What is the preferred initial imaging exam for multiple myeloma?

Updated: Mar 15, 2019
  • Author: Michael E Mulligan, MD; Chief Editor: Felix S Chew, MD, MBA, MEd  more...
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The preferred initial imaging examination for the diagnosis and staging of myeloma (according to the 2014 IMWG consensus statement) remains the skeletal survey. [8]  Patients suspected of having multiple myeloma based on bone marrow aspirate results or hypergammaglobulinemia should undergo a radiographic skeletal survey. Conventionally, this skeletal survey consists of a lateral radiograph of the skull, anteroposterior (AP) and lateral views of the spine, and AP views of the humeri, ribs, pelvis, and femora. Inclusion of at least these bones is important for both diagnosis and staging. CT and MRI are considered most effective for making the diagnosis. [9]  MRI is the gold-standard imaging modality for detection of bone marrow involvement and the preferred imaging technique to rule out spinal cord compression in patients with multiple myeloma, whereas PET/CT provides valuable prognostic data and aids in assessment of response to therapy. [10, 11, 12, 13, 14]

Shortt et al compared FDG PET, whole body MRI, and bone marrow aspiration and biopsy in 24 patients (13 women, 11 men; mean age, 67.1 years; range, 44-83 years) with multiple myeloma proven by bone marrow biopsy. Whole body MRI had a higher sensitivity and specificity than PET, and the positive predictive value of whole body MRI was 88%. When used in combination and with concordant findings, PET and whole body MRI had specificity and positive predictive values of 100%. [15]

Dimopoulos et al (writing for the International Myeloma Working Group) reviewed the literature of all imaging modalities used in multiple myeloma and provided recommendations for each modality. Conventional radiography, according to the authors, was determined to be the criterion standard for staging newly diagnosed cases and in cases of relapse. MRI can provide information that is complementary to a skeletal survey and was recommended for use in patients with normal radiographic images and in all patients with an apparently solitary plasmacytoma of bone. [16]

According to Dimopoulos et al, urgent MRI (or CT, if MRI is not available) is the diagnostic procedure of choice to assess suspected spinal cord compression. Standard 99mTc bone scintigraphy should play no role in the routine staging of myeloma, and sequential dual-energy radiographic absorptiometry (DXA) scans are not recommended, according to the authors. PET or MIBI imaging are also not recommended for routine use, according to the study findings, although both techniques may be useful in selected cases that warrant clarification of previous imaging findings. [16]

Agool et al studied somatostatin receptor scintigraphy (SRS) in 29 myeloma patients and compared the results with radiographic findings. A positive SRS was demonstrated in 44% of 9 newly diagnosed patients; 83% of the 18 relapsed patients; and both of the patients with plasmacytoma. In 40% of the patients, the SRS findings corresponded with radiographic abnormalities, but in 60% of relapsed patients, SRS uptake was demonstrated in areas without new radiographic abnormalities. [17]

Focused examinations of newly painful bones are of value for assessment of impending pathologic fracture. Correlation with all other available imaging studies should be done to help determine the risk of pathologic fracture.

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