[Fire4Effect]

Can an MRI be substituted for an x-ray skeletal survey?

by Fire4Effect on Thu Apr 14, 2016 11:30 am

Hello,

This is my first time posting.

I was sent to a neurologist to see if the symptoms I was experiencing in my feet were due to peripheral neuropathy. The EMG test showed I did not have a peripheral neuropathy so the neurologist cast a wide net of blood tests to see if that might explain the symptoms in my feet. The good news I don’t have AIDS or hepatitis C, but a paraprotein peak was identified in the gamma region accounting for 0.36 gm per dl, or 5.3 percent, of total serum protein. The paraprotein identified was IgG lambda.

My general health is good, but I am HLA-B27 positive and I was diagnosed with an undifferentiated spondyloarthropathy 30 years ago. I have bits and pieces of different inflammatory autoimmune diseases. I was on Embrel from 2005 to 2010, stopped, and then restarted in 2012. I stopped taking Enbrel a few months ago due to cost and fear it may lead to cancer.

RISK FACTORS

• While in the Air Force in the early 70’s, I few in aircraft that were previously used for spraying Agent Orange in Vietnam. The planes smelled of it.

• I have had a lot of exposure to x-rays due to on going back problems over the last 3 decades. In the past year I have had 2 lumbar x-ray series, a chest CT scan to check for a pulmonary embolism, a scoliosis x-ray series and a chest x-ray. NOTE: I do not have scoliosis, but my surgeon was looking for instability that a standard lumbar series might not show.

Question

I will be doing additional blood tests tomorrow (protein electrophoresis PEP) along with a 24 hour urinalysis. I suspect the oncologist I have an appointment with next week will want to do a skeletal x-ray survey, but I am concerned about more radiation exposure. Would an MRI provide the doctor with the information he needs to make a diagnosis?

Below are links to screen shots of my most recent blood test results. Some are from a recent ER visit for supraventricular tachycardia. The neurologist ordered the others.

Electrophoresis Protein

SPEPv2.jpg (63.02 KiB) Viewed 1586 times

Immunofixation ELP

IFEv2.jpg (23.9 KiB) Viewed 1586 times

Comprehensive Metabolic Panel

CMPv2.jpg (51.05 KiB) Viewed 1586 times

CBC Differential Auto

CBCHv2.jpg (42.33 KiB) Viewed 1586 times

CBC Hemogram

CBCHv2.jpg (42.33 KiB) Viewed 1586 times

Thank you for taking the time to read my post and consider my question.

Howard

[Multibilly]

Re: Can an MRI be substituted for an x-ray skeletal survey?

by Multibilly on Thu Apr 14, 2016 12:19 pm

Hi Howard,

Sorry to see you have a paraprotein peak, but welcome to the forum nonetheless.

The good news here is that paraprotein peak (M-spike) of 0.36 g/dL is pretty darn small and could very well be in line with a diagnosis of MGUS instead of symptomatic multiple myeloma. Your calcium, hemoglobin and creatinine levels also look good, further indicating that you likely don't have symptomatic multiple myeloma. The risk of MGUS progressing to symptomatic multiple myeloma is only about 1.5 - 2%/year and most people with MGUS go through life none the worse for it.

Some other key lab tests you want to make sure are run are a serum free light chain assay and a quantified immunoglobulin test.

To answer your question about imaging, it turns out that a WHOLE BODY MRI or PET/CT is now the preferred imaging modality for initial diagnostic purposes.

See these two articles for a discussion on imaging tradeoffs and current recommendations:

https://myelomabeacon.org/forum/pet-scans-for-multiple-myeloma-t3687.html

https://myelomabeacon.org/news/2014/10/26/new-multiple-myeloma-diagnostic-criteria/

Once your doc has all the follow up tests in hand, he/she may be recommending a bone marrow biopsy to complete the diagnostic effort.

Lastly, if you are getting VA benefits and were exposed to agent orange, you would want to read this link as well:

http://www.publichealth.va.gov/exposures/agentorange/conditions/multiple_myeloma.asp

Let us know how things go and good luck.

[Fire4Effect]

Re: Can an MRI be substituted for an x-ray skeletal survey?

by Fire4Effect on Fri Apr 15, 2016 1:38 am

Multibilly,

Thanks so much for your kind and informative response. I sent a message to the oncologist asking about the serum free light chain assay and quantified immunoglobulin test. I will add to this thread as I learn more about my test results and diagnosis.

Howard

[PattyB]

Re: Can an MRI be substituted for an x-ray skeletal survey?

by PattyB on Fri Apr 15, 2016 11:39 am

Howard - Welcome to the Beacon and thanks for posting all your information. Good luck with your diagnosis.

Multibilly - Thanks for great answers to Howard's questions. I always learn something new from your posts.

[Fire4Effect]

Re: Can an MRI be substituted for an x-ray skeletal survey?

by Fire4Effect on Sun Apr 17, 2016 4:47 pm

I just got more blood test results:

KAPPA LIGHT CHAIN, FREE, SERUM (Reference Range 3.3-19.4)
Normal, measured 12.8mg/L.

LAMBDA LIGHT CHAIN, FREE, SERUM (Reference Range 5.7-26.3)
High, measured 26.6mg/L.

I am assuming you just divide 12.8/26.6 to get the kappa/lambda ratio. I calculated 0.48.

BETA-2-MICROGLOBULIN (Reference Range < OR = 2.51)
Normal, measured 2.10mg/L.

BTW, recent nuclear medicine procedures and radiographic contrast media can affect test results for BETA-2-MICROGLOBULIN. I did have an MRI within the last 30 days with contrast.

Multibilly,

Based on what I posted above, I may be only missing the quantified immunoglobulin test. Is this correct?

Thanks so much for suggesting the additional tests.

Howard

[Multibilly]

Re: Can an MRI be substituted for an x-ray skeletal survey?

by Multibilly on Mon Apr 18, 2016 12:25 pm

Howard,

You lambda free light chain (FLC) value and FLC ratio are just barely out of range, further suggesting that this is just a real mild case of MGUS.

It gets confusing, but a lot of the literature will talk about the FLC ratio in terms of the involved/uninvolved FLC ratio (which, in your case is lambda/kappa), instead of the laboratory standard of the kappa/lambda FLC ratio. You just need to be aware of which ratio the particular author is using when you see an FLC ratio referenced.

As far as blood lab tests go, the quantified immunoglobulin test is indeed the key one that is missing. Some docs like to also run 24 hour urine protein electrophoresis test, but then some do not.

[Fire4Effect]

Re: Can an MRI be substituted for an x-ray skeletal survey?

by Fire4Effect on Tue Apr 19, 2016 2:36 am

Multibilly,

Is a serum immunoglobulins panel the same as quantified immunoglobulin test?

Looks like I will have to wait a few more days for blood and urine results. I confess, I am very apprehensive about what the diagnosis and prognosis will be. This site and posters like you are a godsend to those of us who are looking for support and understanding.

Howard

[Multibilly]

Re: Can an MRI be substituted for an x-ray skeletal survey?

by Multibilly on Tue Apr 19, 2016 4:35 am

A serum immunoglobulin test sounds the same to me as a quantified immunoglobulin test.

In any case, you want a blood serum test that measures your IgG, IgA and IgM levels. Immunoglobulins don't make it into your urine (immunoglobulin molecules are really big and therefore they can't make it through all the little tubes in one's kidneys). So, there is no other place in your body to measure them.

[Cheryl G]

Re: Can an MRI be substituted for an x-ray skeletal survey?

by Cheryl G on Tue Apr 19, 2016 6:43 am

A side topic related to this discussion -

Multibilly, you've posted several times here in the forum that whole body MRI and PET/CT are now the 'preferred imaging modalities', vis-a-vis x-rays.

Maybe this is a subtle point, but my understanding is that the new myeloma-related diagnostic criteria give the two newer imaging modalities greater significance than previously was the case. Perhaps that new standing is an equal one with xrays. But I'm not sure that I would necessarily say "preferred."

I know that, combined with my comments about "standard of care" in a different forum thread, this comment will make me sound like some kind of a language nut. I just feel language does matter, and "preferred" seems a strong word.

Thanks!

[Multibilly]

Re: Can an MRI be substituted for an x-ray skeletal survey?

by Multibilly on Tue Apr 19, 2016 10:07 am

Hi Cheryl,

Point taken as I also do not like the use of the "standard of care" tag when it comes to describing multiple myeloma treatments on this forum.

In the case of imaging, I believe there is consensus within the IMWG based on the November 2014 "International Myeloma Working Group Updated Criteria for the Diagnosis of Multiple Myeloma" (published by Lancet and viewable for a fee) that PET-CT, LD whole-body CT, or MRI of the whole-body or spine be done in all patients with suspected smoldering multiple myeloma, with the exact imaging modality determined by availability and resources. No mention of a skeletal xray survey was included in this recommendation.

I admittedly am also personally biased towards more sensitive imaging modalities than xray because I for one would rather know sooner than later if I had had any skeletal issues going on.

But in any case, your point is well taken and I will try to adjust my language in future threads and avoid the blanket use of "preferred" when describing treatment or diagnostic methods.