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Multidetector CT of the Spine in Multiple Myeloma: Comparison with MR Imaging and Radiography

¹ Department of Radiology, University Hospital, University of Technology, Pauwelsstr. 30, D-52074 Aachen, Germany.
² Medical Clinic IV, University Hospital, University of Technology, D-52074 Aachen, Germany.

Received July 11, 2001; accepted after revision December 6, 2001.

 
Address correspondence to A. H. Mahnken.

Abstract

Top Abstract Introduction Subjects and Methods Results Discussion References

 
OBJECTIVE. The purpose of this study was to compare multidetector CT (MDCT) of the thoracic and lumbar segments of the spine with MR imaging and conventional radiography for bone lesion detection and for evaluating the risk of vertebral fracture in multiple myeloma.

SUBJECTS AND METHODS. Eighteen patients with multiple myeloma stage III (according to the criteria of Durie and Salmon) underwent MDCT, conventional radiography, and MR imaging of the lumbar and thoracic spine. MDCT was performed using a standard protocol with no contrast material. Source images were reconstructed using an effective slice thickness of 3 mm with an overlapping reconstruction increment (0.8 mm). Secondary coronal and sagittal multiplanar reformations were exclusively used for establishing the diagnosis. Findings were compared with those of MR imaging and conventional radiography.

RESULTS. In all patients, coronal and sagittal multiplanar reformations depicted the extent of osseous destruction and provided detailed information about osseous infiltration and potential bone instability. Compared with conventional radiography, an additional 24 affected vertebrae, 15 additional vertebral fractures, and six vertebrae at further risk of fracture were detected on MDCT. Compared with MR imaging, three additional endangered vertebrae were detected on MDCT. MR imaging alone would have lead to an understaging of five (27.8%) of 18 patients. Using combined radiography and MR imaging, disease in three (16.7%) of 18 patients would have been understaged.

CONCLUSION. MDCT seems to be preferable to conventional radiography in evaluating bone destruction in multiple myeloma. In combination with MR imaging, detailed information for staging these tumors is obtained. For the initial staging in patients with multiple myeloma, MDCT in combination with MR imaging seems to be the method of choice.

Introduction

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Multiple myeloma is a malignant plasma cell disorder characterized by uncontrolled proliferation of plasma cells seeding throughout the bone marrow. The incidence increases with age; approximately 50 new cases occur per 100,000 persons per year at a patient age of 80 years [1]. Monoclonal gammopathies are a premalignant condition of multiple myeloma. The diagnosis is established by bone marrow aspirate or biopsy, usually performed blindly from the iliac crest [2, 3]. Because the tumor affects the bone marrow throughout the entire body, often causing lytic bone lesions, imaging of this disorder is important. The typical imaging findings on conventional radiography and CT include punched out lytic bone lesions, diffuse osteopenia, fractures, and, rarely, osteosclerosis [4]. On MR images, different signal patterns, ranging from normal-appearing bone marrow to focal lesions or diffuse bone marrow infiltration, have been described. On T1-weighted spin-echo images, signal intensity is typically reduced, with marked enhancement after the administration of contrast material. Even in advanced stages of this disease, up to 20% of radiographs and MR examinations can have normal findings [5].

The presence of lytic bone lesions is important in staging and therapy of the disease. In addition, vertebral fractures are a common complication in multiple myeloma.

The purpose of our study was to investigate the usefulness of multidetector CT (MDCT) of the thoracic and lumbar segments of the spine for bone lesion detection and for evaluating the risk of vertebral fracture in patients with multiple myeloma. Secondary image reconstructions derived from MDCT data sets were compared with MR images and radiographs of the spine.

Subjects and Methods

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Between March and August 2000, 18 patients with multiple myeloma stage III according to the criteria of Durie and Salmon [6] (Table 1) underwent MR imaging, conventional radiography, and MDCT examinations. Fourteen men and four women with a mean age of 67.8 years (range, 50-81 years) were included in a prospective trial. The examined regions were the thoracic and lumbar spine, including the sacrum, on all imaging modalities. Radiography and MDCT also included the pelvis. All examinations were performed within 2 weeks. The mean follow-up period was 12 months (range, 1-15 months). Every patient gave informed consent to the examination.

CT examinations were performed without oral or IV contrast material using an MDCT scanner (Somatom Volume Zoom; Siemens, Forchheim, Germany). A 4 x 2.5 mm collimation protocol was chosen, with 1-sec rotation time, a tube voltage of 140 kV, and a tube current time product of 250 mAs. The scan length was adapted to the length of the thoracic and lumbar spine, with a table speed of 12-15 mm per gantry rotation. Average scan ranges were 613.6 mm (SD, 44.6 mm) in men and 597.4 mm (SD, 34.4 mm) in women. Therefore, scanning time ranged from 42 to 57 sec. For image reconstruction, a medium smooth convolution kernel (B40) and a 512 x 512 matrix was used. The field of view was adapted to the individual patient's physique. All scans were reconstructed with an effective slice thickness of 3 mm and a reconstruction increment of 0.8 mm, generating an overlap of 73.4%. For image analysis, multiplanar reformations in the coronal plane (section thickness, 5 mm) and the sagittal plane (section thickness, 2 mm) were calculated using the standard software provided with the scanner (Wizard, Siemens). For window settings, a bone window setting with a center of 600 H and width of 1600 H was chosen.

Effective radiation doses were calculated with a commercially available software program for arbitrary scanning protocols (WinDose 2.1; Institute of Medical Physics, Erlangen, Germany) according to the International Commission on Radiological Protection (ICRP) 26 [7] and ICRP 60 [8] tissue-weighting coefficients [9].

Diagnoses regarding bone involvement and stability of osseous lesions were established from the multiplanar reformations exclusively. All images were assessed by two radiologists in consensus. Image analysis was performed according to a classification established by Laroche et al. [10] in 1996 for CT and MR examinations. In addition, the CT classification was transferred to the radiographs (Table 2). Each vertebra was classified according to this schema from radiographs, MDCT scans, and MR images separately. In addition to the original schema, we introduced subclassifications for vertebrae at risk of fracture and those already fractured, including infractions of the end plates. A lytic lesion with a volume of more than 50% of the vertebral body was considered to be at risk of fracture. For image analysis of the pelvis, we separately assessed the iliac, pubic, and ischial bones; the proximal femur; and the lateral masses of the sacral bone. Additionally, left and right sides were differentiated. Therefore, every pelvis was separated into 10 areas to assess.

All MR imaging examinations were performed on a 0.5-T MR scanner (Gyroscan T5 NT; Philips, Best, The Netherlands) using a body coil. In all patients, fat-suppressed short tau inversion recovery images (TR/TE, 2000/70; inversion time, 110 msec), T2-weighted turbo spin-echo images (2957/120; echo-train length, 13), and T1-weighted spin-echo images (487/20) before and after the administration of contrast material, including subtraction images, were obtained in the sagittal plane. For contrast-enhanced MR imaging, 15 mL of gadopentetate dimeglumine (Magnevist; Schering, Berlin, Germany) was administered IV. A section thickness of 4 mm, a field of view of 480 mm, and a reconstruction matrix of 205 x 256 were used.

Results

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Multiple Myeloma Infiltration
Three hundred twenty-five vertebrae were assessed by all imaging modalities. On conventional radiographs, 207 vertebra presented with lytic bone lesions of variable size or diffuse osteopenia characteristic of multiple myeloma [11]. On MDCT scans, 231 vertebrae with pathologic changes were observed, whereas 224 vertebrae showed an abnormal bone marrow signal intensity on MR images (Table 3).

Including normal imaging findings, 226 of 325 vertebrae matched exactly in all three imaging modalities. Discrepant findings were observed as follows: compared with conventional radiography, an additional 24 vertebrae with multiple myeloma infiltration were detected on MDCT. Of these 24 lesions, 12 had a diameter of more than 1 cm. All 12 lesions were located either in the thoracic spine (n = 9) or in the sacrum (n = 3). The size of 49 lesions was depicted larger on MDCT than on conventional radiographs, whereas on conventional radiographs only two lesions appeared larger than on MDCT scans. Five vertebrae showing diffuse osteopenia on conventional radiographs and abnormal signal intensity on MR images were considered unremarkable on MDCT scans. Four vertebrae with osteolytic lesions of 5-10 mm on MDCT and conventional radiography with no signs of general osteopenia showed no abnormal bone marrow signal on MR imaging. In five vertebrae, conventional radiography showed a lesion without correlation on MR imaging or MDCT, whereas MDCT depicted eight lesions without correlation on MR imaging or conventional radiography.

These divergent imaging findings between MDCT and MR imaging would have led to an understaging of five patients (27.8%) using the MR studies exclusively, whereas a combination of MR imaging and skeletal radiography led to an understaging of three patients (16.7%) (Table 4).

One hundred eighty pelvic areas were analyzed. Comparing multiplanar reformations from MDCT data sets and conventional radiography of the pelvis, MDCT revealed more lesions than conventional radiography, with a tendency to depict lesions larger than conventional radiography. The examination of the pelvis by conventional radiography revealed 21 lytic lesions bigger than 1 cm. Examination of the same region by MDCT showed 34 lesions with a diameter of more than 1 cm (Table 5). All lesions detected on conventional radiography were also detected on MDCT.

Subclassification of Fractures and Risk of Fracture
On conventional radiographs, 72 vertebral fractures, including infractions of the end plates, were detected. MDCT scans revealed 86 vertebral fractures, whereas on MR images only 62 vertebral fractures were diagnosed. On conventional radiographs, six vertebrae were considered at risk of fracture. Three of these vertebrae were located in the lumbar spine and three in the thoracic spine. On MR images, nine vertebrae were considered at risk of fracture, including the six vertebrae detected on conventional radiographs. MDCT scans revealed 12 vertebrae at risk of fracture; nine of those were already identified on MR images. Therefore, compared with conventional radiographs, an additional six lesions at risk of fracture in either the thoracic spine (n = 4) or the lumbar spine (n = 2) were detected using MDCT.

During follow-up, one of the lesions considered at risk of fracture on all imaging modalities showed a newly diagnosed infraction. Another vertebra showed a minor infraction during follow-up that was previously classified only on MDCT as being at risk of fracture. One patient died during the follow-up period.

Dose Considerations
The examination protocol that we used resulted in a cumulative dose of 23.3 mSv (ICRP 26) and 25.5 mSv (ICRP 60) in men and 39.8 mSv (ICRP 26) and 36.6 mSv (ICRP 60) in women, respectively. Effective energy was calculated as 82.4 keV.

Discussion

Top Abstract Introduction Subjects and Methods Results Discussion References

 
CT is a well-established but rarely used technique for imaging multiple myeloma [12, 13]. Most reports concern the use of axial CT images of circumscribed regions of the spine. Some studies also used multiplanar reformations of limited parts of the spine [14]. Evaluation of the entire spine by CT in patients with multiple myeloma has not been reported, probably because of several limitations of the CT technique. Sequential CT scanning does not allow a gapless assessment of the examined region. Based on slip-ring technology, continuous data acquisition became technically feasible in 1987. Since helical CT was introduced in 1989, volume scanning of parts of the body has been achievable, but because of long acquisition times and limited power of the X-ray tube, scan collimations of 5 mm or more have been used for coverage of large volumes along the z-axis.

For detection of small lytic bone lesions of less than 1 cm, narrow collimation protocols at a high tube current and tube voltage are mandatory, because these parameters determine the intrinsic resolution and image noise. Examinations of the whole spine are feasible with high-performance CT X-ray tubes only, necessitating high heat storage capacities. With the simultaneous acquisition of multiple slices per rotation, scanning time can be shortened significantly to less than a minute for a complete body scan. Faster imaging with no need for higher tube output is possible with the concurrent acquisition of four slices per rotation. The algorithm for image reconstruction uses the entire applied dose, allowing greatest flexibility in clinical practice [15]. These facts form the basis for narrow-collimation protocols at high tube current and tube voltage and the decrease of the effective slice thickness to 3 mm in our series.

Patient cooperation has improved markedly, especially in patients with advanced disease and severe back pain. Scanning time itself is not the major drawback in our setting, because data acquisition is performed without IV or oral contrast material. In this application, the tube current time product is the potential limiting factor: because of the huge increase in X-ray tube power, the tube current time product could be kept in diagnostically accurate ranges (250 mAs) in all patients.

The increased resolution in the axial direction (z-resolution) demands optimized dedicated postprocessing of the CT data set. Reconstruction of high-quality multiplanar reformations of the entire spine can be integrated into routine work flow by using an efficient and quick postprocessing unit that is integrated in the CT package.

Because of highly overlapping image reconstruction increments, all our high-quality data sets consisted of up to 800 axial images. For image interpretation, the number of images was reduced to a limited and reasonable number, using multiplanar reformations of the spine in sagittal and coronal orientations. Compared with MR imaging and radiography, multiplanar image reconstruction of MDCT data sets allows an adaptation to the individual patient's features (e.g., scoliosis). In case of an abnormal finding, the axial source slices of the region may provide additional information on tumor size and soft-tissue involvement.

According to the staging system introduced by Durie and Salmon [6] more than 20 years ago, the osseous infiltration in multiple myeloma has significant influence on therapy. Patients suffering from multiple myeloma stage I with only limited alterations in blood parameters and less than two skeletal lesions on radiography are followed up clinically without therapy, whereas patients with stage II or III multiple myeloma require chemotherapy. Therefore, it is important to sufficiently assess the osseous extension in multiple myeloma at initial staging.

Radiographs are indispensable for providing detailed information on cortical and trabecular bone. The substitution of MR imaging for radiography of the spine and pelvis leads to an understaging of about 10% of the patients with stage III multiple myeloma [16]. The superiority of CT to radiography for evaluating tumor extent in circumscribed areas of the spine in patients with multiple myeloma has been shown by several studies [12, 17] (Fig. 1A,1B,1C). In our patient population, we found more bone lesions on MDCT than on conventional radiography by assessing multiplanar reformations exclusively (Fig. 2A,2B,2C). Especially in the sacrum and the pelvis, MDCT revealed noticeably more osseous lesions (Fig. 3A,3B). Among the limited number of patients in our study, five (27.8%) of 18 presented with two or more lytic bone lesions on MDCT that were not adequately recognized on MR imaging alone (Fig. 4A,4B,4C). When conventional radiography was used, three patients (16.7%) with advanced lytic bone lesions were not adequately recognized. These patients were therefore understaged by MR imaging and radiography. Merely diffuse osteopenia was difficult to assess on MDCT. Because that finding is nonspecific, a correlation of MDCT or conventional radiography with MR imaging seems to be necessary for further evaluation of osteopenia (Fig. 5A,5B,5C,5D,5E). Nevertheless, up to 20% of MR imaging examinations can be unremarkable despite a major bone marrow infiltration [18, 19].

View larger version (69K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A. —77-year-old man with multiple myeloma stage III according to criteria of Durie and Salmon [6]. Lateral radiograph of lumbar spine shows multiple myeloma affecting L2-L4.

View larger version (83K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B. —77-year-old man with multiple myeloma stage III according to criteria of Durie and Salmon [6]. Sagittal reformation of multidetector CT data set depicts diffuse osteopenia and focal lesions as signs of multiple myeloma infiltration of entire spine. Focal lesion close to end plate of L1 (arrows) is not visible on conventional radiograph (A).

View larger version (99K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C. —77-year-old man with multiple myeloma stage III according to criteria of Durie and Salmon [6]. Sagittal T1-weighted MR image (TR/TE, 487/20) shows multiple myeloma infiltration of entire spine, including lesion of L1 (arrows).

View larger version (71K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A. —68-year-old man with newly diagnosed multiple myeloma, stage III according to criteria of Durie and Salmon [6]. Lateral radiograph of lumbar spine corresponding to multidetector CT (MDCT) and MR image shows large osteolytic lesion affecting posterior crest of L5 (arrows). Further lesions larger than 1 cm in diameter in lumbar spine and in T3 and T9 are not recognizable on conventional radiographs.

View larger version (76K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B. —68-year-old man with newly diagnosed multiple myeloma, stage III according to criteria of Durie and Salmon [6]. MDCT scan depicts lesions with diameter greater than 10 mm in L5 (arrows) as well as in L1—L4, T3, and T9 (arrowheads). Diffuse osteopenia or lesions with diameters between 5 mm and 1 cm are visible in all vertebrae depicted. Ground-plate impression is visible in L1.

View larger version (64K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2C. —68-year-old man with newly diagnosed multiple myeloma, stage III according to criteria of Durie and Salmon [6]. Sagittal T2-weighted MR image (TR/TE, 2957/120; echo-train length, 13) shows tumor infiltration of all depicted vertebrae. Lesions larger than 1 cm in lumbar spine (arrowheads), especially in L5 (arrow), are clearly depicted.

View larger version (118K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A. —77-year-old man with lengthy history of multiple myeloma. Radiograph of pelvis depicts large osteolysis of right iliac bone (arrows), including iliac crest. Osteosynthesis was performed on left side after pathologic fracture of left femoral neck due to multiple myeloma infiltration.

View larger version (94K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B. —77-year-old man with lengthy history of multiple myeloma. Multiplanar reformation of multidetector CT data set reveals destruction of right acetabulum (straight arrows) and smaller metastatic lesion of left acetabulum (asterisk). Osteolysis of right iliac bone is visible (curved arrows). Additional metastasis of left iliac bone (arrowheads), not seen on conventional radiograph (A), is evident.

View larger version (63K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A. —68-year-old man with history of multiple myeloma, stage III according to criteria of Durie and Salmon [6]. Lateral radiograph of lumbar spine shows several lytic bone lesions, one in L5 (arrow).

View larger version (84K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B. —68-year-old man with history of multiple myeloma, stage III according to criteria of Durie and Salmon [6]. Same lesion in L5 is visible on multiplanar reformation calculated from multidetector CT data set (arrow).

View larger version (88K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4C. —68-year-old man with history of multiple myeloma, stage III according to criteria of Durie and Salmon [6]. Sagittal T1-weighted MR image (TR/TE, 48/20) depicts homogeneous signal of L5 with no focal lesion.

View larger version (69K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A. —82-year-old woman with multiple myeloma, stage III according to criteria of Durie and Salmon [6]. Lateral radiograph of thoracic spine shows diffuse osteopenia of all vertebrae.

View larger version (91K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B. —82-year-old woman with multiple myeloma, stage III according to criteria of Durie and Salmon [6]. Radiograph of lumbar spine presents same finding as A.

View larger version (65K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5C. —82-year-old woman with multiple myeloma, stage III according to criteria of Durie and Salmon [6]. Sagittal multiplanar reformation of lumbar and thoracic spine calculated from multidetector CT data set also depicts diffuse osteopenia. Some lesions larger than 5 mm but smaller than 1 cm are also visible.

View larger version (51K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5D. —82-year-old woman with multiple myeloma, stage III according to criteria of Durie and Salmon [6]. Sagittal T1-weighted MR image (TR/TE, 487/20) depicts diffuse tumor infiltration of all lumbar and thoracic vertebrae.

View larger version (55K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5E. —82-year-old woman with multiple myeloma, stage III according to criteria of Durie and Salmon [6]. After administration of gadopentetate dimeglumine, sagittal T1-weighted MR image (487/20) of thoracic and lumbar vertebrae shows diffuse contrast enhancement.

Evaluation of the risk of vertebral fracture is another difficulty in patients with multiple myeloma. Previous studies failed to show a correlation between focal bone marrow lesions on MR images and vertebral compression fractures [19, 20]. Because multiple myeloma leads not only to focal osseous lesions but also to diffuse reduction of the trabecular structure presenting as osteopenia on CT and conventional radiography, estimating the risk of fracture of these vertebrae will still be challenging. Therefore, we assessed focal vertebral lesions only for potential instability. On MDCT, we saw twice as many potentially unstable lesions as on conventional radiography and still more lesions considered at risk of fracture than on MR imaging.

A major advantage of CT compared with MR imaging for evaluating osseous stability is the distinct delineation of the cortical bone structures. Nevertheless, during a 1-year follow-up, we observed only two new minor infractions. Both were correctly predicted with MDCT, whereas on MR imaging and conventional radiography only one of these fractures could be predicted. Notably, seven vertebrae considered at risk of fracture on MDCT and six vertebrae considered at risk of fracture on MR imaging were located in the thoracic spine; on conventional radiography only three of these lesions were recognized. This observation reflects the difficulty of assessing thoracic spine radiographs. Superimposition by lung structures and the shoulder girdle is a well-known handicap in this respect. Therefore, cross-sectional imaging is helpful for the assessment of multiple myeloma, especially in the thorax. Additionally, CT allows an evaluation of the rib cage and the shoulder, which are common regions for multiple myeloma infiltration, in a single examination.

In conclusion, MDCT allows imaging of the entire spine using thin-collimation protocols. Multiplanar reformations of MDCT data sets reduce the number of images to be assessed and provide detailed information on osseous involvement in multiple myeloma. Especially in anatomically complex regions like the pelvis and the thoracic spine, MDCT is superior to conventional radiography. However, the high dose exposure makes a strict regimen essential for this examination protocol. Because multiple myeloma affects mostly elderly patients, we believe this high-dose protocol is suitable for osseous assessment in multiple myeloma. Dose considerations are therefore not a major drawback in this respect. For follow-up examinations, reduced-dose protocols must be considered.

Compared with conventional radiography and MR imaging, MDCT provides more detailed information on the risk of vertebral fracture. Evaluation of osteopenia by CT and conventional radiography is nonspecific and might lead to a misinterpretation of the imaging findings if MDCT or conventional radiography is used without correlation to MR imaging. For evaluating diffuse bone marrow changes, MR imaging is still the imaging modality of choice. Because MR imaging of the spine shows normal findings in up to 20% of patients with proven bone marrow infiltration, the initial staging of multiple myeloma should include MR imaging in combination with MDCT of the spine.

In addition, the method presented is suitable for assessing osseous lesions in other tumors and can be used as an adjunct to combined MDCT of the chest and entire abdomen in a single examination.

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