[Ben S.]

Imaging Tools

by Ben S. on Mon Jan 23, 2012 5:18 pm

Hi,

I have a question on the best imaging tools for different stages of multiple myeloma. There are a few tools now available - X ray, MRI, PET and CT. The concensus seems to be that X-ray is not detailed enough to pick up small lesions. But how should a patient compare MRI, PET and CT? Which one is the best for a smoldering versus an active patient? Many thanks!

Ben

[Shayt]

Re: Imaging Tools

by Shayt on Tue Jan 24, 2012 6:53 am

See here.
http://www.springerlink.com/content/x8274413441544w5/
though each method has its pros and cons, it seems like PET-CT is the most recommended one. Too bad that that in my country, Pet-CT is not "approved" for multiple myeloma.

Shay

[Nancy Shamanna]

Re: Imaging Tools

by Nancy Shamanna on Tue Jan 24, 2012 10:11 am

Thanks for the helpful links!

Last edited by Nancy S on Wed Jan 25, 2012 12:02 pm, edited 1 time in total.

[Ben S.]

Re: Imaging Tools

by Ben S. on Tue Jan 24, 2012 2:49 pm

Thanks, Shayt, for the link. Though PET/CT was deemed the most informative imaging tool for the disease, the concerns have always been the radiation involved in the test and probably the higher cost as well. My wife was diagnosed smoldering and went through the Whole Body MRI. I just want to be sure that it was adequate for the disease at her status. That seems to be confirmed by the article in that, for that disease stage, the PET/CT may not be very effective.

[Dr. Edward Libby]

Re: Imaging Tools

by Dr. Edward Libby on Wed Jan 25, 2012 12:57 pm

Hello Ben,
The International Myeloma Workshop Consensus Panel 3 recently published their recommendations for imaging in the evaluation of myeloma.. Blood. 2011;117(18):4701-4705)
Their recommendations follow:

1) The skeletal survey remains the standard method for imaging screening at diagnosis

2) Magnetic resonance imaging is a noninvasive technique that provides detailed information about bone marrow involvement, and its pattern (focal, diffuse, or variegated) is useful for the
assessment of the extent and nature of soft tissue disease arising from bone lesions, and can detect unsuspected, asymptomatic lesions. An MRI of the spine and pelvis is mandatory in all patients with a presumed diagnosis of solitary plasmacytoma. An MRI should also be considered in patients with smoldering (asymptomatic) myeloma because it can detect occult lesions and, if positive, can predict for more rapid progression to symptomatic. myeloma.MRI can be considered in patients with symptomatic myeloma as routine evaluation because (1) unsuspected focal lesion and soft tissue plasmacytomas involving the spine and pelvis can be visualized; and (2) patterns of MRI abnormality (ie, diffuse pattern or a high number of focal lesions) may have prognostic significance. However, MRI is mandatory in symptomatic patients for a detailed evaluation of a painful area of the skeleton to look for a soft tissue mass arising from a bone lesion or for the investigation of patients with a suspicion of cord compression, providing an accurate assessment of the level and extent of cord or nerve root compression, size of the tumor mass, and degree to which it may affect the epidural space. An MRI of the spine is valuable in defining the etiology of new, painful collapsed vertebra (ie, because of osteoporosis or myelomatous involvement). Osteoporosis with compression fracture requires thorough evaluation with an MRI. If a focal myelomatous lesion is detected, then the patient has symptomatic myeloma, which requires treatment. However, if the fracture is the result of osteoporosis (especially in certain populations, such as elderly white women), then other criteria, such as degree of marrow infiltration and anemia, should be considered to diagnose symptomatic myeloma. Occasionally, an MRI-assisted CT-guided biopsy of the collapsed vertebra is needed to make the diagnosis. Furthermore, an MRI is strongly indicated in patients with nonsecretory myeloma for their initial assessment and follow-up of response to treatment.

3) The role of PET-CT is yet to be clearly defined in multiple myeloma. It is helpful for detection of extraosseous soft tissue masses and evaluation of rib and appendicular bone lesions.
PET-CT is especially useful in patients with elevated lactate dehydrogenase, Bence Jones protein escape, and otherwise rapidly recurrent disease or with suspected extramedullary plasmacytoma. Unlike MRI, PET-CT obviates the need for a skeletal survey. A recent study showed an independent predictive value of baseline fluorodeoxyglucose-PET/CT and of fluorodeoxyglucose suppression before high-dose therapy. here is recent evidence that the
combination of PET-CT and MRI may improve the diagnostic accuracy of solitary plasmacytoma but is not recommended.

Thanks for asking this important question Ben. As you can se the role of MRI and CT/PET is evolving and these newer imaging techniques are recomended for specific situations but not yet for all patients. Best of luck !

[Nancy Shamanna]

Re: Imaging Tools

by Nancy Shamanna on Wed Jan 25, 2012 5:23 pm

Hi Dr. Libby, Thanks so much for the information regarding 'imaging'. Having in my family history osteoporosis, as you mentioned, in female relatives, have always been interested in this topic. Of course one tries to exercise daily, eat properly, and take in sufficient calcium plus vitamin D, but even with all of that, bone disease can creep in. Add myeloma to that, and there is serious concern! It is very good to know what the imaging approach to this sort of thing is, especially at diagnosis. Will be watching this area of my health carefully into the future.

[Ben S.]

Re: Imaging Tools

by Ben S. on Thu Jan 26, 2012 1:12 am

Hi, Dr. Libby:

This is very useful information, Many thanks for the detailed explanation!

Ben

[suzierose]

Re: Imaging Tools

by suzierose on Thu Jan 26, 2012 3:57 am

Hi Dr. Libby

Thanks for the useful evaluative differentiation of the two tests, MRI vs. PET

What is the cummulative radiation involved and what is the lifetime radiation acceptable, when it comes to these tests? I believe MRI has no radiation involved. Is that correct?

Taking these tests is essential to evaluation, I just worry about the radiation and what it means over time.

Could you please share that risk involvement?

thanks

suzierose

[Dr. Edward Libby]

Re: Imaging Tools

by Dr. Edward Libby on Thu Jan 26, 2012 9:17 pm

You are correct. MRI has no radiation. CT scans have significant levels of radiation.
I am not a radiation physicist and do not keep the radiation risks of CT scans in my memory banks. The risk of cancer due to radiation from CT scans is low but not zero. The medical community is now alerted to the issue and is trying to decrease the use of CT scans unless truly needed.