Diffuse Marrow Infiltration Research Articles

Value of third-generation of VNCa dual-energy CT for differentiating diffuse marrow infiltration of multiple myeloma from red bone marrow.

This study aims to investigate the ability of bone marrow imaging using third-generation dual-energy computed tomography (CT) virtual noncalcium (VNCa) to differentiate between multiple myeloma (MM) with diffuse bone marrow infiltration and red bone marrow (RBM). Bone marrow aspiration or follow-up results were used as reference. We retrospectively reviewed 188 regions of interests (ROIs) from 21 patients with confirmed MM and diffuse bone marrow infiltrations who underwent VNCa bone marrow imaging between May 2019 and September 2022. At the same time, we obtained 98 ROIs from 11 subjects with RBM for comparative study, and 189 ROIs from 20 subjects with normal yellow bone marrow for the control group. The ROIs were delineated by 2 radiologists independently, the interobservers reproducibility was evaluated by interclass correlation coefficients. The correlation with MRI grade results was analyzed by Spearman correlation coefficient. Receiver operating characteristic (ROC) curve analysis was used to determine the optimal threshold for differentiating between these groups and to assess diagnostic performance. There were statistically significant differences in VNCa CT values of bone marrow among the MM, RBM, and control groups (all P < .001), with values decreasing sequentially. A strong positive rank correlation was observed between normal bone marrow, subgroup MM with moderately and severe bone marrow infiltration divided by MRI and their corresponding CT values (ρ = 0.897, 95%CI: 0.822 to 0.942, P < .001). When the CT value of VNCa bone marrow was 7.15 HU, the area under the curve (AUC) value for differentiating RBM and MM was 0.723, with a sensitivity of 50.5% and a specificity of 89.8%. When distinguishing severe bone marrow infiltration of MM from RBM, the AUC value was 0.80 with a sensitivity 70.9% and a specificity 78.9%. The AUC values for MM, RBM, and the combined group compared to the control group were all >0.99, with all diagnostic sensitivity and specificity exceeding 95%. VNCa bone marrow imaging using third-generation dual-energy CT accurately differentiates MM lesions from normal bone marrow or RBM. It demonstrates superior diagnostic performance in distinguishing RBM from MM with diffuse bone marrow infiltration.

Imaging of Multiple Myeloma: Present and Future.

Multiple myeloma (MM) is the second most common adult hematologic malignancy, and early intervention increases survival in asymptomatic high-risk patients. Imaging is crucial for the diagnosis and follow-up of MM, as the detection of bone and bone marrow lesions often dictates the decision to start treatment. Low-dose whole-body computed tomography (CT) is the modality of choice for the initial assessment, and dual-energy CT is a developing technique with the potential for detecting non-lytic marrow infiltration and evaluating the response to treatment. Magnetic resonance imaging (MRI) is more sensitive and specific than 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) for the detection of small focal lesions and diffuse marrow infiltration. However, FDG-PET/CT is recommended as the modality of choice for follow-up. Recently, diffusion-weighted MRI has become a new technique for the quantitative assessment of disease burden and therapy response. Although not widespread, we address current proposals for structured reporting to promote standardization and diminish variations. This review provides an up-to-date overview of MM imaging, indications, advantages, limitations, and recommended reporting of each technique. We also cover the main differential diagnosis and pitfalls and discuss the ongoing controversies and future directions, such as PET-MRI and artificial intelligence.

Quantitative Analysis of Whole-Body MRI for Accessing the Degree of Diffuse Infiltration Patterns and Identifying High Risk Cases of Newly Diagnosed Multiple Myeloma.

Accurate identification of high-risk multiple myeloma (HRMM) is important for prognostication. The degree of diffuse infiltration patterns on magnetic resonance imaging (MRI) is associated with patient prognosis in multiple myeloma. However, objective indexes to determine the degree of diffuse infiltration patterns are unavailable. To investigate whether qualitative and quantitative evaluations of diffuse infiltration patterns on MRI could identify HRMM. Retrospective. Totally, 180 patients (79 HRMM and 101 standard-risk MM) were assessed. The presence of del(17p), t(4;14), t(14;16), t(14;20), gain 1q, and/or p53 mutations was considered to indicate HRMM. 3.0 T/diffusion-weighted whole-body imaging with background body signal suppression (DWIBS), modified Dixon chemical-shift imaging Quant (mDIXON Quant), and short TI inversion recovery (STIR). Qualitative analysis involved assessing the degree of diffuse marrow infiltration (mild, moderate, or severe), and quantitative analysis involved evaluating apparent diffusion coefficient (ADC), fat fraction (FF), and T2* values. Clinical data such as sex, age, hemoglobin, serum albumin, serum calcium, serum creatinine, serum lactate dehydrogenase, β2-microglobulin, and bone marrow plasma cells (BMPCs) were also included. Univariate and multivariate analyses, receiver operating characteristic (ROC) curve. P < 0.05 was considered statistically significant. The high-risk group had significantly higher ADC and T2* and lower FF compared with the standard-risk group. Multivariate analysis indicated BMPCs as a significant independent risk factor for HRMM (odds ratio (OR) = 1.019, 95% CI 1.004-1.033), while FF was a significant independent protective factor associated with HRMM (OR = 0.972, 95% CI 0.946-0.999). The combination of BMPCs and FF achieved the highest areas under the curve (AUC) of 0.732, with sensitivity and specificity of 70.9% and 68.3%, respectively. Compared with qualitative analysis, FF value was independently associated with HRMM. The quantitative features of diffuse marrow infiltration on MRI scans are more effective in detecting HRMM. 3 TECHNICAL EFFICACY: Stage 2.

Whole-Body Low-Dose CT in Multiple Myeloma: Diagnostic Value of Appendicular Medullary Patterns of Attenuation.

OBJECTIVE. The purpose of this article is to analyze whole-body low-dose CT-detected appendicular medullary patterns of attenuation in patients with newly diagnosed multiple myeloma and to determine the diagnostic performance of whole-body low-dose CT in detecting diffuse marrow infiltration. MATERIALS AND METHODS. A total of 76 patients with myeloma who underwent whole-body low-dose CT and spinal MRI at initial assessment were retrospectively analyzed. The medullary cavities of femurs and humeri were evaluated qualitatively and quantitatively on CT. Medullary attenuation and SD-to-mean attenuation ratio were recorded for each long bone. The pattern of marrow involvement on spinal MRI was used as reference. The chi-square test was used to evaluate the relationship between the CT-based appendicular medullary cavity pattern and the MRI pattern, and ROC analysis was performed to assess the diagnostic accuracy of CT attenuation measurements for the differentiation between diffuse and mixed CT-based appendicular medullary cavity patterns. RESULTS. Medullary attenuation differed significantly among mixed, nodular, and diffuse CT-based appendicular medullary cavity patterns in the femurs (mean, 34.23 HU and range, 15-61 HU; mean, 66.26 HU and range, 26-104 HU; mean, 92.80 HU and range, 53-127 HU, respectively) and humeri (mean, 22.18 HU and range, 9-41; mean, 61.18 HU and range, 23-93 HU; mean, 77.50 and range, 25-105 HU, respectively). To discriminate between diffuse and mixed CT-based appendicular medullary cavity patterns, optimal cutoff attenuation values were 63 HU (sensitivity, 97.7%; specificity, 100.0%) for the femurs, and 52 HU (sensitivity, 97.4%; specificity, 100.0%) for the humeri. A total of 24 of 30 (80.0%) patients with a diffuse MRI pattern showed a diffuse CT-based appendicular medullary cavity pattern on whole-body low-dose CT, and all patients with a diffuse CT-based appendicular medullary cavity pattern also showed a diffuse pattern on MRI. CONCLUSION. According to analysis of peripheral medullary patterns of attenuation, whole-body low-dose CT can identify patients with multiple myeloma with diffuse marrow involvement.

Cryptochrome-1 Gene Expression is a Reliable Prognostic Indicator in Egyptian Patients with Chronic Lymphocytic Leukemia: A Prospective Cohort Study

ObjectiveTraditional prognostic factors have proved insufficient to account for heterogeneity in the clinical behavior of chronic lymphocytic leukemia (CLL). Cryptochrome-1 (CRY-1) is a circadian clock gene essential in maintaining the circadian rhythm and regulating cell proliferation. We evaluated CRY-1 gene expression in CLL and addressed its putative role as a prognostic indicator for the clinical course of CLL.Materials and MethodsA total of 100 CLL patients at diagnosis were studied for CRY-1 gene expression by real-time reverse-transcription polymerase chain reaction and were followed for assessment of time to first treatment (TFT).Results CRY-1 was expressed in 94% of the CLL patients at diagnosis. The median CRY-1 relative gene expression level (0.006) stratified patients into high and low expression groups. Forty of 100 (40%) CLL patients showed high CRY-1, 54/100 (54%) showed low CRY-1, and 6/100 (6%) had undetectable CRY-1 gene expression. High CRY-1 gene expression was concordant with CD38+, Zap-70+, and double CD38+Zap-70+ expression; unfavorable/intermediate cytogenetics; unmutated immunoglobulin heavy-chain variable-region gene; and diffuse marrow infiltration. The high CRY-1 gene expression patient group exhibited shorter TFT than the patients with low CRY-1 gene expression. A Cox proportional hazard regression model identified CRY-1 gene expression to be independently predictive for TFT.Conclusion CRY-1 is differentially expressed among CLL patients, stratifying them into low-risk and high-risk groups. CRY-1 gene expression could constitute a reliable prognostic indicator for CLL progression, complementing the role of standard well-established prognostic factors. CRY-1 gene expression could be employed as a prognostic indicator for disease progression during the initial prognostic work-up and follow-up for CLL patients.

Imaging of Multiple Myeloma and Related Plasma Cell Dyscrasias

Multiple myeloma (MM) is an incurable plasma cell malignancy of the bone marrow. MM has 3 components: diffuse marrow infiltration, focal bone lesions, and soft-tissue (extramedullary) disease. The hallmark biomarker in blood or urine is a monoclonal immunoglobulin, the monoclonal protein. Waldenstrom macroglobulinemia is a similar disease with secretion of IgM. Staging is classically performed with the 1975 Durie-Salmon system, which includes conventional radiographs. Recently updated, the Durie-Salmon Plus staging system includes CT, MRI, and (18)F-FDG PET/CT. The hallmark radiographic lesion of symptomatic MM is a well-demarcated, focal osteolytic bone lesion. The number of focal bone lesions correlates inversely with outcome. Extramedullary disease is typically an aggressive, poorly differentiated form of MM that confers inferior outcome, with median survival of less than 1 y if present at diagnosis. Achievement of a complete response on (18)F-FDG PET before stem-cell transplantation correlates with a superior outcome.

Outcome prediction of advanced mantle cell lymphoma by international prognostic index versus different mantle cell lymphoma indexes: one institution study

The aim of this study was to evaluate the prognostic significance of international prognostic index (IPI), mantle cell lymphoma IPI (MIPI), simplified MIPI (sMIPI), and MIPI biological (MIPIb), as well as their correlation with immunophenotype, clinical characteristics, and overall survival (OS), in a selected group of 54 patients with advanced-stage mantle cell lymphoma (MCL), treated uniformly with CHOP. Seventeen patients had IV clinical stage (CS), while other 37 had leukemic phase at presentation. Diffuse type of marrow infiltration was verified in 68.5% and nodular in remainder patients. Extranodal localization (25.9%) included bowel (20.4%), pleural effusion, sinus, and palpebral infiltration. All of analyzed patients expressed typical MCL immunophenotypic profile: CD19(+)CD20(+)CD22(+)CD5(+)Cyclin-D1(+)FMC7(+)CD79b(+)smIg(+)CD38(+/-)CD23(-)CD10(-). Median OS of the whole group was 23 months, without significant differences between IV CS and leukemic phase patients. Thirty-two patients (59.3%) responded to initial treatment, 9 (16.7%) with complete and 23 (42.6%) with partial remission. Negative prognostic influence on OS had high IPI (P < 0.01), high sMIPI (P < 0.001), MIPI (P < 0.01), MIPIb (P < 0.01), extranodal localization (P < 0.01), and diffuse marrow infiltration (P < 0.01). Testing between randomly selected groups showed that patients with lower proportion of CD5(+) cells (<80%) correlated with cytological blastoid variant and had shorter survival comparing with the group with higher proportion of CD5(+) cells (>80%) (P < 0.01). Using univariate Cox regression, we proved that IPI, sMIPI, MIPI, and MIPIb had an independent predictive importance (P < 0.01) for OS in uniformly treated advanced MCL patients, although sMIPI prognostic significance was the highest (P < 0.001).

As Rare As It Gets — Gastric Plasmacytoma Presenting as Jaundice: A Case Report

Purpose: INTRODUCTION: Primary or secondary involvement of the GI tract by plasma cell dyscrasias is exceptionally rare. We hereby present the case report of a gastric plasmacytoma that had a unique and novel presentation of jaundice. CASE DESCRIPTION: A 68 y/o female with h/o HTN, recurrent DVT, and asthma presented with abdominal pain for two weeks. Pain was associated with nausea, occasional vomiting and yellowish discoloration of skin and sclera. She denied any weight loss or itching. Abdominal exam showed mild distension, hepatomegaly and right upper quadrant tenderness. Laboratory results showed creatinine 1.8 mg/dl, Hgb 6.1g/dl, MCV 112.8, platelet count 45000cells/cubic millimeter, albumin 2.5 g/dl, total bilirubin 4.0 umol/l, direct bilirubin 2.9 umol/l, ALP 209 U/L, AST 75 U/L and ALT 36 U/L. Chest X-ray showed an abnormal lesion on the right 6th rib. Abdominal ultrasound showed coarsened echotexture of the liver, gall bladder sludge, perihepatic ascites and no cholecystitis. MRCP showed nodular liver without any significant gallbladder or CBD findings. EGD showed a nodule at the incisura of the stomach and a non bleeding ulcer. Histopathology of the gastric nodule revealed hyperplastic foveolar polyp containing a nodular cluster of plasma cells. Immunohistochemistry was consistent with a nodular collection of predominantly lambda positive cells in the lamina propria diagnostic of gastric plamacytoma. Bone marrow biopsy and flow cytometry analysis were interpreted as marked cell dyscrasia, diffuse marrow infiltration with monoclonal IgG/lambda + plasma cells. Immunohistochemistry showed that 90-95% of the nucleated cells in the biopsy were CD138 positive. DISCUSSION: Multiple Myeloma (MM) involves GI tract only in about <5% of the cases. Gastrointestinal involvement rarely is the first or sole presenting symptom of extramedullary MM. It is either an incidental finding or manifests as a secondary system involvement. Liver is the most commonly involved site followed by the small intestine, pancreas, stomach, peritoneum and colon. Gastric plamacytoma has a varied endoscopic appearance of thickened folds, polyposis, ulcers and multiple nodules. Differential diagnoses include amyloidosis, poorly differentiated neoplasms, MALT lymphoma and GIST. Tissue pathology including flow cytomtery and immunohistochemistry play a vital role in diagnostic differentiation. Complete resection of the gastric lesion is usually recommended with or without combination with irradiation or chemotherapy. Gastric or any extra nodal involvement in a patient with multiple myeloma carries a poor prognosis.

Normal Variants of the Bone Marrow at MR Imaging of the Spine

It is the radiologist's cornerstone to decide if imaging findings are normal or abnormal and to differentiate between clinically significant and insignificant findings. This challenge is extremely common in routine clinical practice when performing magnetic resonance (MR) imaging of the spine because it is frequently performed to assess patients with cancer or with spine-related symptoms. MR appearance of the normal vertebral marrow shows important variations not only with age but also among individuals of the same age range. On the contrary, marrow distribution and signal intensity patterns show little variation among each vertebral body of the same subject. Focal alterations in signal intensity can be observed that reflect local variation in the amount of normal expected vertebral components, including fat and hematopoietic cells, bone, and vessels. A more recently recognized condition related to the presence of notochordal cells deserves further study because it could account for some frequent tiny marrow changes. Diffuse alteration in vertebral signal intensity can also be observed and can be difficult--or even impossible--to differentiate from diffuse marrow infiltration by an abnormal process, given the lack of specificity of MR imaging. This article highlights the normal variants and frequent alterations of the vertebral bone marrow as encountered on MR studies of the spine and that can simulate significant lesions.

I-123 MIBG Scan of Metastatic Neuroblastoma Mimicking a Bone Scan

A 21-year-old man presented to an outside institution with longstanding right hip pain. Magnetic resonance imaging revealed diffuse marrow infiltration in the lumbar spine, sacrum, ilium, and right proximal femur. Biopsy of a left upper quadrant mass was consistent with stroma poor neuroblastoma with differentiation. The patient underwent left radical adrenalectomy, left retroperitoneal lymph node dissection with gross resection of residual tumor and 5 cycles of high-dose chemotherapy (cyclophosphamide, doxorubicin, and vincristine) with evidence of disease progression. A short course of irinotecan was given for palliation. A protocol with low-dose 1-131 MIBG was started for symptomatic control.

Vertebral and Spinal Cord Sarcoidosis

Campbell SE, Reed CM, Bui-Mansfield LT, Fillman E 64-year-old woman with a history of sarcoidosis presented with back and abdominal pain and was unresponsive to nonsteroidal antiinflammatory medications. In addition, the patient complained of weakness in her right arm. Physical examination of the abdomen was unremarkable, and examination of the spine revealed normal flexion and extension and no focal tenderness. Neurologic examination revealed slightly decreased strength in the right arm and hand. A posteroanterior chest radiograph showed a bilateral diffuse reticulonodular pulmonary parenchymal pattern, right paratracheal stripe thickening, and bilateral hilar lymphadenopathy (Fig. 1A). CT of the chest confirmed bilateral hilar, right paratracheal, and subcarinal lymphadenopathy and interstitial pulmonary disease. CT also revealed widespread retroperitoneal lymphadenopathy and multiple lytic lesions within the vertebral bodies and posterior elements of the thoracolumbar spine. Subsequent MRI of the spine revealed decreased T1 signal intensity and increased T2 signal intensity scattered throughout the spine (Fig. 1B). After IV sodium gadopentate was administered to the patient, multiple brightly enhancing lesions within the vertebral bodies, pedicles, laminae, and spinous processes were identified. Diffuse leptomeningeal and nerve root enhancement and an enhancing parenchymal spinal cord mass were also present (Fig. 1C). Biopsy of a vertebral lesion revealed noncaseating granuloma consistent with sarcoidosis without evidence of malignancy (Fig. 1D). Gram stains and cultures for fungi, aerobic and anaerobic organisms, and acid-fast bacilli were all negative. The differential diagnosis for diffuse marrow infiltration, enhancing intraaxial spinal cord mass, diffuse meningeal and nerve root enhancement, and mediastinal and retroperitoneal lymphadenopathy includes metastatic disease, lymphoma, leukemia, hematogenous osteomyelitis (tuberculous, fungal), and sarcoidosis [1]. Sarcoidosis is a systemic granulomatous disease of unknown etiology that has been shown to affect nearly every organ system. Osseous involvement occurs in 1–13% of cases, typically in the small tubular bones of the hands and feet [2, 3]. Sarcoidosis may affect either the vertebral column or the spinal cord. Typical vertebral column manifestations are lytic lesions with sclerotic borders that enhance on MRI and enhancement of the intervertebral disk [1, 3–5]. Typical spinal cord manifestations are leptomeningeal enhancement, enhancing spinal cord mass, nerve root “clumping,” and enhancing nerve root [4]. The most common spinal cord manifestation is leptomeningeal disease [4]. Given the variable manifestations of sarcoidosis within the spine, this disease should be considered in the differential diagnosis along with multiple sclerosis [4]; tuberculous meningitis [4]; and widespread vertebral involvement of metastatic disease, infection, or lymphoma [1]. Sarcoidosis is typically treated with corticosteroid therapy, after which clinical symptoms and even MRI findings may completely or partially resolve in 29% of the patients [6]. Prednisone

An unusual presenting feature of precursor T-cell acute lymphoblastic leukemia/lymphoma

Precursor T-acute lymphoblastic leukemia/lymphoma (ALL) comprises approximately 20–25% of adult cases of ALL. Precursor T-ALL tends to present in adolescent males as lymphomas and is characteristically presented with a high leukocyte count or large mediastinal mass at initial presentation. We report here a rare manifestation of precursor T-ALL presenting with clinically significant involvement of ovary and spine at initial presentation. A 33-year-old woman presented with low abdominal pain and lumbago for 1 day in July 2004. Physical examination revealed tenderness in the right lower abdominal region. No enlarged spleen, liver or lymph nodes was palpable. Hematologic data showed Hb level of 8.3 g/dl, 8.91×10/l of WBC with 87% of segmented neutrophils, 10% of lymphocytes, 3% of monocytes, and 328×10/l of platelets. An ultrasound examination of the pelvis revealed a cystic mass with a dimension of 6.5×4.5 cm in the right ovary. An emergent operation was performed for presumed symptomatic ovarian cyst. Ovarian masses were solid masses rather than cystic masses under the laparotomy, and right salpingooophorectomy with left ovary wedge resection was done. Histologic examination of the ovarian masses revealed lymphoblastic infiltration (Fig. 1a). They showed positive immunoreactivity for CD3 (cytoplasmic pattern), CD10 and CD45 (leukocyte common antigen) and negative immunoreactivity for CD20, CD30, CD117 and CD68. On the fourth postoperative day the patient developed abrupt-onset paraplegia and sensory loss of both lower extremities. Magnetic resonance imaging of the spine showed a dorsal epidural mass destroying from T9 to T12, and multiple enhancing lesions in L3, L4, S1 vertebral body were revealed (Fig. 1b). Emergency operative decompression of the spinal cord was done to relieve the lower extremity paraplegia. Autogenous iliac bone graft and from T7 to T12 posterolateral fusion following T9, 10, 11 total and T8 partial decompressive laminectomy was done after the removal of epidural mass. Histologic examination of the spinal mass revealed lymphoblastic and eosinophilic infiltration (Fig. 1c). The lymphoblasts were characterized by positive immunoreactivity for CD3 (cytoplasmic pattern), CD10 and CD45 (leukocyte common antigen) and negative immunoreactivity for CD20, CD30, CD117 and CD68. Under the impression of T lymphoblastic lymphoma, bone marrow examination was done. The bone marrow touch imprint preparation showed that 92% of marrow cells were lymphoblasts. They were variable in size and characterized by high nuclear–cytoplasmic ratio (Fig. 1d). Trephine biopsy showed diffuse infiltration of marrow by lymphoblasts, which revealed numerous mitotic figures (Fig. 1e). Immunohistochemical stain showed positive reactivity for CD3 (cytoplasmic pattern) and negative for CD20 (Fig. 1f). Chromosomal analysis of bone marrow demonstrated a 46XX karyotype in 100% (20/20) of the cells. A CT scan of the chest demonstrated an anterior mediastinal mass approximately 12×8 cm. A diagnosis of precursor T-ALL was made. The patient was started on induction chemotherapy with vincristine, prednisone, daunorubicin and L-asparaginase (VPDL). The anterior mediastinal mass regressed substantially and revealed a focal streaky density on followup chest CT checked on 28 June 2004. In August 2004, remission was successfully achieved as shown by follow-up bone marrow examination. The patient subsequently received further consolidation VPDL therapy and currently remains in good health. Precursor T-ALL is associated with numerous unfavorable presenting features; thus, patients have a worse prognosis than patients with precursor B-ALL. In adults, higher white blood cell counts (>30,000/μl) and older age (>60 years) shorten durations of remissions and overall survival M.-A. Kim (*) . K.-Y. Maeng Department of Laboratory Medicine, Gyeongsang National University Hospital, 90 Chilam-Dong, Jinju, 660-702, South Korea e-mail: givmea2004@yahoo.co.kr Tel.: +82-55-7508639 Fax: +82-55-7622696

Adult Still's disease as a paraneoplastic manifestation of breast cancer

We treated a patient who developed symptoms and findings indistinguishable from those of adult Still's disease as a manifestation of metastatic breast cancer 7 years after treatment for a stage 1 tumor. Although clinical features fulfilled diagnostic criteria for adult Still's disease, examination of a bone marrow biopsy specimen indicated that the apparent adult Still's disease was a paraneoplastic manifestation associated with diffuse marrow infiltration by breast cancer. The fever and polyarthralgia resolved with administration of prednisolone, and antiestrogen therapy with tamoxifen citrate was also started.

Contrast enhancement and quantitative signal analysis in MR imaging of multiple myeloma: assessment of focal and diffuse growth patterns in marrow correlated with biopsies and survival rates.

This study describes infiltration patterns of multiple myeloma in spinal MR imaging and correlates the findings with biopsies, survival rates, and signal intensity measurements in unenhanced and enhanced studies. Fifty-three patients with multiple myeloma and 53 age-matched controls underwent MR imaging of the spine. Twenty-nine patients underwent sagittal T1-weighted spin-echo enhanced imaging and all patients underwent sagittal T1-weighted spin-echo unenhanced and opposed-phase gradient-recalled echo images, and signal intensity measurements were taken. MR imaging was correlated to marrow specimens (n = 40) and a clinical staging system. The probability of survival was also calculated. Finally, we performed qualitative visual evaluation (infiltration pattern, degree of tumor involvement) and a quantitative evaluation (marrow signal intensity ratios, contrast enhancement). Five infiltration patterns were found: normal-appearing marrow with low-grade interstitial infiltration (n = 5), focal (n = 18), diffuse (n = 12), focal and diffuse (n = 13), and salt-and-pepper (n = 5). Infiltration pattern correlated with clinical staging; all patients with normal-appearing and salt-and-pepper patterns were clinically stage I. Diffuse marrow infiltration was assessed by marrow ratios: low-grade infiltration, greater than 2.0; intermediate, 1.0-2.0; highgrade, less than 1.0. Contrast enhancement with a signal intensity increase greater than 40% indicated diffuse infiltration. In the control group, all of whom had no marrow disease, enhancement varied (mean +/- SD, 16% +/- 8.9%) but did not exceed 40%. Marrow involvement on MR images correlated significantly with clinical staging and survival (p < or = .001). MR imaging with opposed gradient-recalled echo sequences and contrast enhancement provided data that allowed us to classify infiltration patterns and to quantify diffuse marrow involvement in multiple myeloma, both of which correlated to clinical staging and biopsy. Also, the MR data was of prognostic value. Therefore, like laboratory parameters, biopsies, and radiographs, MR imaging can be a supporting pillar in staging and planning treatment of patients with multiple myeloma.

Magnetic resonance imaging of the bone marrow in patients with leukemia, aplastic anemia, and lymphoma.

Magnetic resonance imaging (MRI) of the bone marrow was performed in 29 patients with leukemia, aplastic anemia, or lymphoma who were scheduled for bone marrow transplantation, and in 12 normals. T1-weighted coronal images (TR600/TE40) of the pelvis and proximal femurs demonstrated marrow pathology in adult patients. A simple MR grading system was developed to classify patterns of marrow involvement, and MR grading of cellularity was correlated with marrow histology. Normal marrow produced a relatively high signal intensity reflecting the predominance of short T1 fat in the marrow space. MRI of pretransplant patients with chronic myelogenous leukemia and acute leukemia in relapse demonstrated a markedly decreased marrow signal, consistent with the replacement of marrow fat by longer T1 neoplastic tissues. Aplastic anemia could not be differentiated from normal with the pulse sequences employed. Marrow involvement by Hodgkin's lymphoma was detected as diffuse marrow infiltration with superimposed focal areas of even lower signal intensity, reflecting the nodular nature of Hodgkin's. These results indicate that infiltrative marrow disorders can be sensitively detected by MRI.