Multiple myeloma - femur

Case contributed by Assoc Prof Frank Gaillard

Presentation

Severe left sided hip pain. No trauma.

Patient Data

Age: 80 years
Gender: Female

Subtle focal lucencies in the region of the greater trochanter and subtle endosteal scalloping in the proximal and mid femoral diaphysis. A fracture is not identified.

Bone scan

Nuclear medicine

The patient was injected with 99m-Technetium MDP and initial dynamic  (not shown) and whole body blood pool images obtained. Whole body imaging  were obtained 3 hours later. 

With respect to the left femoral head there is increased focal uptake involving the greater and lesser trochanters suspicious for fracture. The distribution of uptake does not fit a usual pattern for neck of femur fracture. Physiological bladder and pudendal uptake is noted. 

On the whole body blood pool images increased perfusion at the proximal left femur was seen. Delayed whole body images demonstrate multiple focal intensities of tracer involving the medial end of the left clavicle as well as the 2nd and 5th ribs anteriorly. There are further areas of focal intensity involving the right 3rd, 4th, 5th, 6th and 7th ribs anteriorly as well as increased tracer uptake in the vertebral body of T9. 

CT left femur

CT

There is a lytic expansile mass in the intertrochanteric region of the left femur measuring 3.6 x 4.6 x 3.4 cm. There is endosteal scalloping of the cortex, with multiple intra-cortical lucencies within the proximal femur in keeping with cortical infiltration. At the anterior aspect of the femur, just medial to be greater trochanter there is complete loss of bone cortex in keeping with cortical breech/pathological fracture. There is soft tissue stranding surrounding the femur in this region.

The marrow of the imaged distal femur demonstrates multiple soft tissue masses in keeping with marrow infiltration.

Annotated image

Annotated image

Endosteal scalloping is often subtle and has to be carefully sought. It represents resorption of the cortical bone where it abuts a medullary lesion. 

This patient went on to have a CT guided biopsy and the diagnosis of multiple myeloma was confirmed. 

Distribution of multiple myeloma

Diagram

Distribution of multiple myeloma. Layout and distribution: Frank Gaillard 2012, Line drawing of skeleton: Patrick Lynch 2006, Creative Common NC-SA-BY

Case Discussion

This case illustrates one of the presentations of multiple myeloma: undisplaced pathological fracture resulting in bone pain. The diagnosis of multiple myeloma was established histologically. 

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