Whole-Body Imaging in Multiple Myeloma Christina Messiou, MD, BMedSci, BMBS, MRCP, FRCR, Martin Kaiser, MD  Magnetic Resonance Imaging Clinics  Volume 26, Issue 4, Pages 509-525 (November 2018) DOI: 10.1016/j.mric.2018.06.006 Copyright © 2018 The Royal Marsden Hospital Terms and Conditions

Fig. 1 Plain film of the bony pelvis in a patient with suspected myeloma (A) shows no focal lytic lesions. However, low-dose CT (B) clearly demonstrates a lytic lesion in the left iliac bone (arrow). Magnetic Resonance Imaging Clinics 2018 26, 509-525DOI: (10.1016/j.mric.2018.06.006) Copyright © 2018 The Royal Marsden Hospital Terms and Conditions

Fig. 2 A b900 DW MR imaging inverse gray-scale maximum-intensity projection (MIP) (A), axial b900 DW MR imaging (B), and ADC map (C) of a patient with a new diagnosis of myeloma show multifocal bone lesions (arrows, A), including a restricted lesion in the posterior left acetabulum (arrows, B, C). The posterior acetabular lesion is not evident on corresponding CT (D) or FDG PET/CT (E) performed on the same day. Following induction chemotherapy, the b900 DW MR imaging inverse gray scale MIP shows reduced burden of disease (F). Although the posterior acetabular lesion is only marginally smaller on b900 DW MR imaging (arrow, G), the increased ADC (arrow, H) indicates a good response. Magnetic Resonance Imaging Clinics 2018 26, 509-525DOI: (10.1016/j.mric.2018.06.006) Copyright © 2018 The Royal Marsden Hospital Terms and Conditions

Fig. 3 FDG PET/CT (A) in a patient with a suspected new diagnosis of myeloma was reported as not showing evidence of marrow disease. Conversely, sagittal T1-weighted MR imaging of the spine (B) shows diffuse low signal in vertebral marrow relative to the discs; b900 maximum-intensity projection (C), b900 axial DW MR imaging (D), and corresponding ADC map (E) confirm diffuse abnormal marrow signal. Trephine confirmed 80% plasma cell infiltration of bone marrow. Magnetic Resonance Imaging Clinics 2018 26, 509-525DOI: (10.1016/j.mric.2018.06.006) Copyright © 2018 The Royal Marsden Hospital Terms and Conditions

Fig. 4 A b900 DW MR imaging inverse gray-scale maximum-intensity projection (A) shows subtle alteration in background marrow signal suspicious but not confirmatory for diffuse infiltration. There are no focal lesions. Axial b50 (B), b900 (C), and ADC map (D) of the pelvis confirm suspicion for diffuse abnormal signal. The right-sided trephine tract is clearly seen at b50, b900, and on the ADC map (arrows) and suggests that marrow sampled appears similar to marrow elsewhere and should, therefore, be representative. Trephine confirmed 20% plasma cell infiltration. Magnetic Resonance Imaging Clinics 2018 26, 509-525DOI: (10.1016/j.mric.2018.06.006) Copyright © 2018 The Royal Marsden Hospital Terms and Conditions

Fig. 5 Sagittal T1-weighted (T1W) MR imaging of the spine in a patient with a suspected new diagnosis of myeloma shows a subtle focal lesion in anterior T11 (arrow, A). Axial b900 images confirm the focal lesion in T11 (C) but also demonstrate small focal lesions in T7 (B, arrow), T12 (D, arrow), and L4 (E, arrow), which were not evident on T1W imaging. Magnetic Resonance Imaging Clinics 2018 26, 509-525DOI: (10.1016/j.mric.2018.06.006) Copyright © 2018 The Royal Marsden Hospital Terms and Conditions

Fig. 6 Core whole-body MR imaging protocol comprises sagittal T1 (A) and T2-weighted (B) sequences of the spine; axial b50 (C), b900 DW MR imaging (D), ADC map (E), and b900 DW MR imaging inverse gray-scale maximum-intensity projection (F); axial water-only (G) and fat-only (H) Dixon imaging. Two focal lesions within T8 are clearly seen on DW MR imaging (D, arrow) but are less well seen on sagittal imaging of the spine (arrow, B). The b50 DW MR imaging through the pelvis (I) shows the left-sided trephine tract (arrow), which suggests that background marrow but not focal lesions are sampled. Magnetic Resonance Imaging Clinics 2018 26, 509-525DOI: (10.1016/j.mric.2018.06.006) Copyright © 2018 The Royal Marsden Hospital Terms and Conditions

Fig. 7 Sagittal T1-weighted MR imaging (A) and b900 DW MR imaging inverse gray-scale MIP (B) in a patient with treated myeloma suggest the presence of multifocal lesions. However, the ADC map (example left humeral lesion arrow, B, C) showed uniformly very high ADC (similar to cerebral spinal fluid) suggesting that these were acellular treated sites of disease. The appearance of multifocal disease on the b900 DW MR imaging inverse gray-scale MIP is an example of T2 shine through. Magnetic Resonance Imaging Clinics 2018 26, 509-525DOI: (10.1016/j.mric.2018.06.006) Copyright © 2018 The Royal Marsden Hospital Terms and Conditions

Fig. 8 A b900 DW MR imaging inverse gray-scale MIP of a patient with diffuse myeloma marrow infiltration confirmed on trephine, which showed 80% infiltration (A). Follow-up b900 DW MR imaging inverse gray-scale MIP (B) following induction chemotherapy shows stable imaging appearances of diffuse abnormal signal; but trephine showed no evidence of myeloma, only reactive, regenerative marrow. The diffuse abnormal signal following therapy was secondary to G-CSF administration. Magnetic Resonance Imaging Clinics 2018 26, 509-525DOI: (10.1016/j.mric.2018.06.006) Copyright © 2018 The Royal Marsden Hospital Terms and Conditions

Fig. 9 Sagittal T1-weighted (A) and T2W (B) MR imaging of the spine in a patient with a suspected new diagnosis of myeloma demonstrates characteristic appearances of a vertebral T10 hemangioma (arrows), which is T1 and T2 bright. The corresponding axial b900 image also shows a corresponding focal lesion (arrow, C); the ADC map (arrow, D) confirms a high ADC, which is more in keeping with a hemangioma than active disease. Magnetic Resonance Imaging Clinics 2018 26, 509-525DOI: (10.1016/j.mric.2018.06.006) Copyright © 2018 The Royal Marsden Hospital Terms and Conditions

Fig. 10 b900 DW MR imaging and ADC map of a patient with a suspected diagnosis of myeloma demonstrates a focal lesion in the left posterior iliac crest (arrows, A, B). The intermediate/high ADC is unusual for a new site of focal active disease, which would usually appear restricted. Close interrogation of the corresponding fat-only and water-only images reveals a trephine tract (arrows, C, D) through the lesion. The lesion was a hematoma that resolved on follow-up. Magnetic Resonance Imaging Clinics 2018 26, 509-525DOI: (10.1016/j.mric.2018.06.006) Copyright © 2018 The Royal Marsden Hospital Terms and Conditions

Fig. 11 A b900 DW MR imaging inverse gray-scale MIP (A), axial b900 DW MR imaging (B), and ADC map (C) of the pelvis in a patient with a new diagnosis of diffuse myeloma infiltration confirmed on trephine. Corresponding sagittal T1-weighted MR imaging of the spine shows diffuse low signal in vertebral marrow (D). Following induction chemotherapy, b900 DW MR imaging inverse gray-scale MIP (E), b900 DW MR imaging (F), and ADC map (G) show normalization of marrow signal. Increased T1 marrow signal (H) confirms the return of normal marrow fat. Magnetic Resonance Imaging Clinics 2018 26, 509-525DOI: (10.1016/j.mric.2018.06.006) Copyright © 2018 The Royal Marsden Hospital Terms and Conditions

Fig. 12 Axial b900 DW MR imaging, ADC map, axial water-only, and fat-only images of the pelvis before (A–D) and after treatment (E–H) in a patient with a new diagnosis of diffuse myeloma infiltration confirmed on trephine. Following induction chemotherapy, the ADC map shows subtle patchy islands of increasing ADC (E), suggesting some response (arrows, F). Corresponding water-only images show diffuse reduced water signal (reduced signal G compared with C), and returning fat signal is seen on fat-only images (increased signal on H compared with D) in keeping with response. Magnetic Resonance Imaging Clinics 2018 26, 509-525DOI: (10.1016/j.mric.2018.06.006) Copyright © 2018 The Royal Marsden Hospital Terms and Conditions