Imaging techniques like X-rays and early generation MRI were once used to determine the extent of bone damage in myeloma patients—damage done by myeloma cells after it occurred. Advances in imaging now can detect potential damage before it happens so that preventive measures can be taken. Moreover, the latest techniques can direct targeted therapy to be more effective, less toxic and determine more effective strategies for relapsed and refractory myeloma. Drs. Jens Hillengass and Ola Landgren discussed how myeloma imaging techniques are important tools and methods to therapy decisions in the Myeloma Crowd Round Table Interactive Webcast held on Saturday, September 12, 2020.
Jens Hillengass, MD, Roswell Park Comprehensive Cancer Center, Buffalo, NY: Myeloma Imaging
Ola Landgren, MD, PhD, Memorial Sloan Kettering Cancer Center, New York, NY: Novel Imaging in Myeloma: Development of Targeted Immuno-PET
Audience Questions & Answers
Questions Answered by Dr. Hillengass in Chat Forum
Answer: Usually PET positive lesions are still active, but there is some data that the bone healing can also show up in PET. Dr. Landgren’s new PET/CT will help to differentiate that.
Answer: I would recommend imaging before to make sure that there is no fracture risk. We currently only let our patients train under supervision by a trainer who is familiar with myeloma to make sure that all the movements are performed in a safe way.
Answer: It depends on the stage of the disease. In smoldering myeloma I recommend yearly MRI. In symptomatic myeloma I recommend PET/CT at first diagnosis, after the main treatment (e.g. stem cell transplantation) and than once a year (if covered by the insurance). This is, of course, based on symptoms.
Answer: Yes, in order to determine that there are no residual lesions in another part in the body than the one where the biopsy was done to assess MRD.
Answer: Good question, but difficult to say. I have a few patients where osteolytic lesions have healed but we don’t know yet, which patients show this. I strongly support using Zometa, but after such a long time Zometa can be harmful because it limits the bone turnover. Please discuss with your provider.
Answer: After 3 years, I personally would repeat a PET/CT. In VERY rare patients the disease can come back without signs in the blood or urine. But again that is very rare.
Answer: Yes, both show focal lesions. MRI shows lesions that have a low metabolism, something that might be negative in PET. But this is rather rare. MRI has also the benefit that it does not use radiation. So in early stages I usually use MRI in follow up rather PET. In case of long term follow up, I then go back to MRI.
Answer: This is almost the same as DWI, which I talked about. It is an MRI technique that measures the molecular movement of water molecules. In tissues with high cellularity these molecules are limited in their movements, in tissues with low cellularity or high perfusion (many blood vessels) they can move further.
Answer: I know the publication but the study was only done in cells and animals. It never became a full paper and we have analyzed several hundred patients who have received Gd MRI contrast agent and couldn’t find any negative prognostic effects. Patients who had significant renal issues had less improvement of their renal function. Also, we don’t need contrast agents for most of the questions we want to answer in myeloma. All the images shown today were done without contrast agents.
Answer: This depends very much on the physicians. Difficult to say. It should be the nuclear medicine specialist, but I am a hematologist and sometimes overrule my colleagues too.
Questions Answered by Dr. Landgren in Chat Forum
Answer: I think a more accurate way to say this is "we do not yet have an established curative therapy for myeloma.” That being said, there is a small subset of patients who have sustained MRD negativity over many years, some of them stay on maintenance and some of them go off therapy, and yet there is no relapse after over 10 years of followup. Unfortunately, this proportion of patients is quite small and we don't yet have the ability to predict who these patients are ahead of time. Our projections based on emerging data is that newer/better therapies will result in higher rates of sustained MRD-negativity.
Answer: Currently no, it does not. When we have done more work (and hopefully have found markers underlying the "treatment escape" that allows the cells to survive (focal MRD). We will open a new myeloma research program in Miami that is designed to go after this. We will move fast forward. Stay tuned! [Dr. Landgren respond to another comment about his upcoming move to Miami, FL:] I am thrilled to join Sylvester Comprehensive Cancer Center/Universiy of Miami as the new leader for the Myeloma Program. I will join on November 1. My myeloma clinic will open in Miami, and my telemedicine clinic will be open for patients independent of where the patient lives.
Answer: It does not have a catchy name yet: First-in-Human Imaging of Multiple Myeloma Using 89Zr-DFO-daratumumab, a CD38-targeting Monoclonal Antibody.
Answer: Standard clinical guidelines recommend that patients shall not have glucose intake right before PET/CT. It is not perfect. Because FDG PET/CT is used for all types of diseases, it is complex. This is a topic that is handled by radiologists, not hematologist/oncologists.
Thanks to our Round Table sponsors
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about the author
Greg Brozeit
Greg Brozeit has been engaged in myeloma patient advocacy since 1998. He began working with the Myeloma Crowd in 2015. Prior to that, he consulted with Dr. Bart Barlogie at the University of Arkansas after working with the International Myeloma Foundation for 15 years, where he inaugurated the public policy advocacy program, patient support group outreach and IMF Europe, organizing more than 100 physician and patient education programs. He earned his BA in political science from Loyola University in New Orleans and lives in northeast Ohio.
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