Which radiography findings are characteristic of multiple myeloma?

Updated: Mar 15, 2019
  • Author: Michael E Mulligan, MD; Chief Editor: Felix S Chew, MD, MBA, MEd  more...
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The classic radiographic appearance of multiple myeloma is that of multiple, small, well-circumscribed, lytic, punched-out, round lesions within the skull, spine, and pelvis. The pattern of lytic or punched-out radiolucent lesions on the skull have been described as resembling raindrops hitting a surface and splashing. [22] ​ Lesions are lytic without reactive bone formation because of tumor factors that combine to activate osteoclasts and inhibit osteoblasts. The lesions tend to vary slightly in size. In addition, the bones of myeloma patients are, with few exceptions, diffusely demineralized. Because myeloma is a disease of the medullary compartment of the bone, more subtle lesions can be detected by the appearance of endosteal scalloping that is seen as slight undulation to the inner cortical margin of bone. This finding is indicative of myelomatous involvement in the appropriate clinical setting.

(See the radiographic images of multiple myeloma below.)

Lateral radiograph of the skull. This image demons 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 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 demonstr 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 demons Radiograph of the right humerus. This image demonstrates a destructive lesion of the diaphysis. Pathologic fracture is seen.
Anteroposterior radiograph of the left shoulder. T Anteroposterior radiograph of the left shoulder. This image shows an expansile process in the glenoid.

Although patients with advanced and extensive myeloma tend to have a number of circumscribed lytic lesions, some may simply have diffuse osteopenia on radiography. [22] Fewer than 10% of patients present with a single myelomatous lesion, a plasmacytoma. These lesions are most common in the vertebral bodies. In other skeletal sites, they may manifest as bubbly expansile lesions, often in a rib or posterior element of the spine, but they can have a variety of shapes and sizes. They are occasionally associated with a soft tissue mass.

There are 2 sclerotic forms of myeloma. One is a rare form, known as POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes), that may demonstrate sclerotic lesions on radiographs or CT studies, but this condition is responsible for less than 1% of myeloma cases. Major and minor criteria to diagnose this condition have been established. The major criteria are polyneuropathy, monoclonal gammopathy, and presence of bone lesions. 

The second form is a standard multiple myeloma case with mixed lytic and sclerotic lesions. Radiographs or CT images of treated myeloma lesions also may rarely show areas of abnormal bone architecture with sclerosis. Usually, little reactive bone sclerosis or periosteal reaction is seen. [23] However, some new treatment agents, such as bortezomib, have been reported to show a higher degree of reactive new bone formation around treated lesions. [24]

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