When it comes to multiple myeloma, imaging is more than just a snapshot. It's a window into how the disease is behaving in your body. But here's the challenge. Not all doctors agree on how often scans should be repeated or which imaging method is best for each situation. If you've been diagnosed with symptomatic myeloma or are living with smoldering myeloma, you might be wondering, how often should I be scanned? What kind of imaging should I get? And does it really make a difference? In this Health Tree University video, we'll break down the role of imaging in myeloma monitoring, explore how recommendations can differ between patients and providers, and help you understand what to expect when it comes to follow-up scans. How often should imaging be repeated for someone with smoldering myeloma and symptomatic myeloma? So starting with smoldering, I would usually recommend once a year or if there are changes in the serological markers, if there's a rise of M-protein or I don't know, hemoglobin lower, calcium higher, creatinine higher. So other reasons for suspicion of progression, then it will repeat again. In symptomatic myeloma, we do the first diagnosis to assess the disease after treatment to see how much is left of the disease. And with the newer techniques, if we use PET-CT and low-dose CT and MRI, it's usually enough to do another imaging and relapse or at any sign of serological changes. I had a few patients who had no changes in serological markers but had changes in the bone marrow. So sometimes it's warranted there. PET-CT helps us also beyond just a myeloma assessment. We also learn about if there are other tumors developing because we know that up to 10% of patients can develop secondary cancers after high-dose chemotherapy with lenalidomide maintenance treatment. So that's another kind of additional question that we can ask for imaging after treatment. So for active myeloma, I probably lean towards doing it more often just because you wanted to understand the changes in the both good and bad ways, particularly if patients are on therapy. Probably every three to six months would be appropriate for people who are on surveillance, including patients who are otherwise looking like they're in a beautiful remission. There needs to also be a balance between over-investigating exposure to radiation and also doing enough. So in those group of patients, I treat them more like smoldering patients, which is just about once a year. This is sort of standard, but it can also be that patient symptoms guide additional imaging. Like say someone's having new onset of pain not explained by any other reasons, we would certainly add extra set of imaging and it can be done sort of to target in that specific area or if there's concern about lesions, new lesions at more than one places, then I would do whole body imaging. It is really to try to do enough but not too much because we know that our smoldering patients, our MGAS patients, unless they're high risk, they may just be smoldering for a very long time. So you could be subjected to a lot of radiation exposure unnecessarily. So the guideline recommends sort of alternating between the whole body, low-dose CT and MRI. So what's the difference? The MRI actually also will give you not only focal lesions, which tend to be what the CT gives us as well, but the MRI will also show the signal within the bone marrow. Sort of is it getting to be turned on more activity within the bone marrow that causes swelling when the cancer cells are there. They're shifting the balance between the amount of fluid and fat within the bone marrow and that's what the MRI picked up. So the guideline is really trying to utilize the best features of both technologies. Smoldering patients, we want to see the changes earlier. So the higher sensitivity of the MRI is very helpful. So in smoldering patients, I'd rather recommend a whole body MRI if available or at least a spinal and pelvic MRI. What imaging modality is used for monitoring myeloma response after treatment? At the moment, the best we have is FDG-PAT, Fluid Deoxyglucose-PAT, which is developed for other cancers and other diseases. But it's the best that we have. It's more or less approved. We can use it for myeloma. At least in the US, you get paid for it. So we get it. We can offer it to our patients. There are new developments called diffusion-weighted imaging, which is a little bit more sensitive. It's not approved yet. It has never been compared head-to-head in a larger prospective trial. Retrospective analysis shows that it has a higher sensitivity, about 10% higher than PET-CT. So at the moment, PET-CT is the standard of care for monitoring after treatment. Diffusion-weighted imaging might be something that is beneficial and there are some colleagues working on that to look into the comparison of those. So these are the two different areas. In our new guidelines, we have these algorithms, what to do when. We recommend Lodo-CT because it's fast, it's cheap, and it's available all over the world. So the recommendations were written for the whole world, basically. In the US, I would say, because we recommend Lodo-CT there without PET, but it's more or less because a lot of countries just don't have access to PET-CT that often. So in the US, I would say PET-CT is the choice with the good CT, as I mentioned earlier. In other countries where there's no access to PET-CT, at least it should be a Lodo-CT. It's kind of this compromise that we recommend there. Once we get to someone with diagnosis of myeloma symptomatic needing treatment, though, they're already needing treatment. So I oftentimes will utilize the PET scan, the PET-CT. So why not just a CT? This has to do with, particularly, if they had those hot spots to start. It's nice to know that those hot spots disappear. But also, oftentimes, when you do a CAT scan, it's very hard to know in the bone that's already damaged previously. Unless you see new lesions, you can't quite tell with just a CAT scan alone on whether those lesions were cold lesions that haven't healed or they're still hot spots. And that's why PET-CT tend to replace it. Imaging is a powerful tool in both smoldering and active multiple myeloma. But knowing when to scan and what to use can make a big difference. While there's no one-size-fits-all answer, the decision often depends on your stage of disease, symptoms, where you live, and what your care team is monitoring. The key takeaway? Work closely with your health care team to create a personalized imaging plan that fits your specific situation. Staying informed and proactive is one of the best ways to manage your care. Found this helpful? Don't forget to like, subscribe, and share with others who might benefit. See you in the next video.
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