Comparison of Whole-Body DWI and 18F-FDG PET/CT for Detecting Intramedullary and Extramedullary Lesions in Multiple Myeloma

18F-FDG PET/CT Imaging of Cutaneous and Intramuscular Multiple Myeloma

ABSTRACT

Cutaneous manifestations of multiple myeloma are rare but, as with other extramedullary manifestations, carry a worse prognosis. We present the case of a 65-year-old man with immunoglobulin G κ multiple myeloma and prior autologous stem cell transplant. On subsequent therapy, he presented with multiple new cutaneous and subcutaneous left hip masses. Biopsy of these lesions revealed plasma cell neoplasm with anaplastic morphology, confirming progression of disease. He subsequently underwent radiation to these lesions with plans for chimeric antigen receptor T-cell therapy due to refractory disease.

FDG PET/CT in Cutaneous Involvement of Plasmablastic Plasma Cell Myeloma

ABSTRACT

Extraosseous manifestations are found in less than 5% of patients with multiple myeloma. They can arise in any tissue, and their presence has been associated with more aggressive disease. We present FDG PET/CT findings of immunoglobulin A κ multiple myeloma with innumerable hypermetabolic right lower extremity lesions of cutaneous and subcutaneous involvement of plasmablastic plasma cell myeloma in a 44-year-old man.

Role of Imaging in Multiple Myeloma: A Potential Opportunity for Quantitative Imaging and Radiomics?

Multiple myeloma (MM) is the second most prevalent hematologic malignancy, particularly affecting the elderly. The disease often begins with a premalignant phase known as monoclonal gammopathy of undetermined significance (MGUS), solitary plasmacytoma (SP) and smoldering multiple myeloma (SMM). Multiple imaging modalities are employed throughout the disease continuum to assess bone lesions, prevent complications, detect intra- and extramedullary disease, and evaluate the risk of neurological complications. The implementation of advanced imaging analysis techniques, including artificial intelligence (AI) and radiomics, holds great promise for enhancing our understanding of MM. The integration of advanced image analysis techniques which extract features from magnetic resonance imaging (MRI), computed tomography (CT), or positron emission tomography (PET) images has the potential to enhance the diagnostic accuracy for MM. This innovative approach may lead to the identification of imaging biomarkers that can predict disease prognosis and treatment outcomes. Further research and standardized evaluations are needed to define the role of radiomics in everyday clinical practice for patients with MM.

Symptomatic Myeloma: PET, Whole-Body MR Imaging with Diffusion-Weighted Imaging or Both

According to international guidelines, patients with suspected myeloma should primarily undergo low-dose whole-body computed tomography (CT) for diagnostic purposes. To optimize sensitivity and specificity and enable treatment response assessment, whole-body MR (WB-MR) imaging should include diffusion-weighted imaging with apparent diffusion coefficient maps and T1-weighted Dixon sequences with bone marrow Fat Fraction Quantification. At baseline WB-MR imaging shows greater sensitivity for the detecting focal lesions and diffuse bone marrow infiltration pattern than 18F-fluorodeoxyglucose PET-CT, which is considered of choice for evaluating response to treatment and minimal residual disease and imaging of extramedullary disease.

MRI-based Zero Echo Time and Black Bone Pseudo-CT Compared with Whole-Body CT to Detect Osteolytic Lesions in Multiple Myeloma

Background MRI is highly sensitive for assessing bone marrow involvement in multiple myeloma (MM) but does not enable detection of osteolysis. Purpose To assess the diagnostic accuracy, repeatability, and reproducibility of pseudo-CT MRI sequences (zero echo time [ZTE], gradient-echo black bone [BB]) in detecting osteolytic lesions in MM using whole-body CT as the reference standard. Materials and Methods In this prospective study, consecutive patients were enrolled in our academic hospital between June 2021 and December 2022. Inclusion criteria were newly diagnosed MM, monoclonal gammopathy of undetermined significance at high risk for MM, or suspicion of progressive MM. Participants underwent ZTE and BB sequences covering the lumbar spine, pelvis, and proximal femurs as part of 3-T whole-body MRI examinations, as well as clinically indicated fluorine 18 fluorodeoxyglucose PET/CT examination within 1 month that included optimized whole-body CT. Ten bone regions and two scores (categorical score = presence/absence of osteolytic lesion; semiquantitative score = osteolytic lesion count) were assessed by three radiologists (two experienced and one unfamiliar with pseudo-CT reading) on the ZTE, BB, and whole-body CT images. The accuracy, repeatability, and reproducibility of categorical scores (according to Gwet agreement coefficients AC1 and AC2) and differences in semiquantitative scores were assessed at the per-sequence, per-region, and per-patient levels. Results A total of 47 participants (mean age, 67 years ± 11 [SD]; 27 male) were included. In experienced readers, BB and ZTE had the same high accuracy (98%) in the per-patient analysis, while BB accuracy ranged 83%-100% and ZTE accuracy ranged 74%-94% in the per-region analysis. An increase of false-negative (FN) findings in the spine ranging from +17% up to +23%, according to the lumbar vertebra, was observed using ZTE (P < .013). Regardless of the region (except coxal bones), differences in the BB score minus the ZTE score were positively skewed (P < .021). Regardless of the sequence or region, repeatability was very good (AC1 ≥0.87 for all), while reproducibility was at least good (AC2 ≥0.63 for all). Conclusion Both MRI-based ZTE and BB pseudo-CT sequences of the lumbar spine, pelvis, and femurs demonstrated high diagnostic accuracy in detecting osteolytic lesions in MM. Compared with BB, the ZTE sequence yielded more FN findings in the spine. ClinicalTrials.gov Identifier: NCT05381077 Published under a CC BY 4.0 license. Supplemental material is available for this article.

Diffusion Weighted Imaging in Spine Tumors

Diffusion weighted imaging (DWI) has developed into a powerful tool for the evaluation of spine tumors, particularly for the assessment of vertebral marrow lesions and intramedullary tumors. Advances in magnetic resonance techniques have improved the quality of spine DWI and diffusion tensor imaging (DTI) in recent years, with increased reproducibility and utilization. DTI, with quantitative parameters such as fractional anisotropy and qualitative visual assessment of nerve fiber tracts, can play a valuable role in the evaluation and surgical planning of spinal cord tumors. These widely available techniques can be used to enhance the diagnostic evaluation of spinal tumors.

Diagnostic value of WB-DWI versus 18F-FDG PET/CT for the detection of multiple myeloma

Background

Whole-body diffusion-weighted imaging (WB-DWI) is commonly used for the detection of multiple myeloma (MM). Comparative data on the efficiency of WB-DWI compared with F-18 fluoro-2-deoxy-d-glucose positron emission tomography-computed tomography (18F-FDG PET/CT) to detect MM is limited.

Methods

This was a retrospective, single-center study of 22 patients with MM enrolled from January 2018 to December 2019. All patients underwent WB-DWI and 18F-FDG PET/CT. Pathological and clinical manifestations, as well as radiologic follow-up, were used for diagnosis. The overall accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of both methods were compared. The apparent diffusion coefficient (ADC) values of MM lesions and false-positive lesions were estimated.

Results

A total of 214 MM bone lesions were evaluated. There was no significant difference in the accuracy of WB-DWI and PET/CT (86.92 versus 88.32%). Though WB-DWI had a higher sensitivity (99.26% versus84.56%) and PET-CT had a higher specificity (96.10% versus 64.56%), these differences were not statistically significant. There was a statistically significant difference in PPV (83.33% versus 96.64%) and NPV (98.08% versus 77.89%) of WB-DWI and PET/CT, respectively. The ADC value for MM lesions was significantly lower than that for false-positive lesions (P < 0.001). Receiver operating curve analysis showed that the AUC was 0.846, and when the cut-off value was 0.745 × 10-3 mm2/s, the sensitivity and specificity were 86.3 and 83.4%, respectively, which distinguished MM lesions from non-MM lesions.

Conclusion

WB-DWI and PET-CT scans have similar overall accuracy for detecting MM lesions. The higher PPV of PET-CT and NPV of WB-DWI make them complementary imaging modalities. The ADC value for MM lesions is significantly lower than that for false-positive lesions. An ADC cutoff value of 0.745 × 10-3 mm2/s results in sensitivity and specificity of 86.3 and 83.4%, respectively.

Clinical Value of FDG-PET/CT in Multiple Myeloma: An Update

FDG-PET/CT is a standardized imaging technique that has reached a great importance in the management of patients affected by Multiple Myeloma. It is proved, in fact, that it allows a deep evaluation of therapy efficacy and provides several prognostic indexes both at staging and after therapy. For this reason, it is now recognised as a gold standard for therapy assessment. Beside this, in reacent years FDG-PET/CT contribution to the understanding of Multiple Myeloma has progressively grown. Papers have been published analyzing the prognostic value of active disease volume measurement and standardization issues, the meaning of FDG positive paramedullary and extrameduallary disease, the prognostic impact of FDG positive minimal residual disease, the relation between focal lesions and clonal eterogenity of this disease and the comparison with whole body DWI-MR in terms of detection and therapy assessment. These newer aspects not of clinical impact yet, of FDG-PET/CT in Multiple Myeloma will be presented and discussed in this review.

Whole body imaging in musculoskeletal oncology: when, why, and how

The use of whole-body imaging has become increasingly popular in oncology due to the possibility of evaluating total tumor burden with a single imaging study. This is particularly helpful in cases of widespread disease where dedicated regional imaging would make the evaluation more expensive, time consuming, and prone to more risks. Different techniques can be used, including whole-body MRI, whole-body CT, and PET-CT. Common indications include surveillance of cancer predisposing syndromes, evaluation of osseous metastases and clonal plasma cell disorders such as multiple myeloma, and evaluation of soft tissue lesions, including peripheral nerve sheath tumors. This review focuses on advanced whole-body imaging techniques and their main uses in musculoskeletal oncology.

Advanced Imaging in Multiple Myeloma: New Frontiers for MRI

Plasma cell dyscrasias are estimated to newly affect almost 40,000 people in 2022. They fall on a spectrum of diseases ranging from relatively benign to malignant, the malignant end of the spectrum being multiple myeloma (MM). The International Myeloma Working Group (IMWG) has traditionally outlined the diagnostic criteria and therapeutic management of MM. In the last two decades, novel imaging techniques have been employed for MM to provide more information that can guide not only diagnosis and staging, but also treatment efficacy. These imaging techniques, due to their low invasiveness and high reliability, have gained significant clinical attention and have already changed the clinical practice. The development of functional MRI sequences such as diffusion weighted imaging (DWI) or intravoxel incoherent motion (IVIM) has made the functional assessment of lesions feasible. Moreover, the growing availability of positron emission tomography (PET)–magnetic resonance imaging (MRI) scanners is leading to the potential combination of sensitive anatomical and functional information in a single step. This paper provides an organized framework for evaluating the benefits and challenges of novel and more functional imaging techniques used for the management of patients with plasma cell dyscrasias, notably MM.

Minimal Residual Disease Assessment in Multiple Myeloma Patients: Minimal Disease With Maximal Implications

Multiple Myeloma (MM), the second most common hematologic malignancy, has been the target of many therapeutic advances over the past two decades. The introduction of novel agents, such as proteasome inhibitors, immunomodulatory drugs, and monoclonal antibodies, along with autologous hematopoietic stem cell transplantation (ASCT) in the current standard of care, has increased the median survival of myeloma patients significantly. Nevertheless, a curative treatment option continues to elude us, and MM remains an incurable disease, with patients relapsing even after achieving deep conventionally defined responses, underscoring the need for the development of sensitive methods that will allow for proper identification and management of the patients with a higher probability of relapse. Accurate detection of Minimal Residual Disease (MRD) from a bone marrow biopsy represents a relatively new approach of evaluating response to treatment with data showing clear benefit from obtaining MRD(-) status at any point of the disease course. As life expectancy for patients with MM continues to increase and deep responses are starting to become the norm, establishing and refining the role of MRD in the disease course is more relevant than ever. This review examines the different methods used to detect MRD and discusses future considerations regarding the implementation in day-to-day clinical practice and as a prospective primary endpoint for clinical trials.

Imaging of treatment response and minimal residual disease in multiple myeloma: state of the art WB-MRI and PET/CT

Bone imaging has been intimately associated with the diagnosis and staging of multiple myeloma (MM) for more than 5 decades, as the presence of bone lesions indicates advanced disease and dictates treatment initiation. The methods used have been evolving, and the historical radiographic skeletal survey has been replaced by whole body CT, whole body MRI (WB-MRI) and [¹⁸F]FDG-PET/CT for the detection of bone marrow lesions and less frequent extramedullary plasmacytomas.Beyond diagnosis, imaging methods are expected to provide the clinician with evaluation of the response to treatment. Imaging techniques are consistently challenged as treatments become more and more efficient, inducing profound response, with more subtle residual disease. WB-MRI and FDG-PET/CT are the methods of choice to address these challenges, being able to assess disease progression or response and to detect "minimal" residual disease, providing key prognostic information and guiding necessary change of treatment.This paper provides an up-to-date overview of the WB-MRI and PET/CT techniques, their observations in responsive and progressive disease and their role and limitations in capturing minimal residual disease. It reviews trials assessing these techniques for response evaluation, points out the limited comparisons between both methods and highlights their complementarity with most recent molecular methods (next-generation flow cytometry, next-generation sequencing) to detect minimal residual disease. It underlines the important role of PET/MRI technology as a research tool to compare the effectiveness and complementarity of both methods to address the key clinical questions.

Review of diffusion-weighted imaging and dynamic contrast-enhanced MRI for multiple myeloma and its precursors (monoclonal gammopathy of undetermined significance and smouldering myeloma)

The last decades, increasing research has been conducted on dynamic contrast-enhanced and diffusion-weighted MRI techniques in multiple myeloma and its precursors. Apart from anatomical sequences which are prone to interpretation errors due to anatomical variants, other pathologies and subjective evaluation of signal intensities, dynamic contrast-enhanced and diffusion-weighted MRI provide additional information on microenvironmental changes in bone marrow and are helpful in the diagnosis, staging and follow-up of plasma cell dyscrasias. Diffusion-weighted imaging provides information on diffusion (restriction) of water molecules in bone marrow and in malignant infiltration. Qualitative evaluation by visually assessing images with different diffusion sensitising gradients and quantitative evaluation of the apparent diffusion coefficient are studied extensively. Dynamic contrast-enhanced imaging provides information on bone marrow vascularisation, perfusion, capillary resistance, vascular permeability and interstitial space, which are systematically altered in different disease stages and can be evaluated in a qualitative and a (semi-)quantitative manner. Both diffusion restriction and abnormal dynamic contrast-enhanced MRI parameters are early biomarkers of malignancy or disease progression in focal lesions or in regions with diffuse abnormal signal intensities. The added value for both techniques lies in better detection and/or characterisation of abnormal bone marrow otherwise missed or misdiagnosed on anatomical MRI sequences. Increased detection rates of focal lesions or diffuse bone marrow infiltration upstage patients to higher disease stages, provide earlier access to therapy and slower disease progression and allow closer monitoring of high-risk patients. Despite promising results, variations in imaging protocols, scanner types and post-processing methods are large, thus hampering universal applicability and reproducibility of quantitative imaging parameters. The myeloma response assessment and diagnosis system and the international myeloma working group provide a systematic multicentre approach on imaging and propose which parameters to use in multiple myeloma and its precursors in an attempt to overcome the pitfalls of dynamic contrast-enhanced and diffusion-weighted imaging.Single sentence summary statementDiffusion-weighted imaging and dynamic contrast-enhanced MRI provide important additional information to standard anatomical MRI techniques for diagnosis, staging and follow-up of patients with plasma cell dyscrasias, although some precautions should be taken on standardisation of imaging protocols to improve reproducibility and application in multiple centres.

Role of FDG PET in the staging of multiple myeloma

¹⁸F-Fluorodeoxyglucose (FDG) PET has been used for staging of hematologic malignancies for years. In multiple myeloma, this imaging modality can be used in many different scenarios, including initial staging, evaluation of treatment response, and investigation of residual disease or early relapse. FDG PET-CT has excellent diagnostic performance, similar to other advanced imaging modalities such as whole-body CT and MRI, and it is particularly helpful for the assessment of extramedullary disease. It also offers important prognostic information on survival and risk of relapse, both at baseline and after therapy. This review will cover the main applications, advantages, and limitations of FDG PET-CT in multiple myeloma and related clonal plasma cell proliferative disorders, such as smoldering multiple myeloma and plasmacytoma.

Metabolic Volume Measurements in Multiple Myeloma

Multiple myeloma (MM) accounts for 10-15% of all hematologic malignancies, as well as 20% of deaths related to hematologic malignant tumors, predominantly affecting bone and bone marrow. Positron emission tomography/computed tomography with 18F-fluorodeoxyglucose (FDG-PET/CT) is an important method to assess the tumor burden of these patients. It is often challenging to classify the extent of disease involvement in the PET scans for many of these patients because both focal and diffuse bone lesions may coexist, with varying degrees of FDG uptake. Different metrics involving volumetric parameters and texture features have been proposed to objectively assess these images. Here, we review some metabolic parameters that can be extracted from FDG-PET/CT images of MM patients, including technical aspects and predicting MM outcome impact. Metabolic tumor volume (MTV) and total lesion glycolysis (TLG) are volumetric parameters known to be independent predictors of MM outcome. However, they have not been adopted in clinical practice due to the lack of measuring standards. CT-based segmentation allows automated, and therefore reproducible, calculation of bone metabolic metrics in patients with MM, such as maximum, mean and standard deviation of the standardized uptake values (SUV) for the entire skeleton. Intensity of bone involvement (IBI) is a new parameter that also takes advantage of this approach with promising results. Other indirect parameters obtained from FDG-PET/CT images, such as visceral adipose tissue glucose uptake and subcutaneous adipose tissue radiodensity, may also be useful to evaluate the prognosis of MM patients. Furthermore, the use and quantification of new radiotracers can address different metabolic aspects of MM and may have important prognostic implications.

Research progress on treatment of extramedullary multiple myeloma

ABSTRACTObjectives: Extramedullary multiple myeloma (EMM) is a relatively less frequent subentity of multiple myeloma (MM) and is generally considered to be a poor prognostic factor. Novel agents and hematopoietic stem cell transplantation (HSCT) have led to a significant improvement in the progression-free survival and overall survival of patients with MM, but outcomes of EMM remain dismal. Little is known regarding the role of novel therapies in this setting. This review summarizes the current available data regarding the roles of proteasome inhibitors, immunomodulators, monoclonal antibodies, chimeric antigen receptor (CAR)-T cell therapy and HSCT in EMM.Methods: A systematic literature review through PubMed was conducted to summarize the published evidence on the therapeutic developments of novel agents and HSCT in EMM. Literature sources published in English were searched, using the terms multiple myeloma, extramedullary and treatment.Results: Long-term outcomes of EMM patients remain dismal despite the utilization of novel agents and HSCT. The standard therapy of EMM has not been established. EMM should be managed as high-risk disease and treated accordingly.Discussion and conclusion: This review will provide an insight on the current and emerging treatment strategies as well as their efficacy in EMM. Further subgroup analyses in large prospective trials focusing on EMM is needed to help optimize the therapy.

Application Value of Mathematical Models of Diffusion-Weighted Magnetic Resonance Imaging in Differentiating Breast Cancer Lesions

Objective

To determine the application value of the mono-exponential model, dual-exponential model, and stretched-exponential model of MRI with diffusion-weighted imaging (DWI) in breast cancer (BC) lesions.

Methods

Totally 64 cases with BC admitted to our hospital between June 2019 and October 2020 were enrolled in this study. They had 71 lesions in total, including 40 benign tumor lesions (including 9 breast cyst lesions) and 31 malignant tumor lesions. After DWI examination, with normal glands as control, mono-exponential model (ADC) map, dual-exponential model (Standard-ADC) map, slow apparent diffusion coefficient (Slow-ADC) map, fast-apparent diffusion coefficient (Fast-ADC) map, and stretched-exponential model (DDC) map were processed, and corresponding values were generated. Then, the situation and significance of each parameter in breast cysts, benign breast tumor lesions, and malignant tumor lesions were analyzed.

Results

The values of ADC, Standard-ADC, and DDC of breast cysts were higher than those of normal glands (all P < 0.05), and the values of ADC and DDC of benign breast tumor lesions were lower than those of normal glands (P < 0.05). In addition, malignant breast tumor lesions had lower values of ADC, Standard-ADC, Slow-ADC, and DDC and a higher Fast-ADC value compared to normal glands (all P < 0.05). Compared with benign tumor lesions, malignant tumor lesions had lower values of ADC, Standard-ADC, Slow-ADC, and DDC and a higher value of Fast-ADC (all P < 0.05). Moreover, the receiver operating characteristic (ROC) curve-based analysis revealed that all the above models could be adopted to effectively evaluate the deterioration of benign breast tumor lesions (all P < 0.05), and DDC value had the most significant diagnostic effect on malignant tumor lesions (P < 0.05).

Conclusion

Both dual-exponential model and stretched-exponential model of DWI can help effectively evaluate the progression of benign breast tumors, and the stretched-exponential model is more effective in the diagnosis of malignant breast tumors. These models are of great help to the future clinical diagnosis of BC.

Prospective Evaluation of Whole-Body MRI versus FDG PET/CT for Lesion Detection in Participants with Myeloma

Purpose To compare disease detection of myeloma using contemporary whole-body (WB) MRI and fluorine 18 (18F) fluorodeoxyglucose (FDG) PET/CT protocols and to correlate imaging with laboratory estimates of disease burden, including molecular characteristics. Materials and Methods In this observational, prospective study, participants were recruited from November 2015 to March 2018 who had a diagnosis of myeloma, who were planned to undergo chemotherapy and autologous stem cell transplantation, and who underwent baseline WB-MRI and FDG PET/CT (ClinicalTrials.gov identifier NCT02403102). Baseline clinical data, including genetics, were collected. Paired methods were used to compare burden and patterns of disease. Results Sixty participants (mean age, 60 years ± 9 [standard deviation]; 35 men) underwent baseline WB-MRI and FDG PET/CT. WB-MRI showed significantly higher detection for focal lesions at all anatomic sites (except ribs, scapulae, and clavicles) and for diffuse disease at all sites. Two participants presented with two or more focal lesions smaller than 5 mm only at WB-MRI but not FDG PET/CT. Participants with diffuse disease at MRI had higher plasma cell infiltration (percentage of nucleated cells: median, 60% [interquartile range {IQR}, 50%-61%] vs 15% [IQR, 4%-50%]; P = .03) and paraprotein levels (median, 32.0 g/L [IQR, 24.0-48.0 g/L] vs 20.0 g/L [IQR, 12.0-22.6 g/L]; P = .02) compared with those without diffuse disease. All genetically high-risk tumors showed diffuse infiltration at WB-MRI. Conclusion WB-MRI helped detect a higher number of myeloma lesions than FDG PET/CT, and diffuse disease detected at WB-MRI correlated with laboratory measures of disease burden and molecular markers of risk. Keywords: MR-Imaging, Skeletal-Appendicular, Skeletal-Axial, Bone Marrow, Hematologic Diseases, Oncology Clinical trial registration no. NCT02403102. Supplemental material is available for this article. © RSNA, 2021.

Clinical Applications of PET/MR Imaging

PET/MR imaging is in routine clinical use and is at least as effective as PET/CT for oncologic and neurologic studies with advantages with certain PET radiopharmaceuticals and applications. In addition, whole body PET/MR imaging substantially reduces radiation dosages compared with PET/CT which is particularly relevant to pediatric and young adult population. For cancer imaging, assessment of hepatic, pelvic, and soft-tissue malignancies may benefit from PET/MR imaging. For neurologic imaging, volumetric brain MR imaging can detect regional volume loss relevant to cognitive impairment and epilepsy. In addition, the single-bed position acquisition enables dynamic brain PET imaging without extending the total study length which has the potential to enhance the diagnostic information from PET.

Prognostic impact of posttransplant FDG PET/CT scan in multiple myeloma

Multiple myeloma (MM) is a heterogeneous disease that may be evaluated by a broad array of imaging and laboratory techniques to measure disease activity and predict prognosis. Fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) scanning has been shown to be predictive of patient outcomes throughout the disease course. We sought to corroborate these findings by examining the prognostic impact of PET/CT scanning in the posttransplant setting. We retrospectively analyzed PET/CT scans in 229 MM patients receiving an autologous stem cell transplant (ASCT) near day 100, and correlated these findings with time to progression(TTP) and overall survival (OS) to assess the impact of day 100 PET/CT scan findings as an independent prognostic factor. The median OS for the entire cohort was 61.5 months (95% confidence interval [CI], 49-75) and the median TTP was 18.5 months (95% CI, 15.4-21.8). Among patients with abnormal day 100 PET findings (PET+), median TTP was 12.4 months vs 24 months among those with normal PET findings (PET-) (P < .0001). The median OS in the PET+ group was 46 months compared with 99 months in the PET- group (P < .0001). We conclude that an abnormal PET/CT scan near day 100 post-ASCT is predictive of shorter TTP and OS, with prognostic significance retained after adjusting for disease response and other prognostic variables in MM.

Comparison of the diagnostic performance and impact on management of 18F-FDG PET/CT and whole-body MRI in multiple myeloma

PURPOSE

Comparative data on the impact of imaging on management is lacking for multiple myeloma. This study compared the diagnostic performance and impact on management of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) and whole-body magnetic resonance imaging (WBMRI) in treatment-naive myeloma.

METHODS

Forty-six patients undergoing 18F-FDG PET/CT and WBMRI were reviewed by a nuclear medicine physician and radiologist, respectively, for the presence of myeloma bone disease. Blinded clinical and imaging data were reviewed by two haematologists in consensus and management recorded following clinical data ± 18F-FDG PET/CT or WBMRI. Bone disease was defined using International Myeloma Working Group (IMWG) criteria and a clinical reference standard. Per-patient sensitivity for lesion detection was established. McNemar test compared management based on clinical assessment ± 18F-FDG PET/CT or WBMRI.

RESULTS

Sensitivity for bone lesions was 69.6% (32/46) for 18F-FDG PET/CT (54.3% (25/46) for PET component alone) and 91.3% (42/46) for WBMRI. 27/46 (58.7%) of cases were concordant. In 19/46 patients (41.3%) WBMRI detected more focal bone lesions than 18F-FDG PET/CT. Based on clinical data alone, 32/46 (69.6%) patients would have been treated. Addition of 18F-FDG PET/CT to clinical data increased this to 40/46 (87.0%) patients (p = 0.02); and WBMRI to clinical data to 43/46 (93.5%) patients (p = 0.002). The difference in treatment decisions was not statistically significant between 18F-FDG PET/CT and WBMRI (p = 0.08).

CONCLUSION

Compared to 18F-FDG PET/CT, WBMRI had a higher per patient sensitivity for bone disease. However, treatment decisions were not statistically different and either modality would be appropriate in initial staging, depending on local availability and expertise.

Correlations between apparent diffusion coefficient values of WB-DWI and clinical parameters in multiple myeloma

Background

Whole-body diffusion-weighted imaging (WB-DWI) is a method for evaluating bone marrow infiltration in multiple myeloma (MM). This study seeks to elucidate the correlation between the apparent diffusion coefficient (ADC) value and some selected clinical parameters.

Methods

A total of 101 Chinese patients with MM who had undergone WB-DWI from May 2017 to May 2019 were enrolled in this study. The ADC values of the MM lesions and the clinical parameters were quantified at the first (baseline) visit and after four-course induction chemotherapy. Multiple linear regression and logistic analyses were carried out to find the implicit inherent relationships within the patients’ data.

Results

The paired Wilcoxon test showed that the ADC values at the baseline visit (ADC₀) were significantly lower than the values after four-course induction chemotherapy (ADC_{4 c}) (p < 0.001), including different therapeutic responses. The Revised International Staging System (RISS) stage, type of MM, and β2-microglobulin (β2-MG) were predictors of clinically significant increases or decreases in the ADC values (p < 0.05). Multiple linear regression showed that the ADC₀ was negatively associated with β2-MG (p < 0.001) and immunoglobulin heavy chain gene rearrangement (p = 0.012), while the RISS Stage III (p = 0.001), type IgG λ (p = 0.005), and albumin were negatively associated with ADC_{4 c} (p = 0.010). The impacts of the therapeutic response were associated with ADC₀ and immunoglobulin heavy chain gene rearrangement (p < 0.001).

Conclusion

The ADC values of WB-DWI may be associated with clinical parameters of MM including the fluorescence in situ hybridization result, and may be useful in the prognosis of patients with MM.

Trial Registration: ChiCTR2000029587

Updates and Ongoing Challenges in Imaging of Multiple Myeloma: AJR Expert Panel Narrative Review

Advances in the understanding and treatment of multiple myeloma have led to the need for more sensitive and accurate imaging of intramedullary and extramedullary disease. This role of imaging is underscored by recently revised imaging recommendations of the International Myeloma Working Group (IMWG). This narrative review discusses these recommendations from the IMWG for different disease stages, focusing on advanced whole-body modalities, and addresses related challenges and controversies. In the recommendations, whole-body low-dose CT is central in initial patient assessment, replacing the conventional skeletal survey. Although the recommendations favor MRI for diagnosis because of its superior sensitivity and utility in identifying myeloma-defining events, FDG PET/CT is recommended as the modality of choice for assessing treatment response. Consensus opinions are offered regarding the role of imaging in multiple myeloma for characterization of disease distribution, determination of prognosis, and response evaluation.

Comparison of [18F]FDG PET/CT and MRI for Treatment Response Assessment in Multiple Myeloma: A Meta-Analysis

The present study was designed to assess the additional value of 2-deoxy-2[¹⁸F]fluoro-D-glucose ([¹⁸F]FDG) positron emission tomography/computed tomography (PET/CT) to magnetic resonance imaging (MRI) in the treatment response assessment of multiple myeloma (MM). We performed a meta-analysis of all available studies to compare the detectability of treatment response of [¹⁸F]FDG PET/CT and MRI in treated MM. We defined detecting a good therapeutic effect as positive, and residual disease as negative. We determined the sensitivities and specificities across studies, calculated the positive and negative likelihood ratios (LR), and made summary receiver operating characteristic curves (SROC) using hierarchical regression models. The pooled analysis included six studies that comprised 278 patients. The respective performance characteristics (95% confidence interval (CI)) of [¹⁸F]FDG PET/CT and MRI were as follows: sensitivity of 80% (56% to 94%) and 25% (19% to 31%); specificity of 58% (44% to 71%) and 83% (71% to 91%); diagnostic odds ratio (DOR) of 6.0 (3.0-12.0) and 1.7 (0.7-2.7); positive LR of 1.8 (1.3-2.4) and 1.4 (0.7-2.7); and negative LR of 0.33 (0.21-0.53) and 0.81 (0.62-1.1). In the respective SROC curves, the area under the curve was 0.77 (SE, 0.038) and 0.59 (SE, 0.079) and the Q* index was 0.71 and 0.57. Compared with MRI, [¹⁸F]FDG PET/CT had higher sensitivity and better DOR and SROC curves. Compared with MRI, [¹⁸F]FDG PET/CT had greater ability to detect the treatment assessment of MM.

Whole-Body Functional MRI and PET/MRI in Multiple Myeloma

Simple Summary

Whole-body magnetic resonance imaging (MRI) is recognized as the most sensitive imaging technique for the detection of bone marrow infiltration, and was therefore, recently included in the new diagnostic myeloma criteria, as proposed by the International Myeloma Working Group. The use of diffusion-weighted MRI further improved the performances of whole-body MRI in the setting of multiple myeloma, and its systematic implementation in general clinical practice is now recommended. Whole-body, dynamic, contrast-enhanced MRI might provide further information on lesions vascularity and might help evaluate response to treatment. Hybrid PET/MRI might act as the optimal imaging modality, owing to the association of the best techniques for both detecting bone marrow involvement and evaluating treatment response, providing one-stop-shop imaging in a whole-body scale. This review provides an overview on the value of whole-body MRI, including diffusion-weighted and dynamic contrast-enhanced MRI and whole-body ¹⁸F-FDG PET/MRI in diagnosis, staging, and response evaluation in multiple myeloma.

Abstract

Bone disease is one of the major features of multiple myeloma (MM), and imaging has a pivotal role in both diagnosis and follow-up. Whole-body magnetic resonance imaging (MRI) is recognized as the gold standard for the detection of bone marrow involvement, owing to its high sensitivity. The use of functional MRI sequences further improved the performances of whole-body MRI in the setting of MM. Whole-body diffusion-weighted (DW) MRI is the most attractive functional technique and its systematic implementation in general clinical practice is now recommended by the International Myeloma Working Group. Whole-body dynamic contrast-enhanced (DCE) MRI might provide further information on lesions vascularity and help evaluate response to treatment. Whole Body PET/MRI is an emerging hybrid imaging technique that offers the opportunity to combine information on morphology, fat content of bone marrow, bone marrow cellularity and vascularization, and metabolic activity. Whole-body PET/MRI allows a one-stop-shop examination, including the most sensitive technique for detecting bone marrow involvement, and the most recognized technique for treatment response evaluation. This review aims at providing an overview on the value of whole-body MRI, including DW and DCE MRI, and combined whole-body ¹⁸F-FDG PET/MRI in diagnosis, staging, and response evaluation in patients with MM.

Prospective comparison of 18-FDG PET/CT and whole-body diffusion-weighted MRI in the assessment of multiple myeloma

Magnetic resonance imaging (MRI) and ¹⁸F-fluorodeoxyglucose positron emission tomography-computed tomography (¹⁸FDG 18F-FDG PET-CT) are standard procedures for staging multiple myeloma (MM). Diffusion-weighted sequences applied to whole-body MRI (WB-DWI) improve its sensitivity. We compared the number of MM bone focal lesions (FLs) detected by ¹⁸F-FDG PET-CT and WB-DWI and evaluated the diagnostic performance of ¹⁸F-FDG PET-CT for diffuse infiltration. Thirty newly diagnosed MM patients prospectively underwent 18F-FDG PET-CT and WB-DWI. The criteria for skeletal region positivity were ≥ 1 focal bone lesions (FLs) and/or diffuse disease. MRI with the MY-RADS criteria was used as a reference standard for the diagnosis of diffuse infiltration. ¹⁸F-FDG PET-CT and WB-DWI were both interpreted as positive in 28/30 patients with an agreement of 1.00 (95% CI 0.77-1.00) between the two methods. The mean numbers of FLs were 16.7 detected by ¹⁸F-FDG PET-CT and 23.9 detected by WB-DWI (P = 0.028). WB-DWI detected more FLs in the skull (P = 0.001) and spine (P = 0.006). Agreement assessed using the prevalence and bias-corrected kappa index was moderate (0.40-0.60) for the spine, sternum-ribs and upper limbs and substantial (0.60-0.80) for the pelvis and lower limbs. As regards the diagnosis of diffuse bone marrow infiltration, the sensitivity, specificity and accuracy of ¹⁸F-FDG PET-CT were 0.75, 0.79 and 0.77, respectively. Although WB-DWI detected more FLs than did ¹⁸F-FDG PET-CT, there was no difference in the detection of bone disease on a per-patient basis. ¹⁸F-FDG PET-CT showed high performance, including for evaluation of diffuse infiltration.

Mid-term response assessment in multiple myeloma using a texture analysis approach on dual energy-CT-derived bone marrow images - A proof of principle study

PURPOSE

To identify textural features on dual-energy CT (DECT)-generated virtual non calcium (VNC) bone marrow images in a small group of patients with multiple myeloma undergoing systemic treatment which could potentially help for mid-term response assessment.

METHODS

44 patients (59.1 ± 11.2 yr.) with multiple myeloma who underwent unenhanced whole-body reduced-dose DECT before and after systemic therapy were evaluated. All patients had current hematologic laboratory tests including serum levels of immunoglobulins, albumin, and total proteins. Using DECT post-processing, bone marrow images of the axial skeleton were reconstructed. The vertebral bodies T10-L5 were segmented for quantification of 1st order (n = 18) and 2nd order Gray Level Co-occurrence Matrix (GLCM) textural features (n = 23) based on an open-source radiomics library (Pyradiomics), which were then compared with the hematologic response category to treatment. Five patients underwent only active surveillance at intervals after previous successful therapy.

RESULTS

According to hematologic diagnosis, 29 patients were classified as complete response (CR), 10 as partial response (PR) and 5 as stable disease (SD). We observed a significant drop of the 1st order textural features "10th percentile" (p = 0.009), "median" (p = 0.01), and "minimum" (p < 0.0001) after treatment, whereas the 1st order feature "range" (p = 0.0004) and the 2nd order GLCM feature "difference variance" (p = 0.007) significantly increased in patients experiencing CR. A similar trend, however, without statistical significance, could be observed in patients achieving PR after treatment. 2nd order GLCM feature "difference variance" proved to be a significant discriminator (p = 0.01) between patients with CR and PR (sensitivity 0.93, specificity 0.70) for a cut-off value of -0.28. In patients classified CR, both the mean serum protein and the beta-2 microglobulin decreased after treatment, whereas the serum albumin increased (p < 0.01). The same trend without significance could be observed in patients classified PR.

CONCLUSIONS

Changes in textural features applied on VNC bone marrow images in the pre- and posttreatment settings correlate well with myeloma-specific hematologic parameters and provide complementary information for the assessment of the late effects of treatment on the bone marrow.

Role of imaging in multiple myeloma

With rapid advancements in the diagnosis and treatment of multiple myeloma (MM), imaging has become instrumental in detection of intramedullary and extramedullary disease, providing prognostic information, and assessing therapeutic efficacy. Whole-body low dose computed tomography (WBLDCT) has emerged as the study of choice to detect osteolytic bone disease. Positron emission tomography/computed tomography (PET/CT) combines functional and morphologic information to identify MM disease activity and assess treatment response. Magnetic resonance imaging (MRI) has excellent soft-tissue contrast and is the modality of choice for bone marrow evaluation. This review focuses on the imaging modalities available for MM patient management, highlighting advantages, disadvantages, and applications of each.

Role of whole-body MRI for treatment response assessment in multiple myeloma: comparison between clinical response and imaging response

BACKGROUND

Whole-body MRI (WB-MRI) including diffusion-weighted image (DWI) have been widely used in patients with multiple myeloma. However, evidence for the value of WB-MRI in the evaluation of treatment response remains sparse. Therefore, we evaluated the role of WB-MRI in the response assessment.

METHODS

In our WB-MRI registry, we searched multiple myeloma patients treated with chemotherapy who underwent both baseline and follow-up WB-MRI scans. Clinical responses were categorized as complete response (CR), partial response (PR), stable disease (SD), or progressive disease (PD), using IMWG criteria. Using RECIST 1.1, MD Anderson (MDA) criteria, and MDA-DWI criteria, imaging responses on WB-MRI were rated as CR, PR, SD, or PD by two radiologists independently. Then, discrepancy cases were resolved by consensus. Weighted Kappa analysis was performed to evaluate agreement between the imaging and clinical responses. The diagnostic accuracy of image responses in the evaluation of clinical CR, objective response (CR and PR), and PD was calculated.

RESULTS

Forty-two eligible patients were included. There was moderate agreement between imaging and clinical responses (κ = 0.54 for RECIST 1.1, κ = 0.58 for MDA criteria, κ = 0.69 for MDA-DWI criteria). WB-MRI showed excellent diagnostic accuracy in assessment of clinical PD (sensitivity 88.9%, specificity 94.7%, positive predictive value [PPV] 84.2%, negative predictive value [NPV] 96.4% in all three imaging criteria). By contrast, WB-MRI showed low accuracy in assessment of clinical CR (sensitivity 4.5%, specificity 98.1%, PPV 50.0%, NPV 71.2% in all three imaging criteria). As to the clinical objective response, the diagnostic accuracy was higher in MDA-DWI criteria than RECIST 1.1 and MDA criteria (sensitivity/specificity/PPV/NPV, 84.2%/94.4%/98.0%/65.4, 54.4%/100%/100%/40.9, and 61.4%/94.4%/97.2%/43.6%, respectively).

CONCLUSIONS

In the imaging response assessment of multiple myeloma, WB-MRI showed excellent performance in the evaluation of PD, but not in the assessment of CR or objective response. When adding DWI to imaging response criteria, diagnostic accuracy for objective response was improved and agreement between imaging and clinical responses was increased.

Imaging Features of Multiple Myeloma Extramedullary Lesions in the Liver with 18F-FDG PET/CT, Contrast-Enhanced CT and MRI

Ηepatic involvement in multiple myeloma is not common; nevertheless, it is associated with poorer outcome. Heterogeneous features have been described in few published reports so far. We present the imaging findings of PET/CT in comparison to those of MRI for two multiple myeloma (MM) patients, one with a liver lesion suspicious for myeloma metastasis on PET and one with multiple liver lesions suspicious for myeloma metastases on MRΙ. The subsequent ultrasound-guided needle biopsies confirmed the extramedullary spread of the disease in both patients. The first case exhibited a match in both functional imaging modalities (PET and MRI) but a mismatch of intense metabolic activity on ¹⁸F-fluorodeoxyglucose (18F-FDG) PET/CT and iso-attenuating liver parenchyma on contrast-enhanced CT. The second case showed a mismatch of signal elevation persistence on diffusion-weighted imaging (DWI) and physiologic 18F-FDG distribution in the liver parenchyma. These cases present different imaging features in MM lesions of the liver using PET/CT and MRI, reflecting the high disease heterogeneity in patients with MM and demonstrating that the use of both PET/CT and MRI may offer complementary information.