Multiple Myeloma with FDG PET Skeletal Superscan

HomeRadiologyVol. 317, No. 1 Previous Reviews and CommentaryFree AccessImages in RadiologyMultiple Myeloma with FDG PET Skeletal SuperscanDong Huang1,2, Yue Chen2 Deputy Editor: Francis DengDong Huang1,2, Yue Chen2 Deputy Editor: Francis DengAuthor Affiliations1Departments of Nuclear Medicine, The First People's Hospital of Mianyang, Mianyang, Sichuan, China2Department of Nuclear Medicine, Affiliated Hospital of Southwest Medical University; Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province; Laboratory for Targeted Radiopharmaceuticals Creation; Institute of Nuclear Medicine, Southwest Medical University, No. 25 TaiPing St, Jiangyang District, Luzhou, Sichuan 646000, ChinaAddress correspondence to: Y.C. (email: [email protected]).Dong Huang1,2Yue Chen2 Published Online:Oct 7 2025https://doi.org/10.1148/radiol.251364MoreSectionsPDF ToolsAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookXLinked In A 47-year-old man presented with low back and hip pain for 1 month. Laboratory tests revealed renal insufficiency, hypercalcemia, anemia, and elevated lactate dehydrogenase level, suggestive of multiple myeloma. Fluorine 18 (18F)-labeled fluorodeoxyglucose (FDG) PET/CT findings showed innumerable osteolytic lesions with diffuse, intense hypermetabolism throughout the axial and proximal appendicular skeleton, manifesting as a skeletal superscan pattern, wherein diffuse skeletal activity eclipses renal and brain activity (Figure). Osteolytic involvement of the skull was multifocal, analogous to the classic appearance known as raindrop skull. Bone marrow biopsy revealed 21% clonal plasma cells, confirming the diagnosis, and identified high-risk cytogenetic features such as t(4;14) and chromosome 1q21 gain. Despite chemotherapy, the patient died 5 months after diagnosis.Extensive skeletal involvement by multiple myeloma on fluorine 18 (18F)-labeled fluorodeoxyglucose (FDG) PET/CT images. (A) Maximum intensity projection PET image shows a skeletal superscan, characterized by diffuse hypermetabolism throughout the axial and proximal appendicular skeleton (maximum standardized uptake value, 16.3), especially on the skull (arrows), more intense than renal and brain activity. (B, C) Axial CT (B) and fused PET/CT (C) images demonstrate numerous osteolytic calvarial lesions, reminiscent of the raindrop skull radiographic pattern, with FDG avidity (arrows). (D, E) Sagittal CT (D) and fusion PET/CT (E) images show heterogeneously intense FDG avidity in the skull, sternum, and vertebrae, while bone destruction was noted with compression fractures (arrows).Download as PowerPoint The hallmark imaging findings of multiple myeloma are focal osteolytic bone lesions and diffuse osteopenia. Corresponding 18F-FDG uptake patterns may be focal, multifocal, diffuse, or mixed (1). A skeletal superscan pattern, originally described with bone scintigraphy, has been uncommonly observed at FDG PET due to diffuse infiltration of multiple myeloma (2). Moreover, raindrop skull, a radiographic pattern of multifocal lytic or punched-out lesions resembling raindrops hitting a surface and splashing, is characteristic of multiple myeloma (3).Disclosures of conflicts of interest: D.H. No relevant relationships. Y.C. No relevant relationships. Funding: This work was supported by Major Science and Technology Project in Gansu Province (23ZDFA014) and the National Natural Science Foundation of China (82472016).References1. Fujino M. The histopathology of myeloma in the bone marrow. J Clin Exp Hematop 2018;58(2):61–67. Medline Google Scholar2. Fu Z, Chen X, Yang X, et al. Skeletal Superscan on 18F-FDG PET/CT in a Patient With Multiple Myeloma. Clin Nucl Med 2019;44(2):169–170. Medline Google Scholar3. Solis F, Gonzalez C. Raindrop Skull. N Engl J Med 2018;378(20):1930. Medline Google ScholarArticle HistoryReceived: May 7 2025Revision requested: June 13 2025Revision received: June 18 2025Accepted: July 2 2025Published online: Oct 07 2025 FiguresReferencesRelatedDetails Vol. 317, No. 1 Metrics Altmetric Score PDF download