Cancer Treatment Today

The role of PET in staging myeloma not clear. Traditionally, myeloma was staged with IgG levels, bone survey and lab tests. While PET is very sensitive for metastases, it can be falsely positive and is not a good study for nodal staging. Only retrospective analyses are available. However, expert opinion as represented by NCCN does recommend PET as an option for stage I – III disease. For followup surveillance, NCCN added “consider PET” in 2007.

“The International Myeloma Working Group consensus aimed to provide recommendations for the optimal use of 18fluorodeoxyglucose (18F-FDG) PET/CT in patients with multiple myeloma and other plasma cell disorders, including smouldering multiple myeloma and solitary plasmacytoma. 18F-FDG PET/CT can be considered a valuable tool for the work-up of patients with both newly diagnosed and relapsed or refractory multiple myeloma because it assesses bone damage with relatively high sensitivity and specificity, and detects extramedullary sites of proliferating clonal plasma cells while providing important prognostic information. The use of 18F-FDG PET/CT is mandatory to confirm a suspected diagnosis of solitary plasmacytoma, provided that whole-body MRI is unable to be performed, and to distinguish between smouldering and active multiple myeloma, if whole-body X-ray (WBXR) is negative and whole-body MRI is unavailable. Based on the ability of 18F-FDG PET/CT to distinguish between metabolically active and inactive disease, this technique is now the preferred functional imaging modality to evaluate and to monitor the effect of therapy on myeloma-cell metabolism. Changes in FDG avidity can provide an earlier evaluation of response to therapy compared to MRI scans, and can predict outcomes, particularly for patients who are eligible to receive autologous stem-cell transplantation” (Cavo M. et al., 2017).

“18F-FDG PET/CT plays an important role in MM where it combines functional imaging provided by PET with morphological evaluation assessed by CT. It enables the detection of metabolically active plasma cells both inside and outside the BM, thus predicting patients’ clinical outcomes.” (Sundaram, S., Driscoll, J., Fernandez-Ulloa, M., de Lima, M., & Malek, E., 2018).

“In addition to the skeletal survey or CT, MRI or PET/CT are needed to exclude the presence of additional lesions and the use of at least one of these examinations is mandatory (Grade 1A). Both are recommended based on small prospective studies, while PET/CT has additional prognostic value. Using both PET/CT and MRI may offer complementary information. When both PET/CT and MRI are not available, a WB-CT approach can be used to exclude other lesions. (Grade 2C). To detect additional soft tissue lesions, PET/CT is recommended for patients with EMP (Grade 1B).” (Caers, J., Paiva, B., Zamagni, E., Leleu, X., Bladé, J., Kristinsson, S. Y., Touzeau, C., Abildgaard, N., Terpos, E., Heusschen, R., Ocio, E., Delforge, M., Sezer, O., Beksac, M., Ludwig, H., Merlini, G., Moreau, P., Zweegman, S., Engelhardt, M., & Rosiñol, L., 2018).

LITERATURE:

Agarwal, A. et al. (2013) Evolving Role of FDG PET/CT in Multiple Myeloma Imaging and Management. American Journal of Roentgenology. 2013;200: 884-890

Caers, J., Paiva, B., Zamagni, E., Leleu, X., Bladé, J., Kristinsson, S. Y., Touzeau, C., Abildgaard, N., Terpos, E., Heusschen, R., Ocio, E., Delforge, M., Sezer, O., Beksac, M., Ludwig, H., Merlini, G., Moreau, P., Zweegman, S., Engelhardt, M., & Rosiñol, L. (2018). Diagnosis, treatment, and response assessment in solitary plasmacytoma: updated recommendations from a European Expert Panel. Journal of hematology & oncology, 11(1), 10. https://doi.org/10.1186/s13045-017-0549-1

Cavo M. et al. (2017). Role of 18F-FDG PET/CT in the diagnosis and management of multiple myeloma and other plasma cell disorders: a consensus statement by the International Myeloma Working Group. Lancet Oncol. 2017 Apr;18(4):e206-e217. doi: 10.1016/S1470-2045(17)30189-4.

NCCN Myeloma 2020

Sundaram, S., Driscoll, J., Fernandez-Ulloa, M., de Lima, M., & Malek, E. (2018). FDG PET imaging in multiple myeloma: implications for response assessments in clinical trials. American journal of nuclear medicine and molecular imaging, 8(6), 421427.