As part of a virtual Case Based Peer Perspective event, Jesus G. Berdeja, MC, director of Myeloma Research, Sarah Cannon Research Institute, in Nashville, Tennesee, discussed the treatment options for stage II multilple myeloma, based on a case of a 71-year female patient.
Targeted Oncology™: Is this patient experiencing a biochemical or clinical relapse?
BERDEJA: This patient is not just having a biochemical relapse. I think we all see patients who we’re following on maintenance, and all of a sudden, their M protein is rising. The light chains are rising, but there are no symptoms or no other findings that warn you that disease is clinically progressing. In this patient’s case, she has become anemic, and she’s fatigued. Clearly this is not just a biochemical relapse. This is a clinical relapse. That’s definitely a reason to start treatment and not delay.
Would you recommend imaging for this patient to confirm relapse?
In terms of imaging, the guidelines are not perfect. Traditionally, we have been doing skeletal surveys, and the truth is, skeletal surveys are terrible. It takes about 40% bone destruction before you see it on x-rays. Most of the patients will be symptomatic before you pick it up on x-ray. We’ve been moving away from that. There’s a lot of literature, especially coming from Europe, that suggests that a low-dose CT scan is preferable [to an x-ray] and is relatively cost-efficient. It’s quick, and you can see the whole skeleton quickly. It provides a significant improvement in sensitivity over a skeletal survey. If we were in Europe right now, you would order a whole body low-dose CT.
In the United States, radiologists have not figured out how to perform a low-dose CT by itself and get reimbursed for it, so we cannot order a low-dose CT. The next best thing is the PET/ CT [scan]. The CT part of the PET is the low-dose CT. It’s important that you get a whole body PET/CT, not just standard PET. You want the radiologist to read the CT portion and give you the skeletal findings.
The PET portion adds more than just the low-dose CT. Lesions will show up , and then you can follow the patient, because the PET portion of a PET/CT can be used follow response.
In general, for a patient [who needs] a new baseline to assess for new disease, I would say I would do a PET/CT. If your PET/ CT shows something of concern or is equivocal, [if it] shows a particular area where the patient’s hurting or is having obviously cord compression or something to that effect, when you need to visualize the bone and the soft tissues around it, the MRI is much more sensitive than the PET/CT. That’s when I would use an MRI instead of a PET/CT.