Multiple Myeloma: 18F-FDG-PET/CT and Diagnostic Imaging Jasna Mihailovic, MD, PhD, Stanley J. Goldsmith, MD  Seminars in Nuclear Medicine  Volume 45, Issue 1, Pages 16-31 (January 2015) DOI: 10.1053/j.semnuclmed.2014.08.002 Copyright © 2015 Elsevier Inc. Terms and Conditions

Figure 1 CT in multiple myeloma. A male patient presents with shortness of breath and pain in the left posterior thorax. (A) Initial CT in April 2013 revealed a large left posterior chest wall-paraspinal mass causing regional osseous destruction of the posterior left 11th rib and left aspect of the T11 and T12 vertebral bodies. Tumor extended into the left neural foramina and likely invaded the adjacent left posterior pleura. Workup including biopsy confirms diagnosis of multiple myeloma. (B) Repeat CT in January 2014 following chemotherapy demonstrates significant decrease in the size of left posterior chest wall and paraspinal mass lesion, with significant interval decrease in the extent of multilevel left-sided foraminal extension. (C) On April 2014, status after radiation therapy and pleurodesis of left pleural plasmacytoma. (CT from 18F-FDG-PET/CT study, Fig. 3). Seminars in Nuclear Medicine 2015 45, 16-31DOI: (10.1053/j.semnuclmed.2014.08.002) Copyright © 2015 Elsevier Inc. Terms and Conditions

Figure 2 MRI in multiple myeloma. Same patient as in Figure 1. Left: section of initial CT in April 2013 (Fig. 1 A). Right: MR T1 image (slightly lower level) 6 weeks after initial CT demonstrating significant decrease in the size of left paraspinal mass lesion and foraminal extension corresponding to clinical improvement. Seminars in Nuclear Medicine 2015 45, 16-31DOI: (10.1053/j.semnuclmed.2014.08.002) Copyright © 2015 Elsevier Inc. Terms and Conditions

Figure 3 18F-FDG-PET/CT in multiple myeloma. Status after radiation therapy and pleurodesis of left pleural plasmacytoma, with 18F-FDG-avid 3.8-cm nodular soft tissue density in the left posterior chest wall, suspicious for residual disease. Residual slightly increased metabolic activity in right chest mass; residual tumor activity vs inflammatory response. Seminars in Nuclear Medicine 2015 45, 16-31DOI: (10.1053/j.semnuclmed.2014.08.002) Copyright © 2015 Elsevier Inc. Terms and Conditions

Figure 4 Multiple myeloma in an 86-year-old woman. (A) Presence of 4 prominent foci on 18F-FDG-PET/CT MIP (maximum intensity projection). Examination of MIP is useful for initial image review as it alerts reader to specific sites, although complete examination of all transaxial slices is essential. All transaxial slices using both soft tissue and vertebral CT windows should be reviewed. (B) Upper: markedly hypermetabolic vertebral lesion (SUV 17), with destruction of medullary component of vertebral body and interruption of multiple cortical segments. Represents potential pathologic fracture and vertebra collapse, potential neurologic complications. Lower: small hypermetabolic focus, left 10th rib (SUV 4), minimal if any CT findings in this area. (C) Upper: right ischium (SUV 4.8); lower: minimal metabolic activity (SUV 1.5) in the right femur marrow cavity, likely an isolated focus of myeloma activity as there is no contiguous or contralateral marrow activity. Seminars in Nuclear Medicine 2015 45, 16-31DOI: (10.1053/j.semnuclmed.2014.08.002) Copyright © 2015 Elsevier Inc. Terms and Conditions

Figure 5 18F-FDG-PET/CT coronal fusion images demonstrating diffuse bone marrow involvement. Upper: mild increase in metabolic activity (SUV 2.4) but greater than expected in a healthy adult. Diffuse increase is not disease specific, compatible with rebound after cessation of chemotherapy and granulocyte colony stimulating factor administration or both. Lower: marked diffuse bone marrow involvement (SUV 12.6). Although myeloma is frequently characterized by focal marrow involvement, diffuse patterns are observed. Correlate with clinical picture. Seminars in Nuclear Medicine 2015 45, 16-31DOI: (10.1053/j.semnuclmed.2014.08.002) Copyright © 2015 Elsevier Inc. Terms and Conditions

Figure 6 Lytic, nonhypermetabolic bone lesions in multiple myeloma. Well-defined lytic lesion in skull (left) and vertebral body (right) in different patients. Both lesions are devoid of metabolic activity indicating response to treatment or spontaneous evolution of a previously active tumor focus demonstrating that lytic lesions alone are not indicative of disease activity. Seminars in Nuclear Medicine 2015 45, 16-31DOI: (10.1053/j.semnuclmed.2014.08.002) Copyright © 2015 Elsevier Inc. Terms and Conditions

Figure 7 (A) 18F-FDG-PET/CT MIP images of an 87-year-old woman, 2 years apart. Initial image (February 16, 2012) shows likely extramedullary disease, with hilar nodal involvement (white arrows) (subsequently confirmed by tissue sampling and characteristic abnormal serum electrophoresis and other clinical findings). After 23 months, soft tissue metabolic activity persists, and a new midline hypermetabolic focus has appeared (black arrows indicate activity in renal collecting system). (B) Transaxial fusion images from both studies. Hilar lesion has remained hypermetabolic. Although SUV has declined, a new lesion has appeared in the sternum (SUV 7.4). MIP, maximum intensity projection. Seminars in Nuclear Medicine 2015 45, 16-31DOI: (10.1053/j.semnuclmed.2014.08.002) Copyright © 2015 Elsevier Inc. Terms and Conditions

Figure 8 18F-FDG-PET/CT in a 44-year-old man. (A) Extensive focal disease including a soft tissue lesion in the right lower lobe (SUV 12.4) as well as multiple sites of skeletal involvement. Mixed (soft tissue and skeletal) involvement represents a poor prognostic observation. (B) Vertebral and right femoral hypermetabolic foci with corresponding lytic osseous findings. Decreased or absent 18F-FDG activity would represent control of disease activity, but osseous lesions on CT will remain. Seminars in Nuclear Medicine 2015 45, 16-31DOI: (10.1053/j.semnuclmed.2014.08.002) Copyright © 2015 Elsevier Inc. Terms and Conditions

Figure 9 18F-FDG-PET/CT in a 54-year-old woman. (A) MIP and midthrorax transaxial images. On the anterior projection of the MIP image, prominent hypermetabolic focus (large arrow) appears to be within the lung but is demonstrated to be a posterior chest wall, paravertebral mass with erosion of the lateral margin of the involved vertebral body. Other smaller foci (small arrows), of likely osseous involvement, are also identified and should be confirmed on appropriate transaxial slices. MIP, maximum intensity projection. Seminars in Nuclear Medicine 2015 45, 16-31DOI: (10.1053/j.semnuclmed.2014.08.002) Copyright © 2015 Elsevier Inc. Terms and Conditions

Figure 10 18F-FDG-PET/CT transaxial slices through pelvis in a 63-year-old woman. Initial study revealed marked osseous destruction of ischium and iliac crests bilaterally but minimal disease activity. After 2.5 years, disease activity has returned to the sites of earlier involvement. Seminars in Nuclear Medicine 2015 45, 16-31DOI: (10.1053/j.semnuclmed.2014.08.002) Copyright © 2015 Elsevier Inc. Terms and Conditions