WHOLE-BODY-LOW-DOSE MDCT

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• WHOLE-BODY-LOW-DOSE MDCT
• IN THE INVESTIGATION OF
• MULTIPLE MYELOMA (MM)
• A NEW APPROCH AND OUR EXPERIENCE
• Kamenetsky Natalya (1), Rachmilewitz Eliezer (2),
• Katz Rama (1),
• (1)Department of Diagnostic Imaging
• (2) Department of Heamatology
• E. Wolfson Medical Center, Holon, Israel.

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• The idea of our study came from lately published
  literature, especially the article
• Whole-body low dose multidetector row-CT
• in the diagnosis of MM
• an alternative to conventional radiography
• EJR,2005.

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MM Definition and diagnosis

• Uncontrolled proliferation of neoplasticplasma
  cell clone in the bone marrow.
• Diagnosis based on laboratory and radiographic
  findings
• Bone marrow containing more then 15 plasma cells
  (normally no more then 4).
• Blood serum or urine containing an abnormal
  protein (M protein, Bence-Jones protein).
• Bone lesions found on skeletal survey as
  generalized osteopenia or lytic bone deposits.

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MM Demographics

• Most common primary bone tumor in adult.
• Multifocal lesions more common
• Solitary (Plasmacytoma) less common
• may be Intra/Extraosseous.
• Age 40 years or older.
• MF 21
• More common in Afro-Americans then in Caucasians.
  Less common in Asians.
• Median survival 3-4 years.

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MM Skeletal involvement

• Osteolytic lesion (80) - found
• particularly with nodular marrow infiltration.
• small discrete lytic areas of bone destruction
• with no reactive bone formation.
• Arises within the medulla, may progress to
• infiltrate the cortex and periosteum and be
• accompanied with extraosseous soft tissue masses.

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MM-Skeletal involvment

• Diffuse osteopenia (85) is associated with a
  packed pattern of marrow infiltration thinning
  of all trabeculae, vertebral body collapse.
• Osteosclerosis rare (1-3), may be focal or
  diffuse.
• Normal survey (10).

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Skeletal involvement in MM

• Frequency in different bones correlates with
  normal sites of red marrow distribution
• Vertebra (66).
• Ribs (45).
• Skull (40).
• Shoulder (40).
• Pelvis (30).
• Long bones (25).

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CT versus plain film

• Bone lesions of the axial skeleton, are
  significantly better recognized by CT by reducing
  the effects of overlying soft tissue and bony
  structures.
• Bone lesions of the appendicular skeleton are
  mostly well recognized in both modalities.

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Roll of imaging in MM patients

• Diagnosis and staging.
• Diagnosis of extramedullary or solitary
  plasmacytoma and directing a biopsy if needed.
• Monitoring treatment response.
• Detection of relapse.
• Assessing fracture risk and directing
  prophylactic treatment.

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Staging by Durie and Saimon

• Stage 1 Stage
  3
• (All) (1
  or more)
• Hemoglobin gt10g/100ml
  lt8.5 g/100ml
• Serum calcium lt12mg/100ml
  gt12mg/100ml
• M component IgG lt5g/100ml
  gt7g/100ml
• IgA lt3g/100ml
  gt5g/100ml
• Urine light chain lt4 g/24hr
  gt12g/24hr
• Bone Lesion none /solitary multiple
  
• Stage 2 Between Stage 1 and 3.
  

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MM Staging

• Patients with more then two unequivocal lytic
  lesions are classified as stage 3, indicating
  immediate treatment.

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Different imaging modalities
in MM

• X-ray Conventional plain film survey, CT.
• MRI
• Radionuclid imaging Tc(99m)- MIBI,
• F-18 FDG-PET.

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Plain film skeletal survey

• Multiple lytic lesions (80).
• Solitary (Plasmacytoma) expansible lytic lesion.
• Osteopenia (85).
• Vertebral body collapse and pathological
  fractures.
• Normal survey (10).
• Shrinking or sclerosing deposits indicate a
  response.
• Residual osteolysis may persist in inactive phase
  of disease.
• No detection of extraosseous involvement.

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CT Imaging

• Detect disease in bone, bone marrow and
  extramedullary sites.
• Focal pattern sharp, lytic lesions with no
  sclerotic rim.
• Diffuse faint osteolysis.
• High (soft tissue) attenuation value of bone
  marrow.
• Positive response to treatment Shrinking or
  sclerosing deposit, disappearance of soft tissue
  masses, reappearance of cortical contour and
  fatty marrow content.

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Our experience

• On April - November 2006 we performed
• 41 CT skeletal surveys
• 30 patients with known diagnosis of MM.
• 5 to exclude MM lesion in MGUS patients.
• 6 in other patients.

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CT survey study protocol

• Patient laying supine, cranio-caudal position,
  arms on abdomen.
• Scan length from top of the skull down to the end
  of the knees.
• With suspended respiration when possible.
• No oral or IV contrast material.

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CT survey study protocol Low dose CT
parameters are based on the article from EJR
2005.

• MDCT 16 slices.
• Surview 1536 mm.
• 120 KV, 70 mAs (300 mAs in spine CT)
• Overall radiation dose of 5 mSv.
• 160.75mm collimation with 0.5 sec rotation time.
• Table speed 18mm/sec.
• Slice thickness 3mm.
• Mean acquisition time 38 sec.

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CT survey study protocol

• Reconstruction was done from raw data.
• bone filter with B60f kernel.
• F.O.V 500mm max.
• multiplanar reformatted (MPR) whole body images
  were reconstructed in sagital and coronal planes.
  
• Divided into 3 different body parts
• Head and neck, including cervical spine
• Chest and abdomen including the relevant spinal
  column and arms
• pelvis and thighs.

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Plain film skeletal survey protocol

• Skull AP and lateral.
• Vertebral column AP and lateral for each level.
• Ribs AP and oblique.
• Pelvis AP.
• Upper and lower extremities AP and lateral.
• Overall - 20 different plain films per patient.
• Radiation dose of 2.4 mSv.

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Our experience results

• The majority had IgG gammopathy and suffered from
  both osteopenia and lytic lesions.
• 12 (29) patients had vertebral collapse.
• 5 (12) patients had large vertebral lytic lesion
  at high risk for collapse.

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Results

• In 7 (17) patients we detected significant
  extramedullary finding
• 2 (4) as part of the MM dieses itself.
• 5 (12) not directly relevant to MM but demand
  forwarder investigation.

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CT versus plain film survey

• 16 MM patients had a conventional plain film
  survey done no more than two weeks before the CT.
• Comparing the two imaging modalities we found
  
• In 5 (31) patients lytic lesion that where not
  found on the conventional survey.
• In 2 (12.5) patients vertebral lytic lesion in
  risk of collapse that were not found on the plain
  film survey.

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CT versus plain film survey

• Advantage
• More sensitive and accurate in identifying and
  characterizing lytic lesions.
• Especially important in the evaluation of
  vertebral collapse and their possible
  complications.
• Most beneficial in the diagnosis of large lytic
  lesions in risk of phatological fracture.

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CT versus plain film survey

• Advantage
• Identify extramedullary involvement of the
  dieses itself or incidental finding that may be
  important.
• Guide biopsies.
• Disadvantage
• Higher radiation dose.

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Radiation dose of X-ray Imaging
CT high dose 250 mAs CT low dose 70 mAs Plain film survey Exam type
25.5 mSv 5 mSv 2.4 mSv Radiation dose
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Summary

• Accurate detection of skeletal lesions is
  essential for the diagnosis, staging and
  treatment in MM.
• The number, size and anatomic location of the
  lesions are important to evaluate the patients
  prognosis and quality of life.
• Whole body low dose CT is much more sensitive and
  accurate than the classic plain film survey.

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Summary

• In low dose CT the radiation dose is about twice
  that of a plain film survey but much lower than
  conventional skeletal CT.
• As in the literature, we propose this study as
  an efficient and relatively available in compare
  to other imaging modalities, for MM patients.

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MERCI! THANK YOU!????!!
MERCI! THANK YOU!????!!