Clues potentially distinguishing lytic lesions of multiple myeloma from those of metastatic carcinoma

This study was conducted to determine whether individual bony lesions are specific for recognizing multiple myeloma and thereby distinguish it from metastatic cancer and leukemia. The lytic skeletal lesions of multiple myeloma are characterized by sharply defined, spheroid lesions. They have smooth borders and effaced/erased trabeculae. Unique spheroid myeloma lesions appear to be responsible for the 'punched out' appearance of affected bone. The total absence of remodeling in myeloma forms a contrast to irregular preservation of trabeculae and buttressing, isolated 'fronts of' cortical bone 'resorption' coalescing to confluence, and the 'golf-ball surface' phenomenon observed in metastatic cancer. The uniform effacement of both cortical and trabecular bone in multiple myeloma also contrasts with some cortical preservation in metastatic cancer. Leukemic lesions are more numerous than those of myeloma, but they lack the latter's 'space-occupied' appearance. The relatively small holes and 'fronts of resorption' of leukemia are quite different from the 'space-occupied' lesions of multiple myeloma. Uniform size is a characteristic traditionally attributed to the bone lesions of multiple myeloma. The occurrence of isolated examples of uniform size lesions in metastatic cancer and of variable size lesions in some individuals with multiple myeloma precludes unequivocal use of size in differential diagnosis. Fortunately, the newly recognized macroscopic characteristics appear to separate multiple myeloma from metastatic cancer, and also distinguish myeloma from leukemia.