Bone Marrow MRI

Lia Angela Moulopoulos • Vassilis Koutoulidis

Bone Marrow MRI

A Pattern-Based Approach

Lia Angela Moulopoulos Professor of Radiology and Chair 1st Department of Radiology University of Athens School of Medicine Athens Greece

Vassilis Koutoulidis Assistant Professor of Radiology1st Department of Radiology University of Athens School of Medicine Athens Greece

ISBN 978-88-470-5315-1 ISBN 978-88-470-5316-8 (eBook) DOI 10.1007/978-88-470-5316-8 Springer Milan Heidelberg New York Dordrecht London

Library of Congress Control Number: 2014956375

© Springer-Verlag Italia 2015 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifi cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfi lms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied specifi cally for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher’s location, in its current version, and permission for use must always be obtained from Springer. Permissions for use may be obtained through RightsLink at the Copyright Clearance Center. Violations are liable to prosecution under the respective Copyright Law. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specifi c statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein.

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To my father, a scientist. With love and admiration. LAM

To my father, Constantinos Koutoulidis, M.D., who passed away during the writing of this book. To Olga and our children, Constantinos and Ariadne. With unstinting love and gratitude.

VK

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Pref ace

Why a Pattern-Based Approach?

Bone marrow, responsible for blood cell production, is a dynamic, ever-shifting, continuously adapting organ. Dynamic changes commence from the moment hematopoietic tissue appears in the cavities of the fetal long bones at approximately the 10th to 11th week of gestation in humans. They continue after birth until the adult pattern of red/yellow marrow distribution is reached at about 25 years of age. After this point, bone marrow fat continues to increase slowly in an orderly, predictable way. Reconversion of yellow marrow into red marrow may occur at any time point when the needs for hematopoiesis increase. All these processes, which alter the composition of bone marrow, complex as they are, can be simplifi ed and better understood by using a pattern-based approach. Patterns are repeatedly recognized when studying both bone marrow physiology and pathology. Orderly patterns predict the way red marrow converts into yellow marrow at the skeletal level as well as at the level of each individual bone. When yellow marrow reconverts into red marrow, patterns reverse from the above are observed. Familiarity with the patterns of normal bone marrow changes is essential to identify the presence of dis-ease. Conditions that affect bone marrow by infi ltrating it with infl ammatory or neoplastic cells do so in ways that may be schematically presented with patterns. MRI provides an excellent means of visualizing these patterns of normal and abnormal marrow.

We fi nd this pattern recognition approach very useful because it provides an organized way of MR image interpretation. Pattern assignment facilitates the learning of bone marrow MRI as it links imaging appearances to underlying pathophysiological changes. It is interesting that discrete patterns of disease are also refl ected in more advanced MRI techniques such as Dynamic Contrast-Enhanced MRI and Diffusion-Weighted MRI. In certain clinical entities, MRI patterns may also have important prognostic value.

We did not set out, therefore, in this book to provide an exhaustive list of MRI features of every single disease that may affect bone marrow. We chose instead this pattern-based approach, which we have found very useful over the years, both for teaching purposes and in day-to-day clinical practice. The fi rst chapters of the book address the anatomy and physiology of bone marrow as well as normal marrow MRI. A chapter is then devoted to the analysis of the different MRI patterns of abnormal marrow, and extensive differential diagnosis lists are provided. The most important disease entities affecting the marrow are presented in the next chapters in a uniform fashion. The relevant clinical information is provided fi rst, followed by fi ndings on other imaging modalities; fi nally, the MRI fi ndings of each disease are presented in detail. Apart from the discussion of imaging features, we have tried to emphasize the clinical implications of MRI fi ndings and the way in which they may affect patient management and treatment. Common diagnostic dilemmas, such as benign versus malignant vertebral fracture

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and treated inactive marrow versus residual active disease, are addressed in separate chapters. With the help of key points highlighting the most important information and a large number of richly annotated fi gures, we hope to make the challenging task of bone marrow MRI interpre-tation a little bit easier for the reader and as exciting as it is for us.

Lia Angela Moulopoulos Vassilis Koutoulidis

Preface

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Acknowledgments

We would like to thank the following:

Our families for their love and understanding and for putting up with us during our intermi-nable preoccupation with “The Book.”

The MRI technologists at our institution (Miltiadis Ioannidis, Maria Roussaki, Virginia Mantikou) for their commitment and excellent work.

The clinical staff in the Department of Clinical Therapeutics—Division of Hematology/Oncology of the University of Athens School of Medicine led by Professor Meletios A. Dimopoulos for their hard work and support.

From Springer, Antonella Cerri for embracing our project with enthusiasm and conviction, Andrea Ridolfi for his expert assistance and encouragement during the writing of the book, and Magesh Rajagopalan and Sushil Kumar Sharma for a fi rst-rate production job.

And, lastly:

LAM wishes to thank VK, a challenging and inspiring partner for all those shared moments of creative thinking and fun.

VK would like to thank LAM: a mentor, a friend, and the best writing partner he could ever hope for.

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1 Νormal Bone Marrow: Anatomy, Function, Conversion, and Reconversion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.1 Normal Bone Marrow: Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.1.1 Bone Marrow Types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.1.2 Vascular Anatomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.1.3 Cellular Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

1.2 Normal Bone Marrow: Function. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31.3 Age-Related Changes in Bone Marrow Composition: Red to Yellow

Marrow Conversion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31.4 Reconversion of Yellow to Red Marrow. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

2 MRI of the Normal Bone Marrow: Pulse Sequences . . . . . . . . . . . . . . . . . . . . . . 72.1 T1-Weighted Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72.2 T2-Weighted Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92.3 Chemical-Shift Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132.4 Contrast-Enhanced Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162.5 Diffusion-Weighted Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

3 MRI of the Normal Bone Marrow: Anatomic Sites . . . . . . . . . . . . . . . . . . . . . . . 253.1 Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253.2 Pelvis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293.3 Extremities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293.4 Rib Cage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323.5 Skull . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

4 The Abnormal Bone Marrow: MRI Patterns . . . . . . . . . . . . . . . . . . . . . . . . . . . . 354.1 Focal Pattern . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

4.1.1 Hyperintense Focal Pattern . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 364.1.2 Hypointense Focal Pattern . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 414.1.3 Signal-Void Focal Pattern . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

4.2 Variegated Pattern . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 464.3 Diffuse Pattern . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

4.3.1 Hyperintense Diffuse Pattern . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 474.3.2 Hypointense Diffuse Pattern . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 474.3.3 Signal-Void Diffuse Pattern . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

4.4 Regional Pattern . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 524.4.1 Hyperintense Regional Pattern . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 524.4.2 Hypointense Regional Pattern. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

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5 MRI of the Abnormal Bone Marrow: Focal Pattern . . . . . . . . . . . . . . . . . . . . . . 575.1 Hemangioma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

5.1.1 Clinical Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 575.1.2 Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 585.1.3 Magnetic Resonance Imaging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

5.2 Metastases: Focal Pattern . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 625.2.1 Clinical Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 625.2.2 Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 635.2.3 Magnetic Resonance Imaging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

5.3 Multiple Myeloma: Focal Pattern . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 765.3.1 Clinical Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 765.3.2 Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 785.3.3 Magnetic Resonance Imaging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80

5.4 Lymphoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 915.4.1 Clinical Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 915.4.2 Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 935.4.3 Magnetic Resonance Imaging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

6 MRI of the Abnormal Bone Marrow: Diffuse Pattern . . . . . . . . . . . . . . . . . . . . 1016.1 Metastases: Diffuse Pattern. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1016.2 Multiple Myeloma: Diffuse Pattern . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1046.3 Lymphomas and Leukemias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113

7 Bone Marrow Edema Pattern . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1157.1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1157.2 Transient Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1167.3 Regional Migratory Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1207.4 Complex Regional Pain Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1207.5 Calcineurin Inhibitor Pain Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1227.6 Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1237.7 Differential Diagnosis of Reversible Versus Irreversible

Bone Marrow Edema Pattern . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125

8 Benign Versus Malignant Vertebral Fractures. . . . . . . . . . . . . . . . . . . . . . . . . . . 1278.1 Clinical Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1278.2 Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1288.3 Magnetic Resonance Imaging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132

8.3.1 Signal Intensity Characteristics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1328.3.2 Morphologic Characteristics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1368.3.3 Quantitative Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1388.3.4 Findings at Other Spinal Levels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139

8.4 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141

9 MRI of Bone Marrow Posttreatment Changes . . . . . . . . . . . . . . . . . . . . . . . . . . 1439.1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1439.2 Effect of Treatment on Normal Bone Marrow . . . . . . . . . . . . . . . . . . . . . . . . . 143

9.2.1 Effect of Radiotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1439.2.2 Effect of Chemotherapy and Hematopoietic Growth Factors. . . . . . . . 1449.2.3 Bone Marrow Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145

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9.3 Effect of Treatment on Abnormal Marrow . . . . . . . . . . . . . . . . . . . . . . . . . . . 1479.3.1 Conventional MR Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1479.3.2 Advanced MRI Techniques. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153

9.4 MRI Assessment of Complications of Treatment. . . . . . . . . . . . . . . . . . . . . . 1549.4.1 Post-radiotherapy Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1549.4.2 Osteonecrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1579.4.3 Bone Marrow Necrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162

10 Bone Marrow MRI: A Quick Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16510.1 Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16510.2 Focal Bone Marrow Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16510.3 Diffusely Abnormal Bone Marrow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16610.4 Vertebral Compression Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16610.5 Posttreatment Assessment of Bone Marrow Malignancies. . . . . . . . . . . . . . . 166

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167

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