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History:

61 y/o woman with a lump on left side of head.

Exam:

Non-tender superficial mass at the left superior frontal region of the skull. No focal neurological deficits.

Image Findings:

Plain radiograph (skull): Multiple “punched-out” lytic lesions are seen throughout the calvarium.
A large lytic lesion at the vertex disrupts both the inner and outer table.

T1 Sag: Large expansile mass lesion which is hypointense to bone marrow extending intracranially from the frontal clavarium.

T1 Cor: Large expansile mass lesion which is hypointense to bone marrow extending intracranially from the frontal clavarium.

T1 Ax +C: Enhancing expansile mass lesion extending intracranially and superficially from the calvarium.

T1 Cor +C: Enhancing expansile mass lesion extending intracranially and superficially from the calvarium.

T2 Ax: Expansile mass which is isointense to bone marrow extending both intracranially and superficially from the calvarium.

Differential Diagnosis:

• Surgical defect
• Lytic metastasis
• Hemangioma
• Brown Tumor
• Hemangiopericytoma
• Meningiomatosis

Actual Diagnosis:

Multiple Myeloma

How Was Dx Confirmed:

Known disease based on prior bone marrow biopsy and characteristic lytic skull lesions.

Treatment and Outcome:

This woman was known to have multiple myeloma and a history of lytic lesions. This evaluation for interval change led to treatment with focused radiotherapy.

Patient Discussion:

Multiple myeloma is characterized by the neoplastic proliferation of a single line of plasma cells producing a monoclonal immunoglobulin. This proliferation replaces normal bone marrow and often results in extensive skeletal destruction with osteolytic lesions, osteopenia, and/or pathologic fractures.

The etiology of multiple myeloma is unknown. It is more common in the elderly and there is a slight increased risk among children and siblings of multiple myeloma patients. There is also an increased incidence amongst petroleum, leather, and cosmetology workers. Additionally, exposure to radiation (greater than 50 rad), hebricides, insecticides, heavy metals, plastics, and asbestos also increases risk.

“Punched-out” lytic lesions are a common finding on plain film. An osteolytic skull lesion is the best diagnostic clue on imaging. The appearance can vary on T1-weighted MRI, ranging from focal hyperintensity in 53% of cases to a focal hypointensity in 25% of cases. Marked lesional enhancement is seen following gadolinium administration. On T2 weighted imaging, an iso- to hyperintense lesion can be seen. Intracranial myeloma, as in this patient, is a rare finding.


References:

Angtuaco EJ, et al. Multiple myeloma: clinical review and diagnostic imaging. Radiology. 2004; 231(1):11-23.

Brant WE, Helms CA. Fundamentals of Diagnostic Radiology. Lippincott, Williams & Wilkins. Philadelphia. 2007

Osborn AG. Diagnostic Neuroradiology. Mosby. St Louis. 1994.

Smith, A, Wisloff, F, Samson, D. Guidelines on the diagnosis and management of multiple myeloma 2005. British Journal of Haematology. 2006; 132:410.