1. MedPix Medical Image Database COW - Case of the Week Case Contributor: Charles F Gould Affiliation: Walter Reed National Military Medical Center

2. MedPix No: 13097 - History Pt Demographics: Age = 61 y.o. Gender = woman 61 y.o. woman with a *lump* on left side of head. Downloaded by (-1)

3. MedPix No: 13097 - EXAM & LABS Non-tender superficial mass at the left superior frontal region of the skull. No focal neurological deficits.

4. Multiple Myeloma Multiple punched-out lytic lesions are seen throughout the calvarium. A large lytic lesion at the vertex disrupts both the inner and outer table. - Downloaded by (-1)

5. Multiple Myeloma Multiple punched-out lytic lesions (red outlines) are seen throughout the calvarium. A large lytic lesion at the vertex disrupts both the inner and outer table. - Downloaded by (-1)

6. Multiple Myeloma Multiple punched-out lytic lesions are seen throughout the calvarium. A large lytic lesion at the vertex disrupts both the inner and outer table. - Downloaded by (-1)

7. Multiple Myeloma A large punched-out lytic lesions (red outline) are seen throughout the calvarium. NOTE: The lesion has a sharp margin, but without any reactive bone (no line at the edge). - Downloaded by (-1)

8. Multiple Myeloma Large expansile mass lesion which is hypointense to bone marrow extending intracranially from the frontal clavarium. Downloaded by (-1)

9. Multiple Myeloma Enhancing expansile mass lesion extending intracranially and superficially from the calvarium. Downloaded by (-1)

10. Multiple Myeloma Expansile mass which is isointense to bone marrow extending both intracranially and superficially from the calvarium. Downloaded by (-1)

11. Multiple Myeloma Expansile extraaxial mass lesion, arising from the skull, which is isointense to bone marrow extending both intracranially and superficially from the calvarium. Notice on the T2W image (left side) a dark line from the intact dura (shown by a red outline). Downloaded by (-1)

12. Multiple Myeloma Large expansile mass lesion which is hypointense to bone marrow extending intracranially from the frontal clavarium. Downloaded by (-1)

13. Multiple Myeloma Large expansile mass lesion which is hypointense to bone marrow extending intracranially from the frontal clavarium. Downloaded by (-1)

14. Multiple Myeloma Enhancing expansile mass lesion extending intracranially and superficially from the calvarium. Downloaded by (-1)

15. Multiple Myeloma Expansile mass which is isointense to bone marrow extending both intracranially and superficially from the calvarium. Downloaded by (-1)

16. 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.

17. DIFFERENTIAL DIAGNOSIS What is your Differential Diagnosis? Surgical defect - Lytic metastasis - Hemangioma - Brown Tumor - Hemangiopericytoma - Meningioma (multiple or Meningiomatosis) - Multiple myeloma

18. Diagnosis: Multiple Myeloma Dx Confirmed by: Prior bone marrow biopsy & characteristic lytic lesions

19. 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. -