Recommendation grades (A-C) and levels of evidence (Ia-IV) are defined at the end of the "Major Recommendations" field.
Minimising Radiation Exposure
- Robust systems should be in place for timely reporting and secure storage of X-ray films in order to avoid repeating investigations that have already been done.
- Accurate clinical information should be provided to the Radiology Department when the imaging request is made to ensure that the right imaging technique is performed at the right time, specifying whether the request pertains to a diagnostic work up or investigation of new symptoms in a patient who is known to have myeloma, including details of prior therapy.
Use of Imaging at Diagnosis
Skeletal Survey
- As part of the staging procedure of newly diagnosed myeloma, the skeletal survey should include a posteroanterior (PA) view of the chest, antero-posterior (AP) and lateral views of the cervical spine (including an open mouth view), thoracic spine, lumbar spine, humeri and femora, AP and lateral views of the skull and AP view of the pelvis. In addition, any symptomatic areas should be specifically visualised with appropriate views (Grade C recommendation; level IV evidence).
Magnetic Resonance (MR) Imaging
- Urgent MR imaging is the diagnostic procedure of choice to assess suspected cord compression in myeloma patients even in the absence of vertebral collapse (Grade B recommendation; level IIB evidence).
- MR imaging of the whole spine should be performed in addition to the skeletal survey as part of staging in all patients with an apparently solitary plasmacytoma of bone irrespective of site of index lesion (Grade B recommendation; level IIB evidence).
- MR imaging should be used to clarify the significance of ambiguous computed tomography (CT) findings, as these two imaging techniques can give complementary information (Grade C recommendation; level IV evidence).
Computed Tomography
- Urgent CT may be used to establish the presence of suspected cord compression in cases where MR imaging is unavailable, impossible due to patient intolerance or contraindicated (e.g. intraorbital metallic foreign bodies or cardiac pacemakers) (Grade B recommendation; level III evidence).
- CT of the spine may be considered to clarify the presence or absence of bone destruction in cases of clinical concern where MR is negative (Grade B recommendation; level III evidence).
- CT should be used to clarify the significance of ambiguous plain radiographic findings, such as equivocal lytic lesions, especially in parts of the skeleton that are difficult to visualise on plain radiographs, such as ribs, sternum and scapulae (Grade B recommendation; level III evidence).
- CT may identify lesions that are negative on plain radiography, and should be considered in patients who remain symptomatic despite having no evidence of osteolysis on the skeletal survey (Grade B recommendation; level III evidence).
- CT is indicated to delineate the nature and extent of soft tissue disease, and where appropriate, tissue biopsy may be guided by CT scanning (Grade B recommendation; level IIB evidence).
Bone Scintigraphy
- Bone scintigraphy has no place in the routine staging of myeloma.
Dual Energy X-Ray Absorptiometry (DEXA) Scanning
- Routine assessment of bone mineral density cannot be recommended, owing to the methodological difficulties of the technique and the universal use of bisphosphonates in all symptomatic myeloma patients.
Positron Emission Tomography (PET) and 99Technitium Sestamibi (MIBI) Scanning
- Based on currently available evidence, neither PET nor MIBI imaging can be recommended for routine use in the management of myeloma patients.
- Either technique may be useful in selected cases that warrant clarification of previous imaging findings, but such an approach should ideally be made within the context of a clinical trial (Grade C recommendation; level IV evidence).
- The evidence for the sensitivity of PET scanning is most convincing in the setting of extramedullary disease. It is therefore reasonable to consider PET scanning in this setting, to clarify the extent of extramedullary disease, in cases where other imaging techniques have failed to clarify the situation (Grade B recommendation; level III evidence).
- If the decision to perform PET scanning has been taken, it is advisable to avoid undertaking the procedure within 4 weeks of chemotherapy or 3 months of radiotherapy (Grade B recommendation; level III evidence).
Serum Amyloid P (SAP) Component Scintigraphy
- A diagnostic SAP scan should be requested if possible in any patient suspected of having primary (AL) amyloidosis as a complication of their plasma cell dyscrasias in addition to obtaining tissue biopsy evidence whenever possible (Grade B recommendation; level IIB evidence).
- Follow up SAP scans should be performed every 6 to 12 months in accordance with specialist centre policy, to assess response to therapy or to monitor a patient with confirmed amyloidosis on a watchful waiting programme (Grade B recommendation; level IIB evidence).
Use of Imaging in the Management of Vertebral Collapse
- Urgent MR imaging is the diagnostic procedure of choice to assess suspected cord compression in myeloma patients with vertebral collapse (Grade B recommendation; level IIB evidence).
- Patients being considered for percutaneous vertebroplasty should undergo AP and lateral views of the cervical, thoracic and lumbar spine and CT or MR imaging of the target area to exclude spinal cord compression (Grade C recommendation; level IV evidence).
Assessment of Response to Therapy and Disease Relapse
Skeletal Survey
- There is insufficient evidence of benefit to recommend routine follow up skeletal surveys in untreated asymptomatic patients in the absence of signs of disease progression.
- In the event of clinical or laboratory evidence of disease progression in treated or untreated patients, the skeletal survey should be repeated as part of the restaging process. Any newly symptomatic areas of the skeleton should be specifically targeted. However, if disease progression occurs within 3 months of the previous skeletal survey, in the absence of new skeletal symptoms, a new skeletal survey is unlikely to provide additional information (Grade C recommendation; level IV evidence).
MR Imaging
- There is insufficient evidence to recommend routine MR imaging for the follow up of treated disease.
- In selected cases, where there are persisting unexplained symptoms, it is reasonable to discuss the potential usefulness of follow up MR imaging with the radiologist (Grade C recommendation; level IV evidence).
- MR imaging is the investigation of choice for suspected avascular necrosis of the femoral head (Grade B recommendation; level III evidence).
Computed Tomography
- Routine follow up CT scanning of treated disease cannot be recommended on current evidence and concern regarding radiation exposure.
- In selected cases, however, it is reasonable to use CT scanning in the monitoring of the response of soft tissue masses to therapy (Grade B recommendation; level III evidence).
- In selected cases, where there are persistent unexplained symptoms or there is concern about on-going fracture risk, or a lack of response to therapy, it is reasonable to discuss the potential usefulness of performing a CT scan in treated patients (Grade B recommendation; level III evidence).
PET and MIBI Scanning
- Neither PET nor MIBI scanning can be recommended on the basis of current evidence for use in routine follow up of treated myeloma patients.
- It would be reasonable to consider either technique for the follow up of selected patients, such as those with predominant extramedullary or non-secretory disease, but this would be best performed in the context of a clinical trial (Grade C recommendation; level IV evidence).
Definitions:
Levels of Evidence
Ia Evidence obtained from meta-analysis of randomised controlled trials
Ib Evidence obtained from at least one randomised controlled trial
IIa Evidence obtained from at least one well-designed, non-randomised study, including phase II trials and case-control studies
IIb Evidence obtained from at least one other type of well-designed, quasi-experimental study (i.e. studies without planned intervention including observational studies)
III Evidence obtained from well-designed, non-experimental descriptive studies. Evidence obtained from meta-analysis or randomised controlled trials or phase II studies which is published only in abstract form
IV Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities
Grades of Recommendations
Grade A, Evidence levels Ia and Ib Recommendation based on at least one randomised controlled trial of good quality and consistency addressing specific recommendation
Grade B, Evidence levels IIa, IIb, and III Recommendation based on well-conducted studies but no randomised controlled trials on the topic of recommendation
Grade C, Evidence level IV Evidence from expert committee reports and/or clinical experiences of respected authorities
