5/15/2011
Whole body MRI in Myeloma
Jens Hillengass MD
Department of Hematology and Oncology
University of Heidelberg
and
Department E010 Radiology
German Cancer Research Center
No conflicts of interest to disclose
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Appearance of monoclonal plasma cell diseases in MRI
normal
diffuse
focal
mixed
Appearance of monoclonal plasma cell diseases in MRI
normal
focal
diffuse
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Appearance of monoclonal plasma cell diseases in MRI
20% 30% 30% 20%
Advantages of MRI
1. highest sensitivity for investigation of
bone marrow infiltration1
2. Detection of soft tissue tumors
3. Assessment of bone marrow
cellularity
4. Differentiation between malignant and
,,benigne" fracture
5. no radiation exposure, no contrast
medium needed
6. estimation of treatment response
7. prognostic significance
(1) Ghanem Eur. Radiol. 2006; Gleeson Skeletal Radiol 2008; Baur-Melnyk AJR 2008; Zamagni Haematologica 2007; Shortt
AJR 2009; Scudla IMW 2011 Poster 100
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Prognostic significane of MRI
presence and number of focal lesions
symptomatic MM > 7 focal lesions
asymptomatic MM > 1 focal lesion
(Walker JCO 2006)
(Hillengass JCO 2010)
Whole body MRI
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Whole body MRI
Higher sensitivity compared to CT
Baur-Melnyk 2008 AJR
Gleeson 2009 Skeletal Radiol.
MRI
Comparable sensitivity compared to PET-CT
Fonti 2008 J. Nucl Med.
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Whole body MRI versus MRI of the axial skeleton
· whole body-MRI significantly outperforms spinal-MRI
n = 100
axial
Extra-axial
exceeding
exceeding
intra-osseous
both
intra-osseous
both
cortical bone
cortical bone
24
2
14
24
0
15
axial lesions only
extra-axial lesions only
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10
Bäuerle, Hillengass 2009 Radiology and Louvre Paris
Appearance of monoclonal plasma cell diseases in
whole body MRI
n = 413 untreated patients
· MGUS
n = 96
· solitary plasmacytoma n = 15
· smoldering MM
n = 135
· symptomatic MM
n = 156
· AL-amyloidosis
n = 11
Analysis:
· assessment of diffuse infiltration
· number focal lesions (FL)
- axial versus extra-axial
- intra-osseous versus penetrating cortical bone versus soft tissue
Hillengass unpublished data
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Appearance of monoclonal plasma cell diseases in
whole body MRI
Grading of diffuse infiltration:
0 = normal; 1 = low; 2 = medium; 3 = severe
Hillengass unpublished data
Appearance of monoclonal plasma cell diseases in
whole body MRI
sMM axia l intra-osseo us
140
s
FL axial
nt 120
intra-osseous
penetrating cortical bone
soft tissue
ie 100
80
pat
MGUS
of
60
er
40
bm 20
u
0
N
0123
45678
9 10 >10
solitary PC
Number of FL
MM axia l intra-osseo us
MM axia l penetratin g cortical bone
100
140
s
s
nt
nt 120
80
ie
ie
smoldering MM
100
60
80
pat
pat
of
40
of
60
er
er
40
b
b
20
m
m
20
u
u
N symptomatic
0
MM
0
N
012345
6789 10 >10
012
34
567
89 10 >10
Number of FL
Number FL
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Appearance of monoclonal plasma cell diseases in
whole body MRI
FL extra-axial
sMM extra-axial intra-osseous
intra-osseous
penetrating cortical bone
soft tissue
150
tsn
tiea 100
MGUS
p
of
50
erbmu 0
N
0
123
45
6
7
89
10 >10
solitary PC
Number of FL
MM extra-axial intra-osseous
MM extra-axial penetrating cortical bone
100
150
ts
ts
n
n
e
80
ie
smoldering
tia
MM
100
p
60
pat
f
40
of
ro
50
e
er
b
20
b
m
m
u
u
symptomatic
0
N
MM
0
N
01
2
3
45
6
7
8
9
10 >10
0
1
2
3
45
67
8
9
10 >10
Number of FL
Number of FL
Detection of residual disease after ASCT
n = 100 patients with symptomatic MM
Hillengass ASH 2010
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Whole body MRI for monitoring of treatment
n = 100 patients with symptomatic MM
· Correlation of serological and MRI-derived response
· better prognosis if complete remission in both methods
· response of diffuse infiltration earlier, focal lesions later (residual disease?!)
MRI
functional techniques
1. Dynamic contrast-enhanced MRI (DCE-MRI) => microcirculation
2. Diffusion-weighted imaging (DWI) => cellularity
CT
MRI T1w
MRI T2w
DCE-MRI
DWI
Tan 2011 IMW Poster 121; Hillengass 2009 CCR and 2011 Brit J. Haematol
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MRI
Whole body DWI
Spina 2011 IMW Poster 113; Decaux 2011 IMW Poster 127
Summary
Reasons for the application of Whole body MRI
1. Significantly superior to spinal MRI
2. Assessment of bone marrow infiltration (better than CT and x-ray)
3. No radiation exposure
4. Detection of soft tissue tumors
Further goals
1. Assessment of residual disease
2. Evaluation of the significance for treatment decisions
3. Improvement of resolution
4. Implementation of functional sequences
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Summary
Do we need whole body MRI or is spinal MRI enough?
Summary
Sometimes we have to look at the complete picture
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DKFZ, Heidelberg
Department of Hematology,
· S. Delorme
University of Heidelberg
· B. Stieltjes
· B. Wagner-Gund
· M. Sunkauskaite
· S. Ayyaz
· T. Bäuerle
· R. Shah
· H.P. Schlemmer
· H. Goldschmidt
· K. Neben
Department of Radiology,
· T. Möhler
University of Heidelberg
· M. Raab
· K. Kilk
· D. Hose
· M.A. Weber
· B. Kopp
· H.U. Kauczor
· A.D. Ho
...
Institute of pathology,
University of Heidelberg
· M. Andrulis
Thank you!
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