Presentation on theme: "MR Evaluation of Bone Marrow Disorders"— Presentation transcript:
1 MR Evaluation of Bone Marrow Disorders Nisha Patel, MD
2 IntroductionNearly all imaging modalities evaluate the marrow, which is a site of significant pathologyRadiographyNuclear MedicineCTMRConventional radiography traditionally first study but major disadvantage is poor soft tissue contrast and ;large amount of trabecular bone loss must occur before radiographically detectable. Late findings include cortical erosion, medullary sclerosis and cortical expansion.Nucs- Tc99m diphosphonate and Su Colloid poor anatomic definition and nonspecificCT more sensitive than CR but unable to differentiate normal from abnormal bone marrowMR is most sensitive modality and that is what this talk will focus on today
3 Topics of Discussion Normal marrow anatomy and function MRI appearance of normal marrowBenign and malignant marrow pathologyTODAY MY TALK WILL FOCUS ON THREE AREAS
4 Normal Marrow Anatomy and Function Three basic marrow components:TrabeculaeRed marrowYellow marrowTHE BM IS COMPOSED OF THREE MAJOT COMPONENTS WHICH ARE...
5 TrabeculaeServe as the architectural support for the marrow and as a mineral depot.Number of trabeculae decreases with age.This is a T1W coronal image of the ankle. Note the normal low signal stress trebeculae within the calcaneus and the normal low signal physeal scar.
6 Red MarrowComposed of hematopoietic cellular elements (red and white cells and platelets), supporting stroma (reticulum), and rich sinusoidal vascular supplySmaller fraction of fat cells (40%)It increases if the demand for hematopoiesis increases
7 Yellow Marrow Smaller fraction of red marrow elements. Larger fraction of fat cells (>50%)Poor vascular supplyPaucity of reticulumIncreases with age
8 Topics of Discussion Normal marrow anatomy and function MRI appearance of normal marrowBenign and malignant marrow pathologyNOW WE WILL TURN TO THE...
9 MRI Appearance of Normal Marrow T1W SE and STIR are most commonly used sequences to evaluate the marrow.In general, yellow marrow follows the signal intensity of subcutaneous fat, with relatively high signal on T1W images and low signal on STIR images.Red marrow follows the signal intensity of muscle and has an intermediate signal intensity on T1W images and STIR images.This a T1W coronal image of the knee and STIR image of the pelvis. Note the high signal intensity of the yellow marrow with its similar signal intensity to subcutaneous fat on T1 and lower signal on STIR and the intermediate signal intensity of the red marrow with its similar but higher intensity to muscle on T1 and STIR.
10 Marrow ConversionAmount and distribution of red and yellow marrow changes with time as well as in response to physiologic stressesNormal conversion of red to yellow marrow occurs in a predictable and progressive mannerAt birth, nearly the entire osseous skeleton is composed of red marrow.Conversion proceeds from the appendicular (distal to proximal extremities) and then to the axial skeleton in a bilateral symmetric fashion.THE BM IS A DYNAMIC ORGAN AND THE...
11 Within an individual long bone, conversion occurs in the following sequence: Epiphysis and apophysis Diaphysis Distal metaphysis and proximal metaphysis
12 Marrow Conversion in Long Bones Infantile (0-1y)Childhood (1-10y)Adolescent (10-20y)Adult (25+)BM CONVERSION IN LONG BONES FOLLOWS 4 GENERAL PATTERNS. THIS IS A DIAGRAM DEMONSTRATING THE CONVERSION OF RED TO YELLOW MARROW.
13 Infantile pattern 0-1 year Homogeneous low signal marrow in diaphyses and metaphysesTHE INFANTILE PATTERN IS FOUND DURING THE FIRST YEAR OF LIFE AND IS CHARACTERIZED BY...This a T1W coronal image of the pelvis. Note the intermediate signal intensity epiphyseal cartilage, high signal intensity ossific nucleus, and the low signal intensity red marrow.
14 Childhood pattern 1-10 year Higher signal in diaphyses and metaphyses representing red yellow marrow conversionTHE CHILDHOOD PATTERN IS FOUND DURING AGES 1-10 AND IS CHARACTERIZED BY...T1 Coronal image of a 2 yo and 6 yo which demonstrates increasing signal in the diaphyses and metaphyses signifying yellow marrow conversion and the fat marrow in the epi/apophysis
15 Adolescent pattern 11-20 year Distal metaphyseal marrow converts to yellow marrowResidual islands of red marrow leave a heterogeneous pattern to the metaphyseal marrowIN AGES THE ADOLESCENT PATTERN IS SEEN. DURING THIS TIME THE ...Cor T1 Knee in a 14 yo girl shows the inhomogeneity of the distal metaphyseal marrow
16 Adult pattern25 years +Predominant homogeneous high signal diaphyseal and metaphyseal marrowHematopoietic marrow concentrated in the axial skeleton (skull, ribs, vertebra, sternum, pelvis) and to a lesser degree in the proximal appendicular skeleton (proximal femora and humeri)THE ADULT PATTERN IS CHARACTERIZED BY ...Cor T1 Knee in 23 yo women with homogeneous fat marrow in distal M and E
17 Adult patternAfter adult pattern reached, there is continued and gradual further replacement of hematopoietic marrow with fatty marrowSpine and pelvis on T1 in elderly reflect this change
18 Topics of Discussion Normal marrow anatomy and function MRI appearance of normal marrowBenign and malignant marrow pathologyFINALLY MOVING ON TO THE DISCUSSION OF...
19 Bone Marrow Abnormalities Two USEFUL variablesDistribution of normal hematopoietic marrowHas a characteristic distribution based on age and functional statusThorough knowledge is important as any variation can represent diseaseSignal intensityMuscle or Disc serve as internal controlNormal marrow signal: isointense/hyperintense to muscle or disc on T1WDiseased marrow: hypointense T1 signal compared to the muscle or discBM ABNORMALITIES MAY BE THE FIRST INDICATION OF A FOCAL OR SYSTEMIC DISORDER AND CAREFUL EVALUATION IS NECESSARY.PROCESSES RESULTING IN OBVIOUS SIGNAL ABNORMALITY ARE NOT DIFFICULT BUT DIFFERENTIATING SUBTLE ALTERATIONS AS NORMAL OR ABNORMAL CAN BE DIFFICULT ESPECIALLY WITH PATCHY HEMATOPOIETIC MARROW WHICH CAN SIMULATE A MALIGNANT PROCESS.TO DIFFERENTIATE THESE, THERE ARE (TWO USEFUL VARIABLES WHICH ARE DISTRIBN AND SI).AS I DISCUSSED ALREADY, (Normal hemat. Marrow...).THE SECOND VARIABLE TO CONSIDER IF THE DISTRIBUTION IS NORMAL, IS SI
20 Marrow Pathology Disorders of marrow proliferation Disorders of marrow replacementDisorders of marrow depletionVascular and Miscellaneous abnormalitiesDISEASE OF THE BM CAN BE CATGORIZED INTO 3 MAJOR GROUPS...TWO OTHER CATEGORIES ARE...
21 Marrow Proliferative Disorders Arise from the proliferation of cells that normally exist in the marrowInvolve the marrow in a diffuse manner (except for focal multiple myeloma)
22 Marrow proliferative disorders BenignMarrow reconversionMastocytosisAmyloidosisMalignantPolycythemia VeraMyeloid Metaplasia with MyelofibrosisWaldenstrom’s macroglobulinemiaMMLeukemiaTHEY INCLUDE BOTH B9 AND MALIGNANT ETIOLOGIES
23 Marrow ReconversionReconversion is due to increased demand for hematopoiesis.Can be seen in hemolytic anemias, high level athletes, GCSF therapy, smokers, and destruction of red marrow.This is a diagram demonstrating the reconversion of yellow to red marrow. It is the reversal of the marrow conversion sequence.
24 Marrow ReconversionThe first image is a T1W sagittal image of the knee. Note the abnormal red marrow signal intensity within the distal femoral and proximal tibial diaphyses from sickle cell anemia with osteonecrosis in the tibia.
25 Mastocytosis Rare disorder characterized by mast cell proliferation Most commonly occurs as a skin manifestation (urticaria pigmentosa- generally a self-limited dermatologic disorder in children)Systemic form rarer and involves the bone marrow and internal organsXraysLytic or sclerotic lesions in a focal or diffuse distributionMRNonspecific pattern ranging from normal, focally/diffusely heterogeneousTypically involves axial skeleton
26 Courtesy of Tudor Hughes, M.D. Mixed osteopenia and sclerosisCourtesy of Tudor Hughes, M.D.
27 Courtesy of Tudor Hughes, M.D. Cor T1 and STIR showing heterogeneous/salt and pepper pattern of involvementAP pelvis with diffuse marrow inv and HSMCourtesy of Tudor Hughes, M.D.
28 Myeloproliferative disorders Group of diseasesPolycythemia rubra veraAgnogenic myeloid metaplasia (AMM) (Idiopathic myelofibrosis)CMLEssential thrombocytopeniaOlder patients (6th-8th decade)Malignant transformation of pluripotent stem cells resulting in expansion of various BM elementsPV and AMM have similar MR appearanceDiffuse intermediate T1 signalMyelofibrosisDiffuse/Patchy sclerotic boneLow T1 and T2 signal
29 Polycythemia Vera Courtesy of Tudor Hughes, M.D. 75 year old female with right shoulder pain and PVCourtesy of Tudor Hughes, M.D.
30 Myelofibrosis Courtesy of Tudor Hughes, M.D. 57 yo male, follow up R THA with diffuse smmetric patchy sclerosis on CT and Xray from MyelofibrosisCourtesy of Tudor Hughes, M.D.
31 Myelofibrosis Courtesy of Tudor Hughes, M.D. Another patient with patchy areas of sclerosis afffecting the pelvis (not involvement of femora as well as ischia) c/w myelofibrosisCourtesy of Tudor Hughes, M.D.
32 Leukemia Acute: diffuse skeletal involvement Chronic: (adults) involve areas of residual marrow in pelvis, spine, femursInvolvement of the epiphyses/apophyses at any age reflects higher tumor burden
33 This is a T1W sagittal image of the lumbar spine This is a T1W sagittal image of the lumbar spine. Note the abnormal diffuse distribution of low marrow signal intensity from ALL and also that this signal is lower than the disc
34 Multiple Myeloma (MM) Most common primary bone tumor Solitary (plasmacytoma) form and more common multiple (myeloma) formXraysSolitary lytic lesion or numerous focal punched out lesionsGeneralized osteopeniaMRI patterns of MM in order of increasing frequency:normal (low tumor burden)focal lesionheterogeneous (variegated)homogenous (diffuse)
35 This is a T1W and FSE T2W sagittal images of the lumbar spine This is a T1W and FSE T2W sagittal images of the lumbar spine. Note the heterogeneous/variegated pattern of involvement by MM. Do you see the FX?
36 Diffuse marrow involvement in lumbar spine Diffuse marrow involvement in lumbar spine. Note primarily cellular marrow demonstrating reversal of normal MR pattern, with diffuse hypointensity on T1-weighted spin-echo image, diffuse hyperintensity on STIR image, and marked enhancement on gadolinium-enhanced image. There is associated fracture of the T12 vertebral body.Angtuaco, E. J. C. et al. Radiology 2004;231:11-23
37 Marrow Pathology Disorders of marrow proliferation Disorders of marrow replacementDisorders of marrow depletionVascular and Miscellaneous abnormalitiesTHE NEXT CATEGORY IS...
38 Marrow Replacement Disorders Implantation of cells in the marrow that do not normally exist thereUsually focal lesionsMRI appearances include low T1 signal (equal or less than muscle or disc) and variable T2 signal (usually high, unless sclerotic).WHICH RESULTS IN...In contrast to the marrow proliferative disorders, these affect bone in a focal rather than diffuse manner
39 Marrow Replacement Disorders BenignPrimary Bone tumorsOsteomyelitisMalignantMetastasisLymphomaMalignant Bone tumorsTHEY INCLUDE BOTH B9 AND MALIGNANT ETIOLOGIES
40 Metastasis Common primaries: breast, lung and prostate Involve red marrow in spine, pelvis, prox femurs and humeriFocal lesions with low T1 and high T2 and variable surr. edemaThese are T1W and STIR sagittal images of the lumbar spine demonstrating low T1 and high STIR signal lesions, representing metastatic breast cancer.
41 Lymphoma Primary lymphoma of bone rare NHL > HD Xray Permeative and lyticAppendicular skeleton in diaphyses of femur, tibia and humerusT1W and STIR coronal images of the pelvis demonstrate foci of low T1 and high STIR signal representing NHL.
42 Lytic permeative pattern Lytic permeative pattern. (a) Lateral radiograph of a 56-year-old woman shows permeative changes within the distal femur. (b) Coronal shows high signal intensity within the marrow and associated soft-tissue masses (arrows). (c) Sagittal contrast T1shows areas of enhancement within the intramedullary lesion and a soft-tissue mass off the posterior aspect of the femur (arrow).Krishnan, A. et al. Radiographics 2003;23:
43 T1W and STIR coronal images of the pelvis and lspine demonstrate foci of low T1 and high STIR signal representing NHL.
44 Marrow Pathology Disorders of marrow proliferation Disorders of marrow replacementDisorders of marrow depletionVascular and Miscellaneous abnormalitiesTHE LAST CATEGORY IS...
45 Marrow Depletion Disorders Due to ablation of red marrow elementsInvolvement can be diffuse or regional in distribution3 main causes include chemotherapy, radiation, and aplastic anemiaMRI appearances follow the signal intensity of fat
46 ChemotherapySystemically destroys normal hematopoietic marrow and tumor cells1st week post chemoEdematous and hypocellular marrowPost 1st weekProgressive fat replacement of marrow (similar to untreated aplastic anemia)THE SPECIFIC APPEARANCE OF BM FOLLOWING CHEMORX DEPENDS UPON HOW SOON AFTER IMAGING IS PERFORMED...
47 This is a T1W sagittal lumbar spine demonstrating abnormal diffuse distribution of high signal intensity marrow, which is similar in intensity to fat. DX? Chemotherapy
48 Aplastic AnemiaAcquired (infections, drugs, toxins) or congenital causes (Fanconi, TAR Sx, etc)MRClassic descriptionDiffuse fat replacement of marrowFoci of low T1 signal may representResidual islands of red marrowPost Rx regenerative marrowDevelopment of MDS/Leukemia
49 This is a T1W coronal view of the pelvis demonstrating diffuse abnormal distribution of high T1 signal intensity marrow. Do you see another DX besides aplastic anemia? Bilateral AVN
50 Foci of low T1 signal may represent Residual islands of red marrow Post Rx regenerative marrowDevelopment of MDS/LeukemiaT1 and STIR showing ham marrow in GCSF pt. W/O such hx would consider regen marrow residual marrowHemato. marrowPre RxCourse 1Course 2
51 Radiation Acute and Chronic induced changes MR appearance of radiated marrow depends on phase in which it was imaged and dose1st 2 weeks: Increased STIR with slight increase in T13rd-6th weeks: heterogeneous signal>6th weeks: chronic changes of fat replacementDose < 30 Gy may have regeneration after 1 yearDose >30-40 Gy irreversible changesThe effects of radiation induced changes in bone marrow can be divided into acute and chronic. This is a pt with chronic radiation changes on a T1W sagittal image of the lumbar spine demonstrating hypoplasia and abnormal high T1 signal intensity marrow of the lower lumbar and sacral vertebrae.
52 PreRx, 3 days, 46 days STIR demonstrating acute edema early followed by decreased signal later Stevens et al. AJR. 1990; 154:
53 This is a pt with chronic radiation changes on a T1W sagittal image of the lumbar spine demonstrating hypoplasia and abnormal high T1 signal intensity marrow of the lower lumbar and sacral vertebrae.
54 Marrow Vascular and Miscellaneous Abnormalities Hyperemia and IschemiaTransient and regional migratory osteoporosisRSDOsteonecrosisTraumaInfectionTumorsJoint abnormalities (degenerative or neuropathic arthropathy)OtherStorage diseases: Glycogen (Gaucher’s) or IronPaget’s diseaseOsteopetrosis
55 Transient Osteoporosis of the Hip Painful process that affects mainly young and middle age men in either hip or pregnant women more commonly in the left hipOsteoporosis can be severe enough to cause an insufficiency fractureMRHomogeneous Focal/Diffuse well marginated edemaMay spare medial and/or lateral margins of femoral head +/- greater trochanterOccasional acetabular edemaSmall-moderate joint effusion
56 Transient Osteoporosis of the Hip This is a coronal STIR image of the pelvis demonstrating an abnormal high signal intensity focus within the right proximal femur and associated hip effusion, representing TOH.
57 Regional Migratory Osteoporosis Similar MRI and clinical features as TOHNot confined to the hip and migratory in natureSubchondral regions of the knee, ankle, and hip each may be affected in turnThis is a STIR coronal image of the knee demonstrating abnormal high signal intensity marrow and soft tissue, representing RMO.
58 Two sets of images taken 3 months apart, consisting of T1 and T2FS Two sets of images taken 3 months apart, consisting of T1 and T2FS. 1st shows edema in cuboid with linear low signal which thought to represent an insuff fx. 2nd shows resolution of cuboid edema with new ankle joint effusion and talar body edema and talar dome insuff fx.
59 Marrow Ischemia (Osteonecrosis) Synonymous termsAVN (Focal lesions in the epiphyses)Bone infarct ( Metaphysis or diaphysis)CausesTrauma, steroids, HbS, SLE, Gaucher disease, ETOH, pancreatitis, and idiopathicNEXT WE TURN TO LESIONS OF MARROW ISCHEMIA OR OSTEONECROSISThis is a T1w sagittal image of the knee. What is the DX? Osteonecrosis.
60 Xray and MR- patchy sclerosis and lucency in a serpiginous pattern Lonergan, G. J. et al. Radiographics 2001;21:
61 Gaucher DiseaseRare lysosomal storage disease leading to the accumulation of glucocerebroside within the RESMRFocal/Diffuse hypointensity on T1 and T2Active disease hyperintense on T2 FS and STIRLumbar spine involved first followed by appendicular skeleton
62 Gaucher DiseaseTreatment includes administration of the deficient enzymeMRI can be used to monitor treatment demonstrating decreased marrow infiltration on serial exams in those who are respondingThis is a STIR of the pelvis. Note the abnormal high signal intensity within the left hip and right acetabulum and the underlying diffuse low signal intensity marrow, representing Gaucher disease. Is there another focus of osteonecrosis?T1W coronal image of the femora demonstrating normal marrow distribution in this patient with gaucher disease after Rx. The Erlenmeyer flask deformities of the femora remain.
63 SummaryBone marrow disorders have a nonspecific MR appearance but remembering the categories of diseases and correlating this with clinical history can be helpfulMarrow ProliferativeMarrow ReplacementMarrow DepletionVascular/MiscellaneousTwo useful characteristics for evaluating marrow disordersDistributionNormal marrow conversion and reconversion patternsSignal Intensity (muscle and disc serve as internal standard)Normal marrow: same or higher signalAbnormal marrow: lower signal
64 References Clinical Magnetic Resonance Imaging, Edelman et al, 2006. Bone and Joint Disorders, Resnick et al, 2005Moore et al. Red and Yellow Marrow in the femur: age related changes in appearance at MR Imaging. Radiology 175: , 1984.Vande Berg et al.: Classification and detection of bone marrow lesions with magnetic resonance imaging. Skeletal Radiology 27: , 1998.Vande Berg et al.: Magnetic Resonance Imaging of the bone marrow in hematologic malignancies. Eur Radiology 8: , 1998.Parisi et al.: Complication of cancer therapy in children: A radiologist’s guide. Radiographics 19: , 1999.Kaplan et al: Bone marrow patterns in aplastic anemia observations with 1.5T MR imaging. Radiology 164: , 1987.Kaplan et al: Polycythemia Vera and Myelofibrosis:correlation of MR, clinical, and laboratory findings, Radiology 183: , 1992.Avila et al.: Mastocytosis: magnetic resonance imaging patterns of bone marrow disease, Skeletal Radiology 27: , 1998.Stacy E. Smith et al. From the Archives of the AFIP: Radiologic Spectrum of Paget Disease of Bone and Its Complications with Pathologic Correlation. RadioGraphics 2002; 22: 1191.
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