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Nodular liver involvement in light chain multiple myeloma: Appearance on US and MRI
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NODULAR LIVER INVOLVEMENT IN LIGHT CHAIN MULTIPLE MYELOMA: APPEARANCE ON US AND MRI NIKOLAOS L. KELEKIS, DAVID M. WARSHAUER,
MD, MD,
RICHARD C. SEMELKA, AND SABAH SALLAH,
Nodular liver infiltration with multiple myeloma is very rare and its findings on MR images have not been, to our knowledge, previously described. The authors report a case of light chain multiple myeloma nodular liver involvement and describe its appearance on US and MRI. Despite their rarity these lesions have distinct MRI features and should be considered in the diflerential diagnosis of multiple lesions with high SI on T1 -weighted images. 0 Elsevier Science Inc., 1997 KEY WORDS:
Liver neoplasms; Multiple myeloma; Light chain; Magnetic resonance imaging; Ultrasonography
INTRODUCTION Nodular involvement of the liver with multiple myeloma is very rare (1). MRI, using single breathhold spoiled gradient echo (SGE), Tl-weighted fat suppressed spin echo (TlFS), T2-weighted fat suppressed spin echo (T2FS), and dynamic gadolinium enhanced breathhold SGE, has been shown to be sensitive in the evaluation of focal liver disease (2). We describe the US and MRI appearance of multiple liver nodules in a male patient with light chain multiple myeloma. To our knowledge this is the first report of MRI appearance of multiple myeloma nodular hepatic infiltration. From the Departments of Radiology (N.L.K., R.C.S., D.M.W.) and Medicine/Division of Hematology-Oncology (S.S.). University of North Carolina, Chapel Hill, North Carolina.
Address reprint requests to: Richard C. Semelka, MD, Department of Radiology-CB 7510. University of North Carolina, Chapel Hill, NC 27599-7510. Received February 28, 1995; accepted April 20, 1995. CLINICAL IMAGING 1997;21:207-209 0 Elsevier Science Inc., 1997 655 Avenue of the Americas, New York, NY 10010
MD,
MD
CASE REPORT A 32-year-old white male patient was referred from another hospital with a diagnosis of multiple myeloma for further workup. The patient presented with a s-month history of backache, 40 pound weight loss, and a 2month history of progressive malaise, nausea, chest burning, vomiting, and diarrhea. Severe anemia, hypercalcemia, and acute renal failure were present at the time of his hospitalization. An X-ray series demonstrated radiolucent areas in his skull and his spine. A bone marrow biopsy showed 80-90% infiltration by immature plasma cells. At this point the patient was transferred to our hospital. Laboratory investigations on admission showed the following: serum creatinine 7.9 mg/dl and serum calcium 11.8 mg/dl. Serum and urine protein electrophoresis indicated monoclonal bands that were typed as free lambda light chains, and a diagnosis of multiple myeloma light chain disease was established. Ultrasonography demonstrated hepatomegaly with multiple bullseye lesions measuring 1-2 cm in diameter throughout the liver (Figure 1). A CT scan showed liver enlargement without any focal lesion and heterogenous appearance of the spleen; however, due to renal failure and poor intravenous access a reduced volume (
0899-7071/97/$17.00 PI1 SO899-7071(96)00022-8
208
KELEKIS
CLINICAL IMAGING VOL. 21. NO. 3
ET AL.
FIGURE 1. Sagittal US. The US image depicts two round,
well-defined, hypoechoic echoic areas.
nodules with internal hyper-
ages were obtained immediately following contrast (1 set) and at 45 set, 90 set, and 10 min. Multiple focal lesions were identified throughout the entire liver on the TX-weighted images; there were several larger lesions measuring between 1 and 2 cm and numerous small, 2-5 mm, lesions. More lesions were apparent on MRI than on CT or US (Figure 2). Lesions demonstrated high signal intensity (SI) on TlFS, out-of-phase SGE, and TBFS; they were isointense to mildly hyperintense on precontrast in-phase SGE images and demonstrated moderate enhancement with gadolinium. The spleen was low in signal intensity with several lesions. Multiple 5-mm lesions were present also throughout both kidneys, mainly in their cortex. Involvement of several vertebrae, sacrum and iliac bone,and a single right rib lesion was also seen. Bone lesions were also high SI on Tl- and
FIGURE 2. (A) TlFS, (B) TZFS, (C) precontrast SGE, and (D) 1-set postgadolinium SGE h4R images. On the TlFS and TZFS
images multiple high SI nodules are present throughout the liver. Lesions are less well seen on the precontrast SGE image (C) in which they appear isointense to mildly hyperintense. Moderate enhancement is present on 1-set postgadolinium SGE image. Note the high SI bone involvement areas in the vertebral body and the close correlation of their SI to that of liver lesions on all sequences.
MAY/JUNE
1997
US AND MRI OF LIVER MULTIPLE
TZ-weighted images, and their SI was that of the liver, spleen, and kidney lesions. High SI of liver lesions on both Tl- and T&weighted images was considered to represent high protein content lesions, a finding consistent with the patient’s disease.
DISCUSSION There are three previous imaging reports describing the findings on scintigraphy (3), US (4) and US and CT (1)in patients with multifocal multiple myeloma nodules in the liver. No previous MR reports have described multiple liver nodules; however, solitary liver plasmacytomas have been reported (5, 6). The US appearance of lesions in our patient resembled those reported previously, with a target-like appearance. The CT with minimal contrast did not reflect the lack of value of CT, but rather the lack of value of noncontrast or small volume contrast CT in the evaluation of liver disease. The lesions in our case demonstrated high SI on TlFS, out-of-phase SGE, and TZFS images. They were less conspicuous on in-phase precontrast SGE images, presumably due to a degree of fatty liver infiltration in our patient. The differential diagnosis of malignant liver lesions high SI on Tl-weighted images includes melanoma, hemorrhagic metastases, metastases with high protein content, and hepatocellular carcinoma (HCC). Melanoma metastases often have areas of high and low SI because of Tl shortening due to the paramagnetic properties of melanin. Enhancement with gadolinium varies from minimal to substantial. Hemorrhage or coagulative necrosis has been described in metastases from colon cancer, carcinoid, and melanoma. High SI in these cases usualy involves the central portion of lesions and possesses irregular margins. The central hemorrhagic portion does not enhance with gadolinium. Carcinoid metastases are usually hypervascular and demonstrate marked peripheral ring enhancement on early postgadolinium SGE images. HCC are multifocal in up to 50% of the cases. HCC are not uncommonly high in signal on Tl-weighted images; in particular, early HCC has a propensity for this appearance. Enhancement on immediate post gadolinium images is often diffuse and intense in these lesions. Protein containing cystic metastases such as from ovarian cancer or macrocystic cystadenocarcinoma of the pancreas are also not infrequently high in signal. Following contrast administration the cystic nature of these lesions is frequently apparent. In our case the lesions showed moderate enhancement. This appearance is most similar to melanoma of the
MYELOMA
INVOLVEMENT
209
above-mentioned malignant lesions. The high content of light chain protein in the liver lesions in our patient presumably resulted in the high SI on Tl images, while their dense monoclonal cellularity resulted in moderate enhancement (7). The light chains in our case were typed as lambda proteins; two out of the three previously reported cases of multiple liver nodules in patients with multiple myeloma also had light chain disease (one case of kappa and one case of lambda light chain ( (1, 4), which suggests that these tumors may have a propensity toward involving the liver with multiple nodules. Comparing the MR appearance of our lesions with the previously reported solitary plasmacytomas (5. 6) there appears to be some variation. The plasmacytoma reported by Nguyen et al. (5), which was also associated with k-light chain secretion, contained a middle region that was high in signal intensity on Tl-weighted images, which may have been on the basis of high protein content. Both reported plasmacytomas were low in signal on TZ-weighted images, presumably due to their hypovascularity, whereas lesions in our case were high in signal presumably reflecting high water content, which may represent the aqueous component of the light chains. In summary we have described a patient with light chain multiple myeloma with multiple liver nodules that possess distinct signal intensity features on MR images.
REFERENCES R, Penetrante RB. Goolsby HJ, Yusuf NS, Bern1. Thiruvengdam stein ZP. Multiple myeloma presenting as space-occupying lesions of the liver. Cancer 1990:65:2784-2786. 2. Semelka RC, Shoenut PJ. Kroeker MA, Greenberg HM, Simm FC. Minuk GY, Kroeker RM, Mickflikier AB. Focal liver disease: comparison of dynamic constrast-enhanced CT and TZweighted fat-suppressed, FLASH and dynamic Gadolinium enhanced MR imaging at 1.5 T. Radiology 1992:184:687-694. M, Lubin E, Pink3. Garfinkel MD, Salamon F. Sidi Y, Ben-Bassat has J. Multiple plasmocytomas of the liver and spleen. Clin Nucl Med 1985:10(11):819. 4. Caturelli E, Squillante MM, Castelvetere M. Falcone P. Myelomatous nodular lesions of the liver: diagnosis sound-guided fine-needle biopsy. J Clin Ultrasound (2):133-137.
A, Musto by ultra1993:21
5. Nguyen BD, Dash N. Lupetin AR. MR imaging of hepatic macytoma: a case report. Clin Imaging 1992;16(2):98-103.
plas-
S, Ohba H, Nogata Y, Hi6. Ohtomo K, Araki T, Itai Y. Monzawa hara T, Koizumi K, Uchiyama G. MR imaging of malignant mesenchymal tumors of the liver. Gastrointest Radio1 1992: 17(1):58-62. 7. Semelka RC, Bagley AS, Brown ED, Kroeker MA. Malignant lesions of the liver identified on Tl-but not TX-weighted MR images at 1.5 T. JMRI 1994;4:315-318.
NODULAR LIVER INVOLVEMENT IN LIGHT CHAIN MULTIPLE MYELOMA: APPEARANCE ON US AND MRI NIKOLAOS L. KELEKIS, DAVID M. WARSHAUER,
MD, MD,
RICHARD C. SEMELKA, AND SABAH SALLAH,
Nodular liver infiltration with multiple myeloma is very rare and its findings on MR images have not been, to our knowledge, previously described. The authors report a case of light chain multiple myeloma nodular liver involvement and describe its appearance on US and MRI. Despite their rarity these lesions have distinct MRI features and should be considered in the diflerential diagnosis of multiple lesions with high SI on T1 -weighted images. 0 Elsevier Science Inc., 1997 KEY WORDS:
Liver neoplasms; Multiple myeloma; Light chain; Magnetic resonance imaging; Ultrasonography
INTRODUCTION Nodular involvement of the liver with multiple myeloma is very rare (1). MRI, using single breathhold spoiled gradient echo (SGE), Tl-weighted fat suppressed spin echo (TlFS), T2-weighted fat suppressed spin echo (T2FS), and dynamic gadolinium enhanced breathhold SGE, has been shown to be sensitive in the evaluation of focal liver disease (2). We describe the US and MRI appearance of multiple liver nodules in a male patient with light chain multiple myeloma. To our knowledge this is the first report of MRI appearance of multiple myeloma nodular hepatic infiltration. From the Departments of Radiology (N.L.K., R.C.S., D.M.W.) and Medicine/Division of Hematology-Oncology (S.S.). University of North Carolina, Chapel Hill, North Carolina.
Address reprint requests to: Richard C. Semelka, MD, Department of Radiology-CB 7510. University of North Carolina, Chapel Hill, NC 27599-7510. Received February 28, 1995; accepted April 20, 1995. CLINICAL IMAGING 1997;21:207-209 0 Elsevier Science Inc., 1997 655 Avenue of the Americas, New York, NY 10010
MD,
MD
CASE REPORT A 32-year-old white male patient was referred from another hospital with a diagnosis of multiple myeloma for further workup. The patient presented with a s-month history of backache, 40 pound weight loss, and a 2month history of progressive malaise, nausea, chest burning, vomiting, and diarrhea. Severe anemia, hypercalcemia, and acute renal failure were present at the time of his hospitalization. An X-ray series demonstrated radiolucent areas in his skull and his spine. A bone marrow biopsy showed 80-90% infiltration by immature plasma cells. At this point the patient was transferred to our hospital. Laboratory investigations on admission showed the following: serum creatinine 7.9 mg/dl and serum calcium 11.8 mg/dl. Serum and urine protein electrophoresis indicated monoclonal bands that were typed as free lambda light chains, and a diagnosis of multiple myeloma light chain disease was established. Ultrasonography demonstrated hepatomegaly with multiple bullseye lesions measuring 1-2 cm in diameter throughout the liver (Figure 1). A CT scan showed liver enlargement without any focal lesion and heterogenous appearance of the spleen; however, due to renal failure and poor intravenous access a reduced volume (
0899-7071/97/$17.00 PI1 SO899-7071(96)00022-8
208
KELEKIS
CLINICAL IMAGING VOL. 21. NO. 3
ET AL.
FIGURE 1. Sagittal US. The US image depicts two round,
well-defined, hypoechoic echoic areas.
nodules with internal hyper-
ages were obtained immediately following contrast (1 set) and at 45 set, 90 set, and 10 min. Multiple focal lesions were identified throughout the entire liver on the TX-weighted images; there were several larger lesions measuring between 1 and 2 cm and numerous small, 2-5 mm, lesions. More lesions were apparent on MRI than on CT or US (Figure 2). Lesions demonstrated high signal intensity (SI) on TlFS, out-of-phase SGE, and TBFS; they were isointense to mildly hyperintense on precontrast in-phase SGE images and demonstrated moderate enhancement with gadolinium. The spleen was low in signal intensity with several lesions. Multiple 5-mm lesions were present also throughout both kidneys, mainly in their cortex. Involvement of several vertebrae, sacrum and iliac bone,and a single right rib lesion was also seen. Bone lesions were also high SI on Tl- and
FIGURE 2. (A) TlFS, (B) TZFS, (C) precontrast SGE, and (D) 1-set postgadolinium SGE h4R images. On the TlFS and TZFS
images multiple high SI nodules are present throughout the liver. Lesions are less well seen on the precontrast SGE image (C) in which they appear isointense to mildly hyperintense. Moderate enhancement is present on 1-set postgadolinium SGE image. Note the high SI bone involvement areas in the vertebral body and the close correlation of their SI to that of liver lesions on all sequences.
MAY/JUNE
1997
US AND MRI OF LIVER MULTIPLE
TZ-weighted images, and their SI was that of the liver, spleen, and kidney lesions. High SI of liver lesions on both Tl- and T&weighted images was considered to represent high protein content lesions, a finding consistent with the patient’s disease.
DISCUSSION There are three previous imaging reports describing the findings on scintigraphy (3), US (4) and US and CT (1)in patients with multifocal multiple myeloma nodules in the liver. No previous MR reports have described multiple liver nodules; however, solitary liver plasmacytomas have been reported (5, 6). The US appearance of lesions in our patient resembled those reported previously, with a target-like appearance. The CT with minimal contrast did not reflect the lack of value of CT, but rather the lack of value of noncontrast or small volume contrast CT in the evaluation of liver disease. The lesions in our case demonstrated high SI on TlFS, out-of-phase SGE, and TZFS images. They were less conspicuous on in-phase precontrast SGE images, presumably due to a degree of fatty liver infiltration in our patient. The differential diagnosis of malignant liver lesions high SI on Tl-weighted images includes melanoma, hemorrhagic metastases, metastases with high protein content, and hepatocellular carcinoma (HCC). Melanoma metastases often have areas of high and low SI because of Tl shortening due to the paramagnetic properties of melanin. Enhancement with gadolinium varies from minimal to substantial. Hemorrhage or coagulative necrosis has been described in metastases from colon cancer, carcinoid, and melanoma. High SI in these cases usualy involves the central portion of lesions and possesses irregular margins. The central hemorrhagic portion does not enhance with gadolinium. Carcinoid metastases are usually hypervascular and demonstrate marked peripheral ring enhancement on early postgadolinium SGE images. HCC are multifocal in up to 50% of the cases. HCC are not uncommonly high in signal on Tl-weighted images; in particular, early HCC has a propensity for this appearance. Enhancement on immediate post gadolinium images is often diffuse and intense in these lesions. Protein containing cystic metastases such as from ovarian cancer or macrocystic cystadenocarcinoma of the pancreas are also not infrequently high in signal. Following contrast administration the cystic nature of these lesions is frequently apparent. In our case the lesions showed moderate enhancement. This appearance is most similar to melanoma of the
MYELOMA
INVOLVEMENT
209
above-mentioned malignant lesions. The high content of light chain protein in the liver lesions in our patient presumably resulted in the high SI on Tl images, while their dense monoclonal cellularity resulted in moderate enhancement (7). The light chains in our case were typed as lambda proteins; two out of the three previously reported cases of multiple liver nodules in patients with multiple myeloma also had light chain disease (one case of kappa and one case of lambda light chain ( (1, 4), which suggests that these tumors may have a propensity toward involving the liver with multiple nodules. Comparing the MR appearance of our lesions with the previously reported solitary plasmacytomas (5. 6) there appears to be some variation. The plasmacytoma reported by Nguyen et al. (5), which was also associated with k-light chain secretion, contained a middle region that was high in signal intensity on Tl-weighted images, which may have been on the basis of high protein content. Both reported plasmacytomas were low in signal on TZ-weighted images, presumably due to their hypovascularity, whereas lesions in our case were high in signal presumably reflecting high water content, which may represent the aqueous component of the light chains. In summary we have described a patient with light chain multiple myeloma with multiple liver nodules that possess distinct signal intensity features on MR images.
REFERENCES R, Penetrante RB. Goolsby HJ, Yusuf NS, Bern1. Thiruvengdam stein ZP. Multiple myeloma presenting as space-occupying lesions of the liver. Cancer 1990:65:2784-2786. 2. Semelka RC, Shoenut PJ. Kroeker MA, Greenberg HM, Simm FC. Minuk GY, Kroeker RM, Mickflikier AB. Focal liver disease: comparison of dynamic constrast-enhanced CT and TZweighted fat-suppressed, FLASH and dynamic Gadolinium enhanced MR imaging at 1.5 T. Radiology 1992:184:687-694. M, Lubin E, Pink3. Garfinkel MD, Salamon F. Sidi Y, Ben-Bassat has J. Multiple plasmocytomas of the liver and spleen. Clin Nucl Med 1985:10(11):819. 4. Caturelli E, Squillante MM, Castelvetere M. Falcone P. Myelomatous nodular lesions of the liver: diagnosis sound-guided fine-needle biopsy. J Clin Ultrasound (2):133-137.
A, Musto by ultra1993:21
5. Nguyen BD, Dash N. Lupetin AR. MR imaging of hepatic macytoma: a case report. Clin Imaging 1992;16(2):98-103.
plas-
S, Ohba H, Nogata Y, Hi6. Ohtomo K, Araki T, Itai Y. Monzawa hara T, Koizumi K, Uchiyama G. MR imaging of malignant mesenchymal tumors of the liver. Gastrointest Radio1 1992: 17(1):58-62. 7. Semelka RC, Bagley AS, Brown ED, Kroeker MA. Malignant lesions of the liver identified on Tl-but not TX-weighted MR images at 1.5 T. JMRI 1994;4:315-318.