Haematologica 2003 - Supplements

189
Factors Predicting Occult Spinal Cord Compression in
Multiple Myeloma
David A Macdonald, Darrell White, Jill Regan, Derrick
McPhee
Division of Hematology and Department of Radiology, QEII Health
Sciences Centre, Halifax, Nova Scotia, Canada
Introduction: Bone involvement in multiple myeloma (MM) can
lead to significant morbidity, including potentially irreversible
neurologic deficits if spinal cord compression occurs. During a
study comparing MRI to TcMIBI scan for bone involvement in
MM, we encountered patients with evidence of compression of
the spinal cord (SCC) or subarachnoid space (SASC) on MRI, but
without neurologic signs or symptoms.
Methods: 41 patients with newly diagnosed MM or relapsed
disease requiring treatment were enrolled in a prospective study
comparing MRI to TcMIBI for extent of bone involvement,
between August 2000 and February 2003. Imaging was
performed at enrolment, and repeated at time of stable disease or
100 days post autologous stem cell transplant. MRI scans were
reviewed for evidence of MM involvement in the vertebral canal
resulting in either bone fragment or tumour contacting the spinal
cord (SCC) or impressing on the subarachnoid space (SASC). All
charts were then reviewed for clinical manifestations of
SCC/SASC. Clinical markers including patient age, hemoglobin,
serum calcium, percentage plasma cells in bone marrow, M-
protein, extent of disease on skeletal survey, and presence of back
pain were investigated for correlation with presence of
SCC/SASC.
Results: 38 patients completed MRI at baseline, one of whom
had symptomatic SCC. Of 37 patients without neurologic
symptoms at presentation, 10 patients (27%) had occult
SCC/SASC using MRI. One additional patient asymptomatic and
with negative MRI at baseline developed symptomatic SCC with
positive MRI at 10 months, making the overall rate of
SCC/SASC 32% (12/38). Presence of back pain at baseline
(11/12 with positive MRI vs 11/26 with negative MRI, Fisher
exact p =0.0042), baseline hemoglobin (120.8±26 with positive
MRI vs 99.5±13 with negative MRI, p=0.010), and baseline
serum calcium (2.51±0.18 vs 2.37±0.18, p=0.019) were
predictive of a positive MRI at baseline or follow-up. Age at
presentation, %plasma cells in bone marrow, M-protein, and
extent of disease on skeletal survey were not predictive.
Conclusions: In MM patients, we have identified a 27% rate of
occult SCC/SASC. In univariate analysis, patients with back pain,
elevated serum calcium, and near-normal hemoglobin were more
likely to have SCC/SASC on MRI. These predictors may be
useful for identifying patients at risk of developing potentially
irreversible neurologic complications of MM. The skeletal
survey, a standard test for staging multiple myeloma, was not
predictive of SCC/SASC. Longer follow-up is required to
determine if a positive baseline MRI is predictive of development
of symptomatic cord compression.
190
Utility of the MR. in the evaluation of plasma cell bone
marrow infiltration in patients with Multiple Myeloma
before double PBSCT
Hamade H*, Giraldo P, Roca M*, Giménez, R*, Guelbenzu
S*, Rubio-Félix D
*Radiodiagnostic and Haematology Department. Miguel Servet
University Hospital. Zaragoza. Spain
Background: Multiple Myeloma (MM) is a neoplastic disease
characterized by scattered bone marrow plasma cells infiltration.
The information about mapping of disease is not complete when
making solely aspired or marrow biopsy. The MRI has
demonstrated its utility in the evaluation of the bone marrow
infiltration by their capability to distinguish water from fat and
this technique permit to obtain a map of changes in the
hematopoeitic distribution. In MRI three patterns of bone marrow
infiltration are described: diffuse, variegated and focal. Diffuse
pattern is associated with progressive disease. At diagnosis
approximately 20% of patients have not skeletal manifestation,
nevertheless MR showed bone marrow infiltration. Besides MRI
is useful to evaluate bone marrow response after therapy. The
objective of this study is to use the MRI procedure in diagnosis
and evaluation of plasma cell bone marrow infiltration after and
before PBSCT in patients with MM.
Materials and Methods: In twelve consecutive MM patients
diagnosed in Haematology Department of Miguel Servet
University Hospital between 01/00 and 06/02 a prospective study
was carried. All patients received chemotherapy with
VBCMP/VBAD schedule, subsequently double PBSCT were
performed. MRI designed protocol was applied at diagnosis and
4 months after double PBSCT was performed. Type of MRI
study: signal intensity sequences in Ta (TR600 ms TE-20) in
coronal imaging located in lumbar spine, pelvis and femoral
bones. A General Electric System was used (GE MR. max 0.5
Tesla intensity). All the studies were performed and evaluated by
the same radiologist. Three patterns of bone marrow infiltration
were proposed: 1.- normal, 2.- non-homogeneous, 3.-
homogeneous. The non-homogeneous pattern being subclassified
in three different subtypes: reticular, mottled and diffuse
Results: Mean age 56.33 (range 47-63 years), males/females
10/2. Bone marrow biopsy: mean of plasma cells 41.0 (range 0-
75%). M-spike component: mean 2.4 (range 0-8.3 g/dL),
(Immunochemical subtype: IgG 6, IgA 3, Bence-Jones 3),
2microglobulin 3.7 (range 1-15.6 mg/dL), haemoglobin 12.3
(range 6.4-15.4 g/dL). The conventional bone X-ray showed
generalized osteoporosis in 2 patients, osteolitic lesions 6
patients, vertebral collapse 2 and normal 2 patients. MRI was
performed in all patients showing evidence of bone marrow
involvement: diffuse 2, reticular 6, mottled 4. After double
PBCST MRI remained being positive in 11 (91.6%): diffuse 2,
reticular 4 and mottled 5. Relapse has been observed in 7
patients (58.3%), mean free relapsed survival 19.4 months SD
16.4. Apparently MRI pattern does not seem to be related with
free time to relapse.
Conclusion: The MRI is an effective non invasive procedure to
evaluate bone marrow replacement and to determine the extent of
disease in MM. This procedure will be very useful to evaluate the
response to therapy. In our short experience, we have found that
MRI showed persistence of disease in spite of the negativity of
the others evaluated parameters.
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