Diagnostic Imaging Pathways - Multiple Myeloma
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This pathway provides guidance on the imaging of adult patients with suspected multiple myeloma.
Date reviewed: August 2013
Date of next review: 2017/2018
Published: August 2013
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The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
 | None | 0 |
 | Minimal | < 1 millisieverts |
 | Low | 1-5 mSv |
 | Medium | 5-10 mSv |
 | High | >10 mSv |
Images
Image GalleryNote: These images open in a new page | ||
|---|---|---|
| 1 |  |
Multiple Myeloma of the Skull Image 1 (Plain Radiograph): Lateral skull radiograph showing typical multiple small punched out lesions of multiple myeloma. |
| 2 |  |
Multiple Myeloma Image 2 (Magnetic Resonance Imaging): Coronal T1 image showing extensive focal areas of marrow replacement (arrows) in patient with known multiple myeloma. |
| 3a |  |
Multiple Myeloma of the Spine Image 3a and 3b (Magnetic Resonance Imaging): Sagittal T1 and STIR images showing extensive myelomatous infiltration of the lower thoracic and lumbar spine. |
| 3b |  |
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| 4 |  |
Multiple Myeloma Image 4 (H&E, x10): Histological section showing sheets of atypical plasma cells with eccentrically placed nuclei, coarse (clock-face) chromatin and paranuclear hoffs. |
Teaching Points
Teaching Points
- A skeletal survey with plain radiographs is the initial imaging modality of choice
- Multidetector CT has the advantage of superior sensitivity for the detection of bone lesions and has a much more rapid acquisition time
- MRI is also highly sensitive but is generally reserved for symptomatic patients with negative skeletal surveys
- Current guidelines suggest that nuclear medicine scans such as Sestamibi and FDG PET should not be routinely used in diagnosis but may be useful to clarify previous imaging findings in selected cases
ct
Multidetector Computed Tomography (MDCT)
- MDCT allows for the detection of small osteolytic lesions with rapid acquisition times and three dimensional multiplanar reconstruction. This modality has replaced the conventional skeletal survey in some centres 9
- Demonstrates superior sensitivity compared to plain radiography and able to better visualise areas such as the scapulae, ribs and sternum. 10,11 Also characterises trabecular anatomy in detail to differentiate benign and pathological compression fractures 9
- May reveal unsuspected associated pathology such as soft tissue and visceral masses which may be more easily biopsied
- Provides estimation of fracture risk 8
- Main limitation is the exposure to ionising radiation
mri
Magnetic Resonance Imaging
- Highly sensitive modality for the detection of myeloma-related bone lesions. Allows visualisation and assessment of the degree of malignant infiltration of the medullary cavity. It can effectively distinguish benign and malignant compression fractures 9
- MRI is also the modality of choice for suspected cord compression 9
- In comparison to the conventional skeletal survey and MDCT, MRI demonstrates higher sensitivity for the detection of bone lesions 13,17
- According to current guidelines, MRI should be considered in symptomatic patients with a negative skeletal survey. 9 Whole body MRI is preferable, however, MRI of the spine and pelvis is also helpful if resources are limited
- In patients with apparent solitary plasmacytoma on skeletal survey, MRI of the spines should be performed to exclude occult lesions 9
sesta
Whole Body Sestamibi and FDG PET Scans
- 99mTc-sestamibi, 18FDG-PET and PET/CT are all useful additional diagnostic tools for detecting occult myeloma-related lesions. Sestamibi scans correlate well with disease activity. 17 PET/CT is a relatively new modality which overcomes the problem of spatial resolution with PET alone by combining with CT. This fusion scan demonstrates a sensitivity of 85% for the detection of myeloma deposits 18
- In comparison to MRI, both sestamibi and PET/CT scans show a lower sensitivity for the detection of bone lesions 19
- Based on current guidelines, neither sestamibi or PET scans are recommended for routine use in the diagnosis and management of myeloma patients. 10 However, both modalities may be useful to clarify the findings on previous imaging in selected cases, although further studies are required to support this role
- Traditional technetium bone scintigraphy may detect up to 60% of lytic lesions in myeloma. However, it demonstrates a lower sensitivity and specificity compared to plain radiography which is due to osteoblastic dysfunction in myeloma. 10 Other modalities should be used in preference in the diagnosis and monitoring of patients
xray
Skeletal Survey (Plain Radiography)
- Primary method for evaluating skeletal involvement by multiple myeloma 1,2
- Approximately 80% of patients with myeloma will have detectable lesions on skeletal survey, most commonly affecting the vertebrae, ribs and skull 9
- Able to detect lytic lesions, fractures and osteoporosis 1
- Limitations
- Some areas not well visualised (eg, scapulae, ribs, sternum)
- Limited sensitivity with up to 20% false-negatives 9
- Cannot distinguish myeloma-related osteoporosis from steroid-induced or postmenopausal osteoporosis
- Lengthy study requiring multiple films with different patient positions
Bone Scan (Multiple Myeloma)
- Adjunct to radiographs in cases with continued bone pain, unexplained by standard radiographs 1,2
- Hot spots suggest more osteoblastic disease, pathological fracture or other pathology
- Useful in demonstrating pathological fractures, particularly in areas not seen well on standard radiographs, such as the ribs 1,2
- Occasionally may detect areas of early myeloma involvement that are not yet evident on the radiographs 1,2
- Limitations: poor sensitivity for detection of myeloma-related bone lesions and evaluating the extent of the disease. This is due to marrow rather than cortical involvement with myeloma. Should not be considered primary investigative tool for myeloma 1,2
References
References
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Ludwig H, Kumpan W, Sinzinger H. Radiography and bone scintigraphy in multiple myeloma: a comparative analysis. Br J Radiol. 1982;55(651):173-81. (Level II/III evidence)
- Woolfenden JM, Pitt MJ, Durie BGM, et al. Comparison of bone scintigraphy and radiography in multiple myeloma. Radiology. 1980;134:723-8. (Level III evidence)
- Pace Leonardo, Catalano L, Del Vecchio S, et al. Predictive value of technetium-99m sestamibi in patients with multiple myeloma and potential role in the follow-up. Eur J Nucl Med. 2001;28:304-12. (Level III evidence)
- Svaldi M, Tappa C, Gebert U, et al. Technetium-99m-sestamibi scintigraphy: an alternative approach for diagnosis and follow-up of active myeloma lesions after high-dose chemotherapy and autologous stem cell transplantation. Ann Hematol. 2001;80(7):393-7. (Level II/III evidence)
- Orchard K, Barrington S, Buscombe J, et al. Fluoro-deoxyglucose positron emission tomography imaging for the detection of occult disease in multiple myeloma. Br J Haematol. 2002;117:133-5. (Level IV evidence)
- Lecouvet FE, Vande Berg BC, Malghem J, et al. Magnetic resonance and computed tomography imaging in multiple myeloma. Semin Musculoskeletal Radiol. 2001;5(1):43-55.
- Lecouvet FE, Malghem J, Michaux L, et al. Skeletal survey in advanced multiple myeloma: radiographic versus MR imaging survey. Br J Haematol. 1999;106:35-9. (Level II evidence). View the reference
- Mahnken AH, Wildberger JE, Gehbauer G, et al. Multidetector CT of the spine in multiple myeloma: comparison with MR imaging and radiography. AJR Am J Roentgenol. 2002;178:1429-36 (Level III evidence)
- Dimopoulos M, Terpos E, Comenzo RL, et al. International myeloma working group consensus statement and guidelines regarding the current role of imaging techniques in the diagnosis and monitoring of multiple myeloma. Leukemia. 2009. (Guidelines). View the guidelines
- Schreiman JS, McLeod RA, Kyle RA, Beabout JW. Multiple myeloma: evaluation by CT. Radiology. 1985;154:483-6. Level III evidence)
- Mahnken AH, Wildberger JE, Gehbauer G, et al. Multidetector CT of the spine in multiple myeloma: comparison with MR imaging and radiography. AJR Am J Roentgenol. 2002;178:1429-36. (Level III evidence)
- Ghanem N, Lohrmann C, Engelhardt M, et al. Whole-body MRI in the detection of bone marrow infiltration in patients with plasma cell neoplasms in comparison to the radiological skeletal survey. Eur Radiol. 2006;16:1005-14. (Level III evidence)
- Lecouvet FE, Malghem J, Michaux L, et al. Skeletal survey in advanced multiple myeloma: radiographic versus MR imaging survey. Br J Haematol. 1999;106:35-9. (Level II evidence)
- Baur-Melnyk A, Buhmann S, Becker C, et al. Whole-body MRI versus whole-body MDCT for staging of multiple myeloma. AJR Am J Roentgenol. 2008;190:1097-104. (Level III evidence)
- Baur-Melnyk A, Buhmann S, Durr HR, et al. Role of MRI for the diagnosis and prognosis of multiple myeloma. Eur J Radiol. 2005;55:56-63. (Review article). View the reference
- Walker R, Barlogie B, Haessler J, et al. Magnetic resonance imaging in multiple myeloma: diagnostic and clinical implications. J Clin Oncol. 2007;25:1121-8. (Level III evidence)
- Balleari E, Villa G, Garre S, et al. Technetium-99m-sestamibi scintigraphy in multiple myeloma and related gammopathies: a useful tool for the identification and follow-up of myeloma bone disease. Haematologica. 2001;86:78-84. (Level II evidence)
- Bredella MA, Steinbach L, Caputo G, et al. Value of FDG PET in the assessment of patients with multiple myeloma. AJR Am J Roentgenol. 2005;84:1199-204. (Level III evidence)
- Mirzaei S, Filipits M, Keck A, et al. Comparison of Technetium-99m-MIBI imaging with MRI for detection of spine involvement in patients with multiple myeloma. BMC Nucl Med. 2003;3:2. (Level III evidence)
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