Knee MRI & CT

• 72 yo M with vague sense of fatigue, unwellness. Lab testing

demonstrated elevated ESR.
• Further testing showed elevated IgM, beta-2 macroglobulin
• Developed right ankle pain several years later; XR without fracture
• Aug 2018 PET-CT demonstrated intense uptake in left patella,
diagnosed as nondisplaced healed fracture
• Persistent intense uptake in patella on Dec 2019 PET-CT
• MRI obtained few days later
Waldenstrom’s Macroglobulinemia
• Previously known as lymphoplasmacytic lymphoma; type of B-cell lymphoma
• Rare condition, accounting for only 1% of all lymphoproliferative disorders
• Incidence is 1,500 cases per annum in the United States
• Median age of onset is 60-65 years; minority of cases occur in late adolescence
• Clinical presentation
• Most patients asymptomatic at time of diagnosis, which is often incidentally made during blood tests for an unrelated condition
• If symptoms occur, most common ones are fatigue (2/3 of cases) and polyneuropathy (1/4 of cases)
• Less common: fever, night sweats, and unintentional weight loss; hyperviscosity syndrome
• Pathology
• Pathogenesis is poorly understood but may resemble that of chronic lymphocytic leukemia
• Clonal proliferation of functionally impaired B-cells occurs, as well as infiltration of various tissues (predominantly bone marrow,
spleen, and lymph nodes)
• Overproduction of IgM, leading to hyperviscosity syndrome and resultant impaired microcirculation
• Prognosis
• Five-year survival rates of 40-90%, depending on disease severity category
• Untreated, the disease typically progresses indolently, and behaves differently among patients.
Imaging
• Imaging not included in the standard initial workup of patients with
WM
• Radiography may be less sensitive in the early stage of the disease
than in later stages.
• MRI shows replacement of the normal bone marrow signal intensity
• PET/CT can also be useful in determining the extent of disease.
Imaging
• Bone and Bone Marrow
• In original article, Waldenström remarked that “in primary macroglobulinemia, the osseous
system is nearly always intact.”
• There is rarity of destructive bone lesions, initially suggested that this feature can differentiate
WM from multiple myeloma
• However, subsequent studies showed osteopenia, marrow space widening, endosteal erosions,
and osteolytic lesions in 8–24% of patients
• Two patterns of involvement: a diffuse pattern, characterized by complete absence of normal
bone marrow signal intensity, and a variegated pattern, characterized by innumerable small
foci of abnormal signal intensity on a background of intact bone marrow
• In contrast, approximately 30% of patients with myeloma can show a focal pattern of
involvement with circumscribed areas of altered signal intensity
• PET may show a diffuse pattern of bone marrow involvement
• MRI more sensitive than PET
Imaging
• Extramedullary Involvement
• Approximately one-third of patients with WM have involvement of sites other
than the bone marrow, most commonly lymph nodes and spleen
A, 58-year-old man with WM. Sagittal unenhanced T1-weighted MR image of lumbar spine shows diffuse pattern of
involvement with low T1 signal intensity seen almost throughout vertebral bodies. Note severe degenerative changes
at L1–L2 level (arrow).
B, 61-year-old man with WM. MR image shows variegated pattern with interspersed regions of T1 hypointensity and
normal fat marrow signal intensity. Note mild compression deformity of L4 vertebral body (arrow).
Fig. 3A —Focal bone marrow involvement from Waldenström macroglobulinemia (WM) in 56-year-old woman with right hip pain.
B, Coronal T1-weighted unenhanced MR image (B) shows hypointense signal (arrows, B) and contrast-enhanced T1-weighted image (C) shows increased
enhancement (arrows, C) in right intertrochanteric region. Percutaneous biopsy revealed bone marrow infiltration by lymphoplasmacytoid cells.
C, Coronal T1-weighted unenhanced MR image (B) shows hypointense signal (arrows, B) and contrast-enhanced T1-weighted image (C) shows increased
enhancement (arrows, C) in right intertrochanteric region. Percutaneous biopsy revealed bone marrow infiltration by lymphoplasmacytoid cells.
A, Coronal reformatted CT image in soft-tissue window shows increase in density of marrow in right
intertrochanteric region (arrows).
D, Coronal maximum-intensity-projection 18F-FDG PET image shows tracer uptake is limited to right femur
intertrochanteric region (arrow), thus confirming focal pattern of involvement in WM.
References
• https://www.ajronline.org/doi/full/10.2214/AJR.19.21493
• https://
radiopaedia.org/cases/waldenstroms-macroglobulinaemia?lang=us
• https://pubs.rsna.org/doi/10.1148/radiology.188.3.8351330?url_ver=
Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed
• https://www.cancer.org/content/dam/CRC/PDF/Public/8875.00.pdf