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Figure A
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This patient is suffering from multiple myeloma. Multiple myeloma presents on radiograph as punched-out lytic bone lesions (Figure E), most commonly seen in the skull, long bones, and spine. Multiple myeloma (MM) is a cancer of monoclonal plasma cells that produce large amounts of either IgG or IgA. MM is the most common primary tumor of the bone in elderly patients. It most commonly presents with musculoskeletal pain (or pathologic fracture), signs/symptoms of hypercalcemia, and/or signs/symptoms of renal failure. If increased gamma globulins are noted on serum electrophoresis, but the patient is asymptomatic, it is termed monoclonal gammopathy of undetermined significance (MGUS). Nau et al. reviews the diagnosis and treatment of MM. The differential diagnosis of MM includes amyloidosis, non-Hodgkin lymphoma, Waldenström macroglobulinemia, and numerous rare blood disorders. Symptomatic disease is treated with chemotherapy (common agents include melphalan, prednisolone, dexamethasone, vincristine, doxorubicin, bortezomib, and thalidomide), and autologous stem cell transplant. Rothschild et al. discuss differentiation of the lytic lesions of MM from those of metastatic carcinoma on radiographs. MM is characterized by sharply-defined, spheroid lesions with smooth borders - this gives the classic 'punched-out' appearance. In contrast, metastatic lesions undergo remodeling leading to more irregular lesions with some cortical bone preservation. In addition, metastatic lesions tend to vary in size, whereas multiple myeloma often exhibits lesions of uniform size. Illustration A shows bone marrow aspirate from a patient with multiple myeloma. Incorrect Answers: Answer 1: Figure A shows sclerotic (osteoblastic) bone lesions, consistent with metastatic disease to the pelvis. Answer 2: Figure B is a radiograph demonstrating osteoblastic bone metastases of to the spine. Answer 3: Figure C shows a 'cotton-wool' appearance of the skull, consistent with a diagnosis of Padget disease of bone. Answer 4: Figure D is a radiograph from a patient with severe osteoporosis; no lytic lesions are present. Osteoporosis is commonly seen in patients with MM; however, the presence of lytic lesions is more specific to the diagnosis.
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