What is multiple myeloma?

Answer

Multiple myeloma is the most common primary malignant neoplasm of the skeletal system. The disease is a malignancy of plasma cells. Clinical definitions of the various myeloma subtypes have been updated, as have the imaging definitions of what constitutes bone marrow disease and individual bony involvement.^[1]The etiology of multiple myeloma is the monoclonal proliferation of plasma B cells, with resultant marrow infiltration and increase of a single immunoglobulin and its fragments in the serum and urine. Electrophoretic analysis shows increased levels of immunoglobulins in the blood as well as light chains (Bence-Jones protein) in the urine. Radiologically, multiple destructive lytic lesions of the skeleton, as well as severe demineralization, characterize multiple myeloma. A focal lytic lesion must be 5 mm or greater in size to be considered a true abnormality by the latest International Myeloma Working Group (IMWG) criteria.^{[1, 2]}

The marrow infiltration process may involve any bone, but the predominant sites include the vertebral column, ribs, skull, pelvis, and femora. Although the osseous structures may appear radiographically normal or simply osteopenic, the classic appearance is of multiple, discrete, small, lytic lesions. Occasionally, a single lytic lesion is discovered and is termed a plasmacytoma (solitary myeloma). Patients with a single focus of disease often progress to multiple sites of myelomatous involvement.^{[1, 3, 4, 5, 6, 7]}

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Media Gallery

Lateral radiograph of the skull. This image demonstrates numerous lytic lesions, which are typical for the appearance of widespread myeloma.
Lateral radiograph of the lumbar spine. This image shows deformity of the L4 vertebral body that resulted from a plasmacytoma.
Radiograph of the right femur. This image demonstrates the typical appearance of a single myeloma lesion as a well-circumscribed lucency in the intertrochanteric region. Smaller lesions are seen at the greater trochanter.
Radiograph of the right humerus. This image demonstrates a destructive lesion of the diaphysis. Pathologic fracture is seen.
Coronal T1-weighted magnetic resonance image through a myeloma lesion of the humerus. This image shows that the lesion has a low signal intensity. The outer cortical margin is eroded but intact; however, the lesion has transgressed the inner cortex.
A T1-weighted magnetic resonance image of the humerus. This image demonstrates a predominantly hypointense to isointense myelomatous lesion in the medullary space of the diaphysis. The lesion extends through the anterior aspect of the cortex.
A T2-weighted, fat-suppressed magnetic resonance image of a myeloma lesion of the humerus. This image demonstrates the lesion is hyperintense on this sequence, a typical finding.
Anteroposterior radiograph of the left shoulder. This image shows an expansile process in the glenoid.
Axial computed tomography (CT) scan of the glenoid. This image shows a well-defined lesion, with the typical CT scan appearance of myeloma. The cortex is intact.
Axial computed tomography scan of the glenoid (same patient as in the previous image). One year later, the myeloma lesion had grown significantly, extending to the coracoid process and through the cortex of the glenoid.
A T1-weighted magnetic resonance image of the shoulder. This image shows the full extent of myelomatous involvement within the glenoid and coracoid process.
A T2-weighted, fat-suppressed magnetic resonance image of the shoulder (same patient as in the previous image). This image demonstrates the myeloma lesion is hyperintense.
Axial computed tomography (CT) scan through the left shoulder during a CT-guided biopsy (same patient as in the previous image). This image shows a core biopsy needle has been advanced through the coracoid process to obtain a tissue sample.

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Author

Michael E Mulligan, MD Professor, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine; Chief of Radiology, University of Maryland Rehabilitation and Orthopedic Institute; Assistant Chief of Musculoskeletal Imaging, MSK Fellowship Program Director, University of Maryland Medical Center

Michael E Mulligan, MD is a member of the following medical societies: American Roentgen Ray Society, International Skeletal Society, Radiological Society of North America, Society of Skeletal Radiology

Disclosure: Nothing to disclose.

Specialty Editor Board

Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand

Disclosure: Nothing to disclose.

Wilfred CG Peh, MD, MHSc, MBBS, FRCP(Glasg), FRCP(Edin), FRCR Clinical Professor, Yong Loo Lin School of Medicine, National University of Singapore; Senior Consultant and Head, Department of Diagnostic Radiology, Khoo Teck Puat Hospital, Alexandra Health, Singapore

Wilfred CG Peh, MD, MHSc, MBBS, FRCP(Glasg), FRCP(Edin), FRCR is a member of the following medical societies: American Roentgen Ray Society, British Institute of Radiology, International Skeletal Society, Radiological Society of North America, Royal College of Physicians, Royal College of Radiologists

Disclosure: Nothing to disclose.

Chief Editor

Felix S Chew, MD, MBA, MEd Professor, Department of Radiology, University of Washington School of Medicine

Felix S Chew, MD, MBA, MEd is a member of the following medical societies: American Roentgen Ray Society, Association of University Radiologists, International Skeletal Society, Radiological Society of North America

Disclosure: Nothing to disclose.

Acknowledgements

Carol L Andrews, MD Consulting Musculoskeletal Radiologist, Mink Radiologic Imaging; Consulting Staff, Department of Radiology, Antelope Valley Medical Center

Disclosure: Nothing to disclose.

Amilcare Gentili, MD Professor of Clinical Radiology, University of California, San Diego, School of Medicine; Consulting Staff, Department of Radiology, Thornton Hospital; Chief of Radiology, San Diego Veterans Affairs Healthcare System

Amilcare Gentili, MD is a member of the following medical societies: American Roentgen Ray Society, Radiological Society of North America, and Society of Skeletal Radiology

Disclosure: Nothing to disclose.

Sulabha Masih, MD Associate Professor of Diagnostic Radiology, University of California, Los Angeles, David Geffen School of Medicine; Consulting Staff, Department of Radiology, Section of Musculoskeletal Radiology, West Los Angeles Veterans Affairs Medical Center

Sulabha Masih, MD is a member of the following medical societies: American Roentgen Ray Society, Radiological Society of North America, and Society of Skeletal Radiology

Disclosure: Nothing to disclose.

Steven M Sorenson, MD Department of Radiology, Coast Radiology Imaging and Intervention.

Steven M Sorenson is a member of the following medical societies: Radiological Society of North America

Disclosure: Nothing to disclose.

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