Bone Lesions Detected By MRI Can Predict Progression Of Smoldering Myeloma
The presence and number of bone marrow lesions detected by whole body magnetic resonance imaging (MRI) can be used to determine the likelihood of progression from smoldering (asymptomatic) multiple myeloma to active (symptomatic) myeloma, according to a study published in the Journal of Clinical Oncology.
Patients with more than one bone marrow lesion progressed sooner than those with one or zero.
Currently, MRI, a technique commonly used to visualize internal structure of the body, is one of the most sensitive techniques for detecting bone marrow lesions and changes in bone marrow in multiple myeloma patients. Spinal MRI is commonly recommended for detecting bone marrow lesions in patients with asymptomatic blood disorders, such as monoclonal gammopathy of undetermined significance and smoldering myeloma.
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However, spinal MRI misses any bone marrow lesions that occur away from the spine and pelvis, which can amount to 50 percent of bone marrow lesions in myeloma patients. As a result, patients who are at high-risk of progressing to active myeloma may not be identified.
This study included 149 patients diagnosed with smoldering myeloma. Only one patient showed signs of bone disease, and none of the patients received treatment for smoldering myeloma. Follow-up evaluations occurred every 3 to 6 months, and the median time of follow-up for the whole group was 23.7 months.
Bone marrow lesions were found in 28 percent of the study participants, with the number of lesions ranging from one to more than 20. Eight percent of patients had lesions located only on the spine, 13 percent had lesions only away from the spine, and 7 percent had lesions in both areas.
After analyzing how long it took participants to progress from smoldering to symptomatic myeloma, the researchers concluded that patients with more than one bone marrow lesion progressed significantly faster than the rest. Among these high-risk patients, 39 percent had lesions away from their spine only. Such lesions would not have been detected without whole body MRI, and the skeletal involvement of myeloma would have been overlooked.
MRI can also detect when cancerous cells slowly replace normal marrow, known as diffuse bone marrow infiltration. This was detected in 40 percent of study participants, regardless of the presence of bone lesions. Bone marrow infiltration was also found to be adversely associated with progression to symptomatic myeloma; however, it can be difficult to detect.
Additionally, the researchers statistically evaluated several standard factors for assessing the probability of progression to symptomatic myeloma, such as concentration of M protein, plasma cells in the bone marrow, and the presence or absence of certain immunoglobulins (antibodies).
The researchers determined that the MRI-derived risk-factors were the only ones statistically correlated with progression to symptomatic myeloma. A cutoff of more than one bone marrow lesion detected by whole body MRI was the most effective at differentiating between high- and low-risk progression to symptomatic myeloma.
Based on this study, the study authors recommend whole body MRI to determine a patient’s risk group. However, it was not determined whether smoldering myeloma patients who have bone marrow lesions would benefit from treatment.
For more information, please see the research article in the Journal of Clinical Oncology (abstract).
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how does a person know they have bone lesions. Is there pain associated with it?
Hi Mary, bone lesions often result in bone pain, but not always. Lesions can be detected by a bone survey (x-rays of the entire body), MRI, or PET/CT scans.
I have been referred for a bone scan of lower back after having a MRI. What will this show? I did have a small cancer in right breast last year & had a lumpectomy with radiation.
I have low grade B cell follicular lymphoma. Diagnosed about one year ago. Now, I have left thigh pain after sitting for 15 minutes or more. Should I have an MRI or a Pet scan?
I recently had a total skeletal survey, which was normal. I also had a bone scan, which suggested possible bone loss at T8. A PET scan of the thoracic vertebra was then performed to look at this more closely.
The PET scan showed that nothing was wrong with T8. But it did show a lesion at T12. The radiologist stated, however, that based on the morphology of the lesion, it showed the hallmarks of a hemangioma -- which is normally benign - and suggested further testing.
I have no bone pain and my calcium levels -- which I know do not always correlate with bone damage -- are actually a bit below normal: 8.2.
My question is whether further testing is warranted. My oncologist seems convinced that this indicates that I have quite extensive bone disease in need of immediate treatment. I am 51, and my understanding is that hemangiomas are not that rare at my age. While am certainly not adverse to taking aredia or zometa, it seems that I should have a more definive assessment - if only to know whether I should be extra careful in performing physically challenging activities.
Hi Maria and Shane,
I would not draw any conclusions, Maria, based on the pain that you're experiencing. It could be something as similar as arthritis. Does your blood or urine lab results show any signs that anything is going on other than the lymphoma that you have? For example, are there elevated calcium levels, or abnormal levels of protein in your blood.
I would discuss the pain with your doctor the next time you have an appointment and see what she/he says.
Shane, what led you to have a skeletal survey? Have you been diagnosed with multiple myeloma or some other disorder that led to the survey?
I'm hesitant to share any thoughts on what you should do next before you mention a bit more about your current condition. For example, have you been diagnosed with (active) myeloma, or some other related disease such as MGUS or smoldering myeloma?
Thank you TerryH. Are you a physician by chance?
I should have been clear. Yes, I have been diagnosed with early myeloma with mild anemia. No bone pain, standard risk based on cytogenetics, 30-40% bone marrow involvement, steady M-spike of 4.3. But apart from mild anemia, everything is normal, including all white cell counts.
So starting treatment with Rev and dex is my current plan. I am not particularly interested in trying velcade yet. And I may add Biaxin to the mix, because this can not infrequently delay progression for more than 4 years. Of course, I dread the idea of taking any medications. I live a full, active life with a great job, no symptoms, and high energy.
My oncologist has been monitoring me for six months now, and seems hell-bent on starting treatment, and he also was pushing for an upfront ST. Now with his warning of bone disease, he is argung that an immediate ST may be warranted, despite its toxicity. I respect him, but am realizing he has little practical experience -- he evades my questions about how many MM patients he has actually seen -- and I don't think he views a patient as a while.
So no matter what I do, I am also going to start seeing an integrative medicine specialist.
Hi Shane,
Nope, I'm not a physician, which is why I usually preference my comments with phrases like "I'm not an expert." I should have done so in my last comment as well.
I'm not aware of any research showing that bone involvement such as you've described is a rationale for a more aggressive strategy. This seems like something you might want to bring up in the discussion forum to see if anyone there has heard of that sort of rationale.
From some of the things you've said, it seems like you think similarly to some of the folks at Mayo who put a lot of emphasis on quality of life when making treatment decisions. There is an educational paper by Dr. Rajkumar from Mayo that describes their approach to stratifying and treating myeloma patients. You might want to check it out. It is mentioned in the Beacon's ASCO overview article,
http://www.myelomabeacon.com/news/2012/05/16/multiple-myeloma-research-american-society-of-clinical-oncology-48th-annual-meeting-asco-2012/
in the "Controversies" section of the article.
I can see the rationale for including Biaxin in your treatment regimen if you're already going to go for treatment with Revlimid and dexamethasone. I think there's decent evidence that Biaxin improves the efficacy of treatment with immunmodulatory drugs like Revlimid, thalidomide, and pomalidomide.
Given the questions you have about the advice you're getting from your oncologist, perhaps it's worth getting a second opinion from a myeloma specialist at a major cancer center?
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