Whole-Body 18F-FDG PET Identifies High-Risk Myeloma

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FIGURE 1.
Patient with IgA λ-chain myeloma, stage IIIA. Radiographs revealed multiple lytic lesions in areas that showed positive findings on ¹⁸F-FDG PET imaging (e.g., spine, pelvis, and hips). Plasmacytoma in left lung was confirmed on biopsy. Plasmacytomas were noted in left apex and hilar regions on CT scanning. Splenic myeloma was also suspected but not directly confirmed.
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FIGURE 2.
Patient with Bence Jones protein λ-chain myeloma. Extensive disease is seen in spine, and plasmacytomas are seen in right lower lung and left upper abdomen.
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FIGURE 3.
Patient with relapse after stem cell transplantation. Dysphagia developed and was associated with positive finding in distal esophagus. Direct biopsy showed plasma cells with local amyloid deposition. This responded well to local irradiation.

TABLE 2

Whole-Body ¹⁸F-FDG PET Scan Results

Disease status	Result of baseline study	Result of follow-up study
MGUS	14/14 (100%) negative; followed 3–43+ mo	In 1/14 (7%), myeloma developed at 8 mo; in 1 patient, focal plasmacytoma with amyloid developed*
Active myeloma	16/16 (100%) positive; 4/16 (25%) had negative radiography results but multiple focal lesions on scan	In 1 patient, disease was upstaged from stage I to III: Multiple new disease sites were identified
	4/16 (25%) had extramedullary disease	Poor outcome with extramedullary disease
Remission	In 6/10 (60%), new lesions developed over 6–42+ mo	Local irradiation used for focal relapse; nonsecretory relapse detected and treated
Relapse	21/26 (81%) had new sites of disease	Anatomic distribution of lesions documented
	6/26 (23%) had extramedullary disease	Very poor survival with extramedullary disease: median, 7 mo

TABLE 3

Potential Role for ¹⁸F-FDG PET Scan Evaluation Based on Current Data

Suspected disease status	Clinical question	Potential role of ¹⁸F-FDG PET
MGUS*	How likely is progression?	If ¹⁸F-FDG PET results are negative, stable MGUS is likely
Active myeloma*	Is disease smoldering or active?	If ¹⁸F-FDG PET results are positive, active disease is likely, even if radiography results are negative
	What is prognosis?	Extramedullary disease indicates poor prognosis
Remission	Is there true complete remission?	Positive scan findings after transplantation indicate persistent disease or relapse and poorer outcome
	Is there new disease?	New focal disease (especially nonsecretory) can be documented and treated
Relapse	Is there unsuspected new disease?	Can detect clinically important disease requiring unanticipated therapy (e.g., ureteral obstruction)
	What is baseline restaging at relapse?	Can establish baseline for ongoing monitoring in clinical trials

↵* Working definitions for MGUS vs. active myeloma are currently under review by International Prognostic Index Study Group. It is possible that ¹⁸F-FDG PET scanning can contribute to diagnostic or discriminatory criteria.