Contributions
Abstract: PB2169
Type: Publication Only
Background
Whole body MRI is emerging as the most sensitive imaging technique for patients with multiple myeloma (MM) and as such is recommended by the IMWG for all patients with an apparent diagnosis of asymptomatic myeloma. In the UK whole body MRI is first line imaging for all patients with a suspected diagnosis of myeloma, follow up, response assessments and restaging at relapse. MRI is also the most sensitive imaging test for detection of avascular necrosis (AVN) of the femoral heads, a complication of corticosteroid use in MM patients.
Aims
To assess the prevalence and outcome of MM patients with features of AVN on whole body MRI.
Methods
We conducted a retrospective analysis of all whole body MRIs between1st January 2010 to 1st May 2017 for MM patients at the Royal Marsden Hospital. All scans were reported by consultant radiologists with a special interest in myeloma for whom review for skeletal complications of myeloma is routine practice. These radiological reports were searched for the following terms “AVN” and “avascular necrosis”. Images of the patients with AVN were interrogated and correlating clinical information documented.
Results
Out of 650 whole body MRI scans performed in 226 patients, 15 patients (6.6%)(10 male, 5 female, median age 66.5 years [range 31-74]) were identified to have typical MRI features of AVN which included subchondral serpiginous lines and oedema. 2/15 had femoral head collapse and 4/15 had bilateral AVN. 10/15 patients had active disease according to IMWG criteria and 8/15 were being treated with steroid-combination regimens. Indications for scanning included disease assessment post-induction therapy (6/15), biochemical progression (5/15) and bony pains at other sites (1/15). Only 3/15 (20%) patients had reported hip/pelvic pain at the time of AVN detection.
Patients with AVN had received a median cumulative dexamethasone dose of 540mg (range 80-5040mg), while 3/15 patients had had prior femoral radiotherapy. None of the patients had known diabetes. All patients were receiving bisphosphonates on a monthly to 2-monthly basis.
During surveillance, 8/15 patients had scans demonstrating progressive AVN, including worsening femoral head oedema and increasing effusions. Of these, 4/8 reported worsening symptoms in the affected hip(s) and subsequently required surgical intervention with total hip replacements. All other patients were managed conservatively and are continuing to be reviewed by the orthopaedic team.
Conclusion
In keeping with previous published data which has shown a 9% incidence of AVN, the incidence of AVN in MM patients imaged with routine whole body MRI was low (6.6%). However we have shown that asymptomatic AVN can be detected early on whole body MRI before femoral head collapse. Early orthopaedic referral provides an opportunity for interventions to preserve the joint before femoral head collapse and the requirement for total hip replacement. Additionally, when early signs of AVN are identified, rapid de-escalation of steroid dosing should be considered once the patient’s myeloma is well controlled. We recommend that whole body MRI scans in patients with MM should always be interrogated for early signs of AVN.
Session topic: 14. Myeloma and other monoclonal gammopathies - Clinical
Keyword(s): Corticosteroids, MRI, Myeloma
Abstract: PB2169
Type: Publication Only
Background
Whole body MRI is emerging as the most sensitive imaging technique for patients with multiple myeloma (MM) and as such is recommended by the IMWG for all patients with an apparent diagnosis of asymptomatic myeloma. In the UK whole body MRI is first line imaging for all patients with a suspected diagnosis of myeloma, follow up, response assessments and restaging at relapse. MRI is also the most sensitive imaging test for detection of avascular necrosis (AVN) of the femoral heads, a complication of corticosteroid use in MM patients.
Aims
To assess the prevalence and outcome of MM patients with features of AVN on whole body MRI.
Methods
We conducted a retrospective analysis of all whole body MRIs between1st January 2010 to 1st May 2017 for MM patients at the Royal Marsden Hospital. All scans were reported by consultant radiologists with a special interest in myeloma for whom review for skeletal complications of myeloma is routine practice. These radiological reports were searched for the following terms “AVN” and “avascular necrosis”. Images of the patients with AVN were interrogated and correlating clinical information documented.
Results
Out of 650 whole body MRI scans performed in 226 patients, 15 patients (6.6%)(10 male, 5 female, median age 66.5 years [range 31-74]) were identified to have typical MRI features of AVN which included subchondral serpiginous lines and oedema. 2/15 had femoral head collapse and 4/15 had bilateral AVN. 10/15 patients had active disease according to IMWG criteria and 8/15 were being treated with steroid-combination regimens. Indications for scanning included disease assessment post-induction therapy (6/15), biochemical progression (5/15) and bony pains at other sites (1/15). Only 3/15 (20%) patients had reported hip/pelvic pain at the time of AVN detection.
Patients with AVN had received a median cumulative dexamethasone dose of 540mg (range 80-5040mg), while 3/15 patients had had prior femoral radiotherapy. None of the patients had known diabetes. All patients were receiving bisphosphonates on a monthly to 2-monthly basis.
During surveillance, 8/15 patients had scans demonstrating progressive AVN, including worsening femoral head oedema and increasing effusions. Of these, 4/8 reported worsening symptoms in the affected hip(s) and subsequently required surgical intervention with total hip replacements. All other patients were managed conservatively and are continuing to be reviewed by the orthopaedic team.
Conclusion
In keeping with previous published data which has shown a 9% incidence of AVN, the incidence of AVN in MM patients imaged with routine whole body MRI was low (6.6%). However we have shown that asymptomatic AVN can be detected early on whole body MRI before femoral head collapse. Early orthopaedic referral provides an opportunity for interventions to preserve the joint before femoral head collapse and the requirement for total hip replacement. Additionally, when early signs of AVN are identified, rapid de-escalation of steroid dosing should be considered once the patient’s myeloma is well controlled. We recommend that whole body MRI scans in patients with MM should always be interrogated for early signs of AVN.
Session topic: 14. Myeloma and other monoclonal gammopathies - Clinical
Keyword(s): Corticosteroids, MRI, Myeloma