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Bone imaging is a critical aspect of care for patients with multiple myeloma (MM), and recent advances in imaging modalities have improved detection of lytic lesions and bone marrow involvement.
“Bone Imaging Can Make or Break…” It’s not often that I find an article that offers up a pun so readily. Intestingly this issue was central to my own original MM diagnosis. I enjoy making light of my own MM experiences.
To quote my oncologist, Nathan A. Berger M.D. in his lab report dated 2/28/94, “Mr. Emerson clearly had a single plasmycytoma of bone which has been removed and repaired with a bone graft. He has no evidence of systemic myeloma…I told the family that there is no demonstration that systemic adjuvant therapy is effective in early myeloma (chemo doesn’t help a single plasmacytoma).”
Yet despite Dr. Berger’s experience as an general oncologist, according to be my lab reports as well as imaging studies, there was evidence of more MM elsewhere.
The pathologist, John Makley M.D. stated several possibilities based on several different tests.
By diagnosing me as having a single plasmacytoma, Dr. Berger was saying that I didn’t have cancer. I was at a pre-myeloma or pre-cancer stage. Dr. Berger was saying that I had a single bone plasmacytoma. And therefore I did not need any therapy.
Did Dr. Berger mis-diagnose me? Why didn’t he take Dr. Makley’s statements or my imaging studies more seriously?
There are several important takeaways for multiple myeloma patients reading this post.
Bone marrow biopsies (BMB) don’t always reveal the entire diagnostic picture for a complex blood cancer like MM. As we know, MM is systemic. A BMB needle samples one small area of bone marrow.
Imaging studies such as PET scans and x-rays can offer diagnostic information that should be a part of the conversation.
Lastly and most importantly, Dr. Berger is a general oncologist. Studies show that multiple myeloma patients live longer, on average, if they work with MM specialists.
As the article linked and excerpted below explains, bone imaging has advanced greatly since I was first diagnosed with MM in 1994.
Make no mistake. Whole-body “low-dose” CT imparts more radiation to your body than do conventional X-rays. I had dozens of imaging studies done during the first four years of my MM diagnosis. However, the “bone specificity” of today’s imaging studies would have made a huge difference in my therapy plan. A diagnosis of multiple myeloma instead of a single plasmacytoma would have triggered active treatment about a year sooner than it was. As we all know, the sooner the patient begins active treatment the more effective the treatment is.
Have you been diagnosed with a single plasmacytoma or frank multiple myeloma? Have you been in remission and you are wondering if your disease is relapsing? Scroll down the page, post a question or comment and I will reply to you ASAP.
“Bone imaging is a critical aspect of care for patients with multiple myeloma (MM), and recent advances in imaging modalities have improved detection of lytic lesions and bone marrow involvement…
Bone involvement is present in about two-thirds of patients at diagnosis, and nearly all patients will develop bone disease at some point during their disease course. Bone imaging is therefore a cornerstone of MM management…
The novel modality whole-body low-dose CT (WBLDCT) is superior to WBXR for detecting lytic lesions because it has higher sensitivity, increased detection rate, and greater accuracy. WBLDCT does not require contrasting agents and uses low doses of radiation that are 2- to 3-fold lower than conventional CT…
FDG-PET/CT detects bone lesions with a sensitivity and specificity between 80% and 100% and is the most accurate technique for detecting extramedullary disease. It can also be used for prognostication, as the number and metabolism of focal lesions prior to stem cell transplantation has been established as an independent prognostic factor. FDG-PET/CT is also the preferred modality for monitoring metabolic response to MM treatment…
According to Dr Vij, MRI is used in the initial work-up of any plasma cell dyscrasia. “If patients have a normal set of imaging on skeletal survey, whole-body CT, and PET/CT, then an MRI may help distinguish smoldering MM from MM,” he said. Dr Vij also noted that it is used “to evaluate any episode of back pain because it is the best test to rule out spinal cord compression.”
Agents for Bone Disease
There are 2 classes of agents available for the treatment of bone disease in MM: bisphosphates and an anti-RANKL antibody. These agents inhibit osteoclast activity, thereby preventing new osteolytic lesions, pathologic fractures, and hypercalcemia…
Selection between bisphosphonates and denosumab comes down to cost and renal disease. Bisphosphonate are “literally a tenth of the cost of denosumab, but denosumab has little in the way of renal side effects,” Dr Vij said. This is important given that many patients with MM have renal dysfunction at diagnosis or develop it as their disease progresses. For these patients, “denosumab is certainly the best option,” he said, “but to give it to everybody, is certainly not something that most physicians or opinion leaders currently recommend because of the cost.”
“Results-Whole-body CT led to a change in management in 32 patients (28%).Of those, 17 patients with MM precursor disease were found to have MM-related bone disease, 13 patients had progression of MM, requiring a change in treatment, in one patient hepatocellular carcinoma was diagnosed, requiring a change in therapy, and one patient had a rib lesion requiring intervention. In 65 patients (56%), WBCT was performed for surveillance of MM precursor disease or stable treated MM, and did not detect new lesions, thereby providing reassurance to the hematologist on disease status and management. In 15 patients (13%) WBCT was performed as a new baseline before a change or new therapy. In 4 patients (3%), WBCT was performed for a change in symptoms, but did not detect lesions that would lead to a change in management.
Conclusion– Whole-body CT provides important information for disease monitoring and detection of incidental findings, thereby improving the management of patients with MM…”
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