Poorly defined margins were more frequent in the maxilla than in the mandible. Extensive bone resorption presenting multilocular areas was the most frequently observed aspect, being 86.2% for maxilla and 87.9% for mandible. In relation to bisphosphonates, patients who used the medication had more poorly defined bone margins and contortions (68.6%) than those who did not undergo drug therapy (31.4%). No well-defined lesions were observed (p = 0.34%).

CONCLUSION

It was possible to establish a protocol for evaluation of MM lesions in CBCT images and to identify that when evaluated three-dimensional, lesions tend to be poorly defined and have no pattern of description, as described in two-dimensional "punched-out".

Radiological review of skull lesions

Abstract

Calvarial lesions are often asymptomatic and are usually discovered incidentally during computed tomography or magnetic resonance imaging of the brain. Calvarial lesions can be benign or malignant. Although the majority of skull lesions are benign, it is important to be familiar with their imaging characteristics and to recognise those with malignant features where more aggressive management is needed. Clinical information such as the age of the patient, as well as the patient’s history is fundamental in making the correct diagnosis. In this article, we will review the imaging features of both common and uncommon calvarial lesions, as well as mimics of these lesions found in clinical practice.

Teaching Points

• Skull lesions are usually discovered incidentally; they can be benign or malignant.

• Metastases are the most frequent cause of skull lesions.

• Metastatic lesions are most commonly due to breast cancer in adults and neuroblastoma in children.

• Multiple myeloma presents as the classic “punched out” lytic lesions on radiographs.

• Eosinophilic granuloma is an osteolytic lesion with bevelled edges.

Panoramic and skull imaging may aid in the identification of multiple myeloma lesions

BACKGROUND

The purpose of this study was to investigate the presence of punched-out lesions in craniofacial bones using three different radiographic protocols in a large cohort of patients.

MATERIAL AND METHODS

One hundred fifty-five MM patients were evaluated using panoramic and skull (frontal and lateral) radiographs, which were performed in all patients at the time of MM diagnosis. The diagnostic potential for detecting punched-out lesions was compared among the radiographic techniques.

RESULTS

MM punched-out lesions were identified in 135 (87%) panoramic radiographs, 141 (91%) frontal and 144 (93%) lateral skull radiographs. Punched out-lesions were synchronously present in skull and jawbones in 129 (83.23 %) cases. The lesions were detected exclusively in skull in 18 (11.61%) cases and exclusively in jawbones in 6 (3.87%) cases. Punched out-lesion mainly affected the skull and the jawbones in a synchronous way (p<0.001) rather than separately.

CONCLUSIONS

All investigated radiographic techniques (panoramic, frontal and lateral skull approaches) demonstrated high detection rates for MM punched-out lesions in craniofacial bones. Panoramic radiography may aid to the radiographic protocols to identify multiple myeloma bone lesions.

Can dentists detect multiple myeloma through oral manifestations?

Objective

To review published data on oral manifestations of multiple myeloma.

Methods

An electronic database search was performed of articles published from 1971 to November 2016 in order to identify studies that reported oral manifestations of patients with multiple myeloma. Case reports and case series with oral manifestations of multiple myeloma in English were included in the study. An additional search was performed of the references of the selected articles.

Results

Thirty-seven articles that reported 81 patients with oral manifestations of multiple myeloma were selected: 30 case reports (82%) and seven case series (18%). The most common clinical features in the dental cavity were swelling (65.4%), bone pain (33.3%), paresthesia (27.1%) and amyloidosis lesions (11.1%). Osteolytic lesions detected on imaging exams were reported in the majority of the patients (90.1%) as plasmacytomas or ‘punched-out’ lesions.

Conclusions

Swelling and osteolytic lesions represent the most common clinical and radiographic signs of the jaws relating to multiple myeloma, respectively.

Concurrent Multiple Myeloma and Metastatic Osteosarcoma: A Case Report and Literature Review

Multiple myeloma (MM) and osteosarcoma (OS) are two common bone malignancies, however, the simultaneous occurrence of both primary bone tumors in the same patient has not been reported in the United States to date. We present a unique case in which both malignancies present concurrently in a 72-year-old man. Results of spinal magnetic resonance imaging (MRI), radiographic skeletal survey, and hematological workup established the initial diagnosis of MM. Approximately three months later, the patient was admitted with severe right hip pain and shortness of breath and was evaluated with computed tomography (CT) of the right hip, abdomen, pelvis, and chest, revealing an osseous mass with a “sunburst” pattern in the right hip, and several calcified nodules in the lungs. Subsequent wedge resection and histological evaluation of the lung nodules confirmed the diagnosis of metastatic OS to the lungs, with a presumptive diagnosis of primary OS of the right hip. The clinical findings and imaging characteristics in this case are presented. Two similar cases found in the literature are also briefly discussed. The findings of this case report suggest that, in rare instances, MM patients with sclerotic bone findings may have a concurrent diagnosis of OS.

Sclerotic multiple myeloma with an unusual sunburst periosteal reaction occurring in the sternum

Multiple myeloma is a disseminated neoplastic monoclonal gammopathy that usually affects the skull, clavicle, rib, pelvis, spinal column, and proximal portions of the humerus and femur. The initial manifestation of multiple myeloma in the sternum is rare. The classic radiological presentations of multiple myeloma are multiple "punched-out" areas of bone destruction, expansile lytic lesions, and generalized osteoporosis. Primary sclerotic presentation is rare and occurs in only 3 % of cases. A sclerotic multiple myeloma with a sunburst periosteal reaction occurring in the sternum has not been reported in the English literature. We report a case of sclerotic multiple myeloma of a 49-year-old woman. In the sternum, the lesion displayed extensive sclerosis mixed with mottled lytic areas with a sunburst periosteal reaction occurring in the periphery, which radiologically mimicked an osteosarcoma. Multiple focal areas of sclerosis were also found in the right clavicle, pelvis, multiple ribs, and vertebrae.

Solitary plasmacytoma of the sternum with a spiculated periosteal reaction: A case report

Solitary plasmacytomas (SPs) represent ≤5% of all plasma cell neoplasms and mostly occur in the spine, pelvis, ribs and pectoral girdle, while rarely occurring in the sternum. The tumors typically appear as osteolytic lesions. In rare cases, SPs can manifest as bony spicules on the surface of the bone. The present study reports the case of a 74 year-old female with an osteolytic tumor localized in the sternum. The tumor displayed extensive bony destruction, with a large quantity of thick straight spicules on the surface of the bone, resembling a sunray in appearance. The imaging, laboratory and pathological examinations of the patient met the diagnostic criteria of SP. The patient was initially treated with radiotherapy at a dose of 45 Gy. Six months later, chemotherapy consisting of vindesine, Adriamycin and dexamethasone was administered. Vindesine and Adriamycin were administered at a dose of 2 and 15 mg/day, respectively on days 1-4 in a 20-day cycle. Dexamethasone was administered at a dose of 20 mg/day on days 1-4, 9-12 and 17-20 in the 20-day cycle. In total, the patient underwent 6 cycles of chemotherapy, with a total duration of 7 months. The patient was followed-up for two years after beginning therapy. At present, the patient is well, without any evidence of progressive disease or multiple myeloma. To the best of our knowledge, this is the first case in the English literature of SP in the sternum, with an unusual sunray periosteal reaction on radiological imaging. The sites of bony spiculation in the lesions that have previously been described in the literature are the mandible, orbit, vertebral body and skull vault. To the best of our knowledge, the current study presents the first case of a SP of the sternum with a unusual spiculated periosteal reaction on radiological imaging to be reported in the English literature.

Diffuse Myocardial Uptake of (99m)Tc-HDP in Multiple Myeloma

Soft tissue uptake is a rare finding in bone scintigraphy, with an incidence of 2%. Although the mechanism has not yet been fully clarified, several causes have been reported for this unusual uptake pattern. This paper presents a case of diffuse myocardial accumulation of technetium-99m hydroxymethylene diphosphonate ((99m)Tc-HDP) without either solid/visceral organ or soft tissue with multiple myeloma (MM) in skeletal scintigraphy. A 93-year-old man with hypertension and chronic heart failure for 14 years underwent bone scanning due to a 2-month history of back pain within a 1-year period of MM. Three hours later, (99m)Tc-HDP late static images showed diffuse myocardial radiotracer accumulation and there were no other sites of abnormal soft tissue or visceral uptake. Myocardial accumulation had disappeared on 24-h delayed static images. This accumulation was thought to be related with AL-type amyloidosis associated with MM.

Multiple osteolytic lesions

Several systemic diseases initially present with various oral manifestations. Investigation of these oral symptoms may at times lead to the diagnosis of grave underlying life-threatening conditions. We present one such case, where the patient manifested with gross enlargement of the mandible, along with lesions in the lower limbs. These lesions were the initial manifestation and on further investigations the patient was diagnosed with multiple myeloma.

Sclerotic lesions of the spine: MRI assessment

Sclerotic (T2 dark) lesions of the spine are infrequent and, as a result, these are often missed or misdiagnosed. Plain films may not be always available during magnetic resonance imaging (MRI) readout. Knowledge of such lesions and their imaging appearances on MRI evaluation is essential for a reader. Additionally, a systematic approach is important to accurately diagnose these lesions. In this article we discuss the various causes of spinal sclerotic lesions, describe their MRI characteristics with relevant case examples, and outline a systematic approach to their evaluation.