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Journal of Clinical Oncology, Vol 25, No 33 (November 20), 2007: pp. 5319-5320 © 2007 American Society of Clinical Oncology. DOI: 10.1200/JCO.2007.13.4767
Multiple Myeloma Presenting With [18F]Fluorodeoxyglucose Avid Liver Lesions Diagnosed on Positron Emission Tomography ScanDivision of Nuclear Medicine, Department of Radiology, St Luke’s Roosevelt Hospital, New York, NY
Department of Hematology & Oncology, St Luke's Roosevelt Hospital, New York, NY
Department of Radiology, St Luke's Roosevelt Hospital, New York, NY
Division of Nuclear Medicine, Department of Radiology, St Luke's Roosevelt Hospital, New York, NY
Department of Radiology, St Luke's Roosevelt Hospital, New York, NY The patient was a 66-year-old woman with a past medical history of papillary serous carcinoma of the uterus diagnosed approximately 2 years previously and status postabdominal hysterectomy. The patient had a computed tomography (CT) scan of chest/abdomen/pelvis 1 year previously as part of the follow-up for uterine carcinoma. The scan did not reveal any lesions in her liver or bone. Recently, the patient presented with bone pain and right upper quadrant pain. As part of the evaluation, the patient had a CT scan of the abdomen with contrast and it showed nonspecific focal liver lesions in the left and right hepatic lobe and a question of vascular liver lesions was raised. Subsequent magnetic resonance imaging (MRI) showed four hypervascular lesions, the largest one 1.6 x 1.5 cm in the subcapsular aspect of lateral left hepatic lobe (Fig 1; arrows), suspicious for metastasis from unknown primary. The liver and bone marrow biopsy confirmed it as poorly differentiated malignancy, positive for CD-138, suggestive of plasma cell origin. As part of the evaluation and follow-up, a positron emission tomography (PET) -CT scan was performed, this revealed multiple hypermetabolic lesions in both the left and right lobes of the liver (Fig 2; arrows) and multiple hypermetabolic lytic lesions in the axial and appendicular skeleton, consistent with widespread skeletal malignancy. A skeletal survey was also performed, which revealed diffuse demineralization and numerous punched out lytic calvarial lesions (Fig 3), left iliac bone and inferior pubic rami lesions, and probably more permeative lesions in the left and right midshaft of the femur, proximal right humerus, and left humerus.
Plasma cell dyscrasias range from monoclonal gammopathy of undetermined significance to the malignant form of multiple myeloma.1 In the United States, there are an estimated 16,000 new cases per year.1 Multiple myeloma is primarily a bone malignancy. Very rarely, it can involve extramedullary tissues, which consist of soft tissue masses of the plasma cells. The aerodigestive tract is the most common location, but it has been found in orbits, ear canal, rectum, and rarely in liver, spleen, and kidneys.2 The role of imaging in the management of myeloma includes: an assessment of the extent of intramedullary bone disease, detection of any extramedullary lesions, the identification of complications and severity, and follow-up of disease status.1 Residual or recurrent disease, especially extramedullary involvement after therapy, is a poor prognostic factor. Among all the imaging modalities, whole-body PET-CT has a new and unique role in identification of active status of the disease.3,4 The positive findings in the whole body [18F]fluorodeoxyglucose (FDG) -PET can lead to management changes. The involvement of liver in the form of multiple focal lesions is very rare in living patients and has been described as very rare case reports in different imaging modalities including MRI, CT, and ultrasound. The findings of multiple focal liver lesions in multiple myeloma have not been reported in FDG-PET so far. Our case report highlights the importance of whole-body FDG-PET in detecting multiple focal liver lesions in living patient with multiple myeloma and determination of prognosis. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The author(s) indicated no potential conflicts of interest.
REFERENCES 1. Mulligan ME, Badros AZ: PET/CT and MR imaging in myeloma. Skeletal Radiol 36:5-16, 2007[CrossRef][Medline] 2. Goldsweig CD, Remotti H, Jacobson IM, et al: A case report of multiple myeloma involving the liver. Amer J Gastroenterology 95:2575, 2000 3. Durie BG, Waxman AD, D'Agnolo A, et al: Whole-body 18F-FDG PET identifies high-risk myeloma. J Nucl Med 43:1457-1463, 2002 4. Bredella MA, Steinbach L, Caputo G, et al: Value of FDG PET in the assessment of patients with multiple myeloma. Am J Roentgenol 184:1199-1204, 2005
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Copyright © 2007 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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