IMWG Criteria | MRI Patterns | Bone Disease | Orthopaedic Management
MRI INFILTRATION PATTERNS
Critical Must-Knows
- IMWG 2014 criteria: 2 or more focal lesions on MRI (5mm+) = symptomatic myeloma
- Pure lytic lesions - myeloma NEVER produces blastic/sclerotic response
- Radiosensitive tumor - radiation highly effective for local control
- Pathological fracture risk - vertebroplasty/kyphoplasty effective for pain
- Spinal cord compression - emergency requiring urgent decompression
Clinical Pearls
- "CRAB criteria: Calcium elevated, Renal insufficiency, Anemia, Bone lesions
- "MRI more sensitive than CT for detecting bone marrow infiltration
- "Whole-body low-dose CT has replaced skeletal survey
- "Myeloma is radiosensitive - responds well to radiation therapy
Critical Multiple Myeloma Exam Points
CRAB Criteria
Symptomatic myeloma definition: C=Calcium elevated (over 11 mg/dL), R=Renal insufficiency (creatinine over 2), A=Anemia (Hb under 10), B=Bone lesions. Any one of these with clonal plasma cells = requires treatment.
IMWG Imaging
2014 IMWG criteria include MRI: 2 or more focal lesions (5mm or greater) on MRI OR one or more osteolytic lesions on CT = symptomatic myeloma. Single MRI lesion is NOT diagnostic but warrants investigation.
Lytic Only
Myeloma produces ONLY lytic lesions - never blastic. If you see sclerotic response, consider POEMS syndrome (rare) or other diagnosis. The "punched out" lytic lesions are pathognomonic.
Radiosensitive
Myeloma is radiosensitive - unlike many solid tumor metastases. Radiation provides excellent local control. Surgery reserved for mechanical instability or decompression needs.
Multiple Myeloma vs Metastatic Carcinoma
| Feature | Multiple Myeloma | Metastatic Carcinoma |
|---|---|---|
| Lesion type | PURE LYTIC only | Lytic, blastic, or mixed |
| Primary site | Bone marrow (plasma cells) | Breast, prostate, lung, kidney, thyroid |
| Bone scan | Often NEGATIVE (no osteoblastic) | Usually positive |
| MRI sensitivity | Very high (marrow infiltration) | High for lytic lesions |
| Radiosensitivity | Highly radiosensitive | Variable by histology |
| Systemic markers | M-protein, free light chains | Tumor markers (PSA, CEA, etc) |
At a Glance
Multiple myeloma is a plasma cell malignancy with 80% having bone disease at diagnosis, with the spine being the most common site (49%). It produces only pure lytic lesions (never blastic) - the classic "punched out" appearance. Symptomatic disease is defined by CRAB criteria (Calcium elevation, Renal insufficiency, Anaemia, Bone lesions). The 2014 IMWG criteria include imaging: ≥2 focal lesions (≥5mm) on MRI is diagnostic. Myeloma is highly radiosensitive, so radiation provides excellent local control. Surgery is reserved for mechanical instability (SINS score) or spinal cord decompression; vertebroplasty/kyphoplasty effectively manages painful vertebral lesions.
CRAB CCRAB Criteria for Symptomatic Myeloma
| C | Calcium elevation Serum calcium over 11 mg/dL or 0.25 mmol/L above ULN |
| R | Renal insufficiency Creatinine over 2 mg/dL or CrCl under 40 mL/min |
| A | Anemia Hemoglobin under 10 g/dL or over 2 g/dL below normal |
| B | Bone lesions One or more osteolytic lesions on imaging |
| C | Calcium elevation Serum calcium over 11 mg/dL or 0.25 mmol/L above ULN | A | Anemia Hemoglobin under 10 g/dL or over 2 g/dL below normal |
| R | Renal insufficiency Creatinine over 2 mg/dL or CrCl under 40 mL/min | B | Bone lesions One or more osteolytic lesions on imaging |
Hook:CRAB criteria define end-organ damage requiring treatment
IMWG BSLiM Criteria - New IMWG Biomarkers
| S | Sixty percent Clonal bone marrow plasma cells 60% or more |
| Li | Light chain ratio Involved/uninvolved FLC ratio 100 or more |
| M | MRI lesions 2 or more focal lesions (5mm+) on MRI |
| S | Sixty percent Clonal bone marrow plasma cells 60% or more |
| Li | Light chain ratio Involved/uninvolved FLC ratio 100 or more |
| M | MRI lesions 2 or more focal lesions (5mm+) on MRI |
Hook:SLiM criteria added in 2014 - can diagnose myeloma WITHOUT CRAB symptoms
MRI IMRI Infiltration Patterns
| F | Focal Discrete lesions in normal background marrow |
| D | Diffuse Homogeneous marrow replacement - worst prognosis |
| M | Mixed Combination of focal lesions and diffuse change |
| V | Variegated Salt-and-pepper or heterogeneous pattern |
| N | Normal Normal marrow (MGUS or early disease) |
| F | Focal Discrete lesions in normal background marrow | V | Variegated Salt-and-pepper or heterogeneous pattern |
| D | Diffuse Homogeneous marrow replacement - worst prognosis | N | Normal Normal marrow (MGUS or early disease) |
| M | Mixed Combination of focal lesions and diffuse change |
Hook:FDMVN patterns - Diffuse pattern has worst prognosis
Overview and Epidemiology
Multiple myeloma is a plasma cell neoplasm characterized by clonal proliferation of malignant plasma cells in the bone marrow, monoclonal protein in blood/urine, and end-organ damage including bone disease.
Epidemiology:
- Second most common hematologic malignancy (after NHL)
- Approximately 10% of all hematologic cancers
- Median age at diagnosis: 65-70 years
- Male to female ratio: 1.4:1
- Higher incidence in African Americans (2-3x)
Bone Disease Distribution:
| Site | Frequency | Clinical Significance |
|---|---|---|
| Vertebrae | 49% | Most common - compression fractures |
| Skull | 35% | "Pepper pot" appearance |
| Pelvis | 34% | May cause pathological fractures |
| Ribs | 33% | Pain, fracture risk |
| Proximal femur/humerus | 20% | Impending fracture concern |
Pathogenesis of Bone Disease:
Myeloma cells activate osteoclasts and suppress osteoblasts through:
- RANKL upregulation
- DKK1 (Dickkopf-1) inhibits Wnt signaling
- MIP-1alpha (macrophage inflammatory protein)
- IL-6, IL-1beta, TNF-alpha secretion
Why Pure Lytic?
Myeloma causes ONLY lytic lesions because it suppresses osteoblast activity through DKK1. Without osteoblastic response, bone scans are often negative (no radioisotope uptake). This is why MRI and CT are preferred over bone scan for myeloma.
Pathophysiology
Disease Spectrum
Monoclonal Gammopathy of Undetermined Significance
Precursor condition with low risk of progression:
- M-protein under 3 g/dL
- Clonal plasma cells under 10% in marrow
- No CRAB features or myeloma-defining events
- 1% per year progression to myeloma
- No treatment required - observation only
MRI typically normal or minimal abnormality in MGUS.
Bone Marrow Infiltration
The pattern of bone marrow infiltration on MRI correlates with prognosis:
| Pattern | Description | Prognosis | Treatment Response |
|---|---|---|---|
| Normal | No signal abnormality | Best | N/A (MGUS/early) |
| Focal | Discrete lesions, normal background | Good | Generally favorable |
| Diffuse | Homogeneous marrow replacement | Worst | Higher tumor burden |
| Mixed | Focal + diffuse changes | Intermediate | Variable |
| Variegated | Salt-and-pepper heterogeneous | Variable | Depends on extent |
Diffuse Pattern Significance
Diffuse bone marrow infiltration on MRI indicates high tumor burden and correlates with worse prognosis and higher ISS stage. These patients often have more severe cytopenias and higher beta-2 microglobulin levels.
Classification and Staging
International Staging System (ISS)
| Stage | Criteria | Median Survival |
|---|---|---|
| I | Beta-2 microglobulin under 3.5 mg/L AND Albumin 3.5 g/dL or more | 62 months |
| II | Neither I nor III | 44 months |
| III | Beta-2 microglobulin 5.5 mg/L or more | 29 months |
ISS is based on two readily available serum markers. Beta-2 microglobulin reflects tumor burden while albumin reflects performance status.
Single MRI Lesion
A single focal lesion on MRI does NOT meet IMWG criteria for myeloma diagnosis. However, it should prompt further investigation with CT (one lytic lesion on CT IS diagnostic) or biopsy.
Clinical Presentation
Presenting Features
Bone Pain (70% at presentation):
- Most common symptom
- Often back pain from vertebral involvement
- Worse with movement, may improve at rest
- Pathological fractures common
Systemic Symptoms:
- Fatigue (anemia)
- Weight loss
- Recurrent infections (immunoparesis)
- Hyperviscosity symptoms (rare)
Spinal Manifestations
Vertebral Compression Fractures:
- Present in 55-70% at diagnosis
- May be presenting feature
- Multiple levels common
- Thoracolumbar junction most common
Spinal Cord Compression:
- Emergency presentation
- From vertebral collapse or extraosseous extension
- Requires urgent assessment and treatment
- Good prognosis if treated promptly (radiosensitive)
Radiculopathy:
- Neural foraminal narrowing
- Extraosseous tumor extension
- May present before diagnosis
Red Flags
- Age over 50 with new back pain
- Pathological fracture (minimal trauma)
- Anemia, renal insufficiency
- Hypercalcemia
- Elevated ESR/plasma viscosity
- Recurrent infections
Differential Diagnosis of a Lytic/Destructive Vertebral Lesion
Differential Diagnosis of a Lytic Vertebral Lesion in an Adult
| Diagnosis | Discriminating features | Key investigation |
|---|---|---|
| Multiple myeloma | Pure lytic, often bone scan negative, M-protein, CRAB | SPEP/UPEP, serum free light chains, marrow biopsy |
| Metastatic carcinoma | Lytic, blastic or mixed; bone scan usually positive; known primary | CT chest/abdo/pelvis, tumour markers, biopsy |
| Solitary plasmacytoma | Single lesion, less than 10% marrow plasma cells, no CRAB | Whole-body MRI/PET, marrow biopsy |
| Lymphoma of bone | Permeative pattern, large soft-tissue mass relative to bone destruction | Biopsy with immunohistochemistry |
| Osteoporotic compression fracture | No marrow replacement on MRI, benign fluid sign, retropulsion uncommon | MRI (fat-suppressed), DEXA |
| Infection (TB/pyogenic spondylodiscitis) | Disc involvement and endplate destruction, raised CRP, systemic sepsis | MRI with contrast, CT-guided biopsy and culture |
A pivotal exam discriminator: myeloma and metastasis characteristically spare the intervertebral disc, whereas infection crosses the disc space and destroys adjacent endplates. Marrow replacement on T1 MRI distinguishes a malignant collapse from a benign osteoporotic fracture.
Investigations
Laboratory Studies
Essential Panel:
- FBC (anemia, rouleaux formation)
- Renal function, electrolytes
- Calcium (hypercalcemia)
- Total protein, albumin (AG ratio)
- LDH, beta-2 microglobulin
Myeloma-Specific Tests:
- Serum protein electrophoresis (SPEP) - M-spike
- Urine protein electrophoresis (UPEP) - Bence-Jones protein
- Serum free light chains (kappa/lambda ratio)
- Immunofixation (identifies M-protein type)
Bone Marrow:
- Aspirate and trephine biopsy
- Plasma cell percentage
- Cytogenetics/FISH for prognostic markers
Imaging
Whole-Body Low-Dose CT (WBLDCT)
Now preferred first-line imaging (replaced skeletal survey):
- Higher sensitivity than conventional skeletal survey for osteolytic disease (IMWG 2019 consensus)
- One lytic lesion (5mm or larger) on CT = diagnostic criterion
- Better detection of rib/pelvic lesions
- Can assess fracture risk
Findings:
- Punched-out lytic lesions
- NO sclerotic rim (unlike metastases)
- Pathological fractures
- Osteopenia
WBLDCT is first-line imaging for initial staging per IMWG.
Management
Systemic Treatment
First-Line Therapy (Haematology):
Orthopaedic surgeons should understand systemic treatment:
- Triplet therapy: VRd (Bortezomib, Lenalidomide, Dexamethasone)
- Quadruplet therapy: Adding daratumumab for fit patients
- Autologous stem cell transplant: For eligible patients under 70
Bone-Targeted Therapy:
- Bisphosphonates: Zoledronic acid monthly
- Denosumab: Alternative if renal impairment
- Reduces skeletal events by 40%
Orthopaedic Management
Conservative Measures
Most patients managed non-operatively:
- Analgesia (WHO ladder)
- Bracing for vertebral fractures
- Activity modification
- Physiotherapy
Vertebral Augmentation:
- Kyphoplasty/Vertebroplasty highly effective
- 80-90% pain relief
- Can be done under local anesthesia
- Multiple levels in single session
- Good option for pathological compression fractures
Vertebral augmentation is first-line for painful compression fractures.
Spinal Cord Compression
Oncological Emergency in Myeloma:
Unlike metastatic carcinoma, myeloma cord compression has excellent prognosis if treated promptly:
Management:
- Dexamethasone 10mg IV bolus then 4mg q6h
- MRI whole spine (skip lesions common)
- Assessment for surgery:
- If mechanically unstable = surgery + radiation
- If stable = radiation alone effective
- Radiation highly effective (radiosensitive)
Outcomes:
- Ambulatory patients: 90%+ maintain ambulation
- Non-ambulatory: 50-70% recover ambulation (better than carcinoma)
Myeloma vs Carcinoma Cord Compression
Unlike metastatic carcinoma, myeloma is highly radiosensitive. If the spine is mechanically stable (SINS under 7), radiation alone is often sufficient for cord compression. Surgery is not automatically required as in radioresistant tumors.
Complications
Skeletal Complications
Pathological Fractures:
- Vertebral compression fractures (55-70%)
- Long bone fractures (less common)
- Rib fractures
Spinal Cord Compression:
- 5-10% of myeloma patients
- Usually from vertebral collapse
- Extraosseous extension less common
Hypercalcemia:
- Present in 25-30% at diagnosis
- From osteoclast activation
- Medical emergency if severe
Treatment-Related Complications
Bisphosphonate Therapy:
- Osteonecrosis of jaw (ONJ) - 1-10%
- Renal toxicity (especially zoledronic acid)
- Atypical femoral fractures (rare)
Surgical Complications:
- Wound healing issues (immunosuppression)
- Hardware failure (poor bone quality)
- Infection risk (hypogammaglobulinemia)
Disease Progression
Extramedullary Disease:
- Occurs in 10-20% during disease course
- More aggressive biology
- Requires modified treatment approach
Evidence Base
IMWG 2014 Updated Diagnostic Criteria (SLiM-CRAB)
- Added validated SLiM biomarkers to the existing CRAB definition
- 2 or more focal lesions on MRI (each 5mm+) = myeloma-defining event
- Clonal bone marrow plasma cells 60% or more = myeloma-defining
- Involved/uninvolved serum free light chain ratio 100 or more = myeloma-defining
Revised International Staging System (R-ISS)
- Pooled analysis of 4,445 newly diagnosed patients from 11 international trials
- Combines ISS with high-risk cytogenetics (del(17p), t(4;14), t(14;16)) and LDH
- 5-year overall survival: R-ISS I 82%, R-ISS II 62%, R-ISS III 40%
- 5-year progression-free survival: 55%, 36% and 24% respectively
IMWG Consensus on Imaging in Plasma Cell Disorders
- Low-dose whole-body CT has higher sensitivity than conventional skeletal survey for bone disease
- WBLDCT recommended as the standard first-line imaging for newly diagnosed disease
- Whole-body MRI is the most sensitive modality for marrow infiltration and cord compression
- PET/CT preferred for treatment response and minimal residual disease assessment
Vertebroplasty/Augmentation in Spinal Malignancy
- Systematic review of 30 studies and 987 patients with metastases or myeloma
- Pain reduction ranged from 47% to 87%, comparable with osteoporotic augmentation
- Serious procedure-related complication rate approximately 2%
- No correlation between pain reduction and cement volume
MRI Marrow Infiltration Pattern and Prognosis
- 228 newly diagnosed symptomatic patients (41% diffuse, 41% focal, 15% normal pattern)
- Diffuse MRI pattern associated with high-risk cytogenetics (50% vs 31%) and poorer survival
- Diffuse pattern + ISS-3 + high-risk cytogenetics defined a very poor group (median OS 21 months)
- Diffuse-pattern patients benefited more from novel agents than conventional chemotherapy
IMWG Bone Working Group: Bone Disease Management
- Bisphosphonates (zoledronic acid) or denosumab recommended for all patients requiring anti-myeloma therapy
- Denosumab preferred over zoledronic acid in renal impairment (not renally cleared)
- Low-dose radiotherapy (8 Gy single fraction up to 30 Gy) for uncontrolled pain, impending fracture or cord compression
- Vertebral augmentation recommended for symptomatic vertebral compression fractures; surgery for instability or neurological compromise
Clinical Decision Scenarios
Use these scenarios to practise clinical reasoning and management decisions
New Diagnosis with Back Pain
"A 68-year-old man presents with 3 months of progressive thoracic back pain. Blood tests show Hb 9.5, creatinine 1.8, calcium 2.8 mmol/L. SPEP shows M-protein 45 g/L. MRI shows multiple T1-hypointense vertebral lesions."
Cord Compression from Myeloma
"A 72-year-old woman with known myeloma presents with 48-hour history of progressive leg weakness. Examination shows 3/5 bilateral LE power. MRI shows T8 vertebral collapse with Bilsky grade 2 epidural compression."
Painful Compression Fractures
"A 65-year-old woman with myeloma in remission presents with severe L1 and L3 compression fractures (50% and 40% collapse). SINS 7. She has severe mechanical pain limiting mobility."
Solitary Plasmacytoma
"A 55-year-old man presents with a single T12 lytic lesion. Biopsy confirms plasmacytoma. Bone marrow shows 5% plasma cells. SPEP shows small M-protein 8 g/L. No CRAB features. Whole-body imaging shows no other lesions."
MULTIPLE MYELOMA SPINE
Clinical summary
CRAB Criteria
- •C: Calcium over 11 mg/dL
- •R: Renal - Creatinine over 2 mg/dL
- •A: Anemia - Hb under 10 g/dL
- •B: Bone - 1 or more lytic lesions
- •Any CRAB + clonal plasma cells = symptomatic myeloma
SLiM Biomarkers (IMWG 2014)
- •S: Sixty percent or more plasma cells in marrow
- •Li: Light chain ratio 100 or more
- •M: MRI - 2 or more focal lesions (5mm+)
- •Any SLiM = myeloma WITHOUT needing CRAB
Key Imaging Points
- •WBLDCT replaced skeletal survey (first-line)
- •MRI most sensitive for marrow infiltration
- •2 or more MRI lesions = diagnostic criterion
- •Bone scan often NEGATIVE (no blastic response)
- •Pure LYTIC - never blastic in myeloma
MRI Patterns
- •Focal: Best prognosis, discrete lesions
- •Diffuse: Worst prognosis, homogeneous replacement
- •Mixed: Focal + diffuse
- •Variegated: Salt-and-pepper heterogeneous
- •Normal: MGUS or early disease
Treatment Pearls
- •Myeloma is RADIOSENSITIVE - radiation very effective
- •Vertebroplasty/kyphoplasty for painful fractures
- •Surgery only if unstable (SINS 13+) or failed RT
- •Cord compression: If stable = RT alone effective
- •Bisphosphonates reduce skeletal events by 40%
vs Metastatic Carcinoma
- •Myeloma: Pure lytic, radiosensitive, bone scan negative
- •Carcinoma: May be blastic/mixed, variable sensitivity
- •Myeloma cord compression: RT alone often sufficient
- •Carcinoma cord compression: Usually needs surgery
MCQ Practice Points
Clinical Pearl
Q: What is the SINS score and its role in myeloma spine management?
A: Spinal Instability Neoplastic Score (SINS): Evaluates tumor-related spinal instability. Components: Location, pain, bone quality, radiographic alignment, vertebral body collapse, posterolateral involvement. Score 0-6: Stable. 7-12: Potentially unstable (surgical consultation). 13-18: Unstable (surgical stabilization indicated).
Clinical Pearl
Q: What are the indications for surgical intervention in spinal myeloma?
A: Neurological deficit from cord compression, spinal instability (SINS greater than 12), intractable pain unresponsive to radiation/chemotherapy, pathological fracture with deformity, need for tissue diagnosis when uncertain. Surgery typically combined with radiation and systemic chemotherapy. Goal is palliation and function preservation.
Clinical Pearl
Q: What is the role of vertebroplasty/kyphoplasty in spinal myeloma?
A: Percutaneous cement augmentation provides pain relief and mechanical stability for compression fractures without cord compression. Can be performed under local anesthesia in frail patients. Contraindicated if: posterior wall breach with epidural extension, neurological deficit, coagulopathy. May be combined with radiation.
Clinical Pearl
Q: Why do myeloma lesions not appear on bone scan?
A: Myeloma cells secrete osteoclast-activating factors (RANKL, IL-6) causing pure bone resorption while suppressing osteoblast activity (via DKK1). Bone scan relies on osteoblastic activity for tracer uptake. No osteoblast response = no bone scan uptake. Use skeletal survey, whole-body low-dose CT, or MRI for myeloma staging.
Clinical Pearl
Q: What is the typical surgical approach for myeloma cord compression?
A: Posterior decompression and stabilization most common - allows access to most vertebral levels, provides immediate stability. Circumferential approach (anterior + posterior) for significant anterior compression or vertebral body destruction. Separation surgery concept: Decompression to create space, then radiation for tumor control.
Guidelines, Registries & Global Practice
Global Epidemiology
Multiple myeloma accounts for roughly 1% of all cancers and about 10% of haematological malignancies, with an age-standardised incidence of approximately 2 per 100,000 worldwide and a marked rise in absolute case numbers driven by ageing populations. Incidence is two- to threefold higher in people of African ancestry than in white populations and lower in East Asian populations, a disparity that persists after adjustment for access to care. The spine is the most common site of skeletal involvement, so the orthopaedic and spinal surgeon is frequently the first clinician to encounter undiagnosed disease through a pathological vertebral fracture.
Major Guidelines, Side by Side
| Body (region) | Position | Evidence basis |
|---|---|---|
| IMWG (international) | SLiM-CRAB diagnostic criteria; WBLDCT first-line imaging, whole-body MRI most sensitive; bone-targeted agent for all patients on therapy | Consensus statements (Rajkumar 2014; Hillengass 2019; Terpos 2021) |
| NICE NG35 (UK) | Offer whole-body MRI first-line for suspected myeloma (CT if MRI unsuitable); zoledronic acid as preferred bone-protective agent; consider cement augmentation for non-responsive pain | Guideline, GRADE-appraised |
| BOA / NICE metastatic spinal cord compression (MSCC) | Treat suspected MSCC as an emergency; MRI whole spine within 24 hours; definitive treatment within 24 hours of diagnosis | Guideline / national standard |
| NCCN (US) | R-ISS staging; triplet/quadruplet induction; bisphosphonate or denosumab for bone disease; radiotherapy for cord compression or uncontrolled pain | Category 1-2A consensus |
| EFORT / orthopaedic-oncology consensus | SINS for instability assessment; separation surgery plus radiotherapy for radioresistant compression; myeloma usually radiosensitive so radiotherapy alone often sufficient if stable | Expert consensus |
A key cross-guideline point of agreement, and a frequent exam discriminator, is that myeloma is radiosensitive: unlike most solid-tumour metastatic spinal cord compression (where decompressive surgery before radiotherapy improves ambulation, per Patchell), a mechanically stable myeloma cord compression can often be treated with radiotherapy alone.
Registry and Real-World Evidence
Myeloma bone disease is tracked less by arthroplasty-style implant registries than by national cancer and trials networks: the SEER programme (US), the Haematological Malignancy Research Network (UK), and the Australian Myeloma and Related Diseases Registry (MRDR) provide population-level survival and practice-pattern data. These consistently show improving median survival (now exceeding 5-6 years in transplant-eligible patients) following the introduction of proteasome inhibitors, immunomodulatory drugs and anti-CD38 antibodies, while also documenting persistent under-use of bone-protective therapy and variation in time-to-diagnosis.
Practice Variation
In high-resource settings whole-body MRI or PET/CT and quadruplet induction with autologous transplant are standard. In limited-resource settings skeletal survey and plain radiography remain in use, and access to novel agents, denosumab and timely radiotherapy is restricted, so vertebral augmentation and conventional fractionated radiotherapy carry proportionally greater importance. The orthopaedic priorities, structural stabilisation, pain control and preservation of neurological function, are universal even where systemic options differ.
Australian Context
In Australia management follows IMWG guidance coordinated through haematology services, with Myeloma Australia providing patient support and the MRDR capturing outcomes. Bone-targeted therapy with zoledronic acid or denosumab (preferred in renal impairment) is available for patients with bone disease, typically given monthly with subsequent de-escalation by response. Vertebral augmentation and radiotherapy are accessible through public and private hospitals, and optimal outcomes depend on coordinated haematology, radiation-oncology and spinal-surgery input.
References
- Rajkumar SV, Dimopoulos MA, Palumbo A, et al. International Myeloma Working Group updated criteria for the diagnosis of multiple myeloma. Lancet Oncol. 2014;15(12):e538-48. PMID: 25439696. doi:10.1016/S1470-2045(14)70442-5
- Hillengass J, Usmani S, Rajkumar SV, et al. International Myeloma Working Group consensus recommendations on imaging in monoclonal plasma cell disorders. Lancet Oncol. 2019;20(6):e302-e312. PMID: 31162104. doi:10.1016/S1470-2045(19)30309-2
- Palumbo A, Avet-Loiseau H, Oliva S, et al. Revised International Staging System for Multiple Myeloma: A Report From International Myeloma Working Group. J Clin Oncol. 2015;33(26):2863-9. PMID: 26240224. doi:10.1200/JCO.2015.61.2267
- Moulopoulos LA, Dimopoulos MA, Kastritis E, et al. Diffuse pattern of bone marrow involvement on magnetic resonance imaging is associated with high risk cytogenetics and poor outcome in newly diagnosed, symptomatic patients with multiple myeloma. Am J Hematol. 2012;87(9):861-4. PMID: 22641455. doi:10.1002/ajh.23258
- Chew C, Craig L, Edwards R, et al. Safety and efficacy of percutaneous vertebroplasty in malignancy: a systematic review. Clin Radiol. 2010;66(1):63-72. PMID: 21147301. doi:10.1016/j.crad.2010.09.011
- Terpos E, Zamagni E, Lentzsch S, et al. Treatment of multiple myeloma-related bone disease: recommendations from the Bone Working Group of the International Myeloma Working Group. Lancet Oncol. 2021;22(3):e119-e130. PMID: 33545067. doi:10.1016/S1470-2045(20)30559-3