‘Practice Changing’ MRI Recommendations in Multiple Myeloma

The International Myeloma Working Group (IMWG) has issued practical recommendations on the use of MRI in patients with multiple myeloma (MM) and in patients with asymptomatic disease, such smoldering MM and monoclonal gammopathy of undetermined significance (MGUS).


For smoldering MM, the consensus statement recommends “that patients with more than one unequivocal focal lesion (diameter of >5 mm) should be considered to have symptomatic myeloma that requires therapy (grade B). Patients with equivocal focal lesions should repeat the MRI after 3 to 6 months, and in cases of MRI progression, patients should be considered as symptomatic patients who need therapy (grade C; panel consensus). The biopsy of such lesions should be encouraged. Regarding diffuse MRI marrow pattern, we need additional studies before its incorporation into the definition of symptomatic myeloma.”

For MGUS, the statement notes that “WB-MRI identifies patients with MGUS with focal lesions that possibly reflect infiltration by monoclonal plasma cells in the bone marrow. These patients seem to have increased risk of progression to myeloma. To date, MRI is not recommended as part of the routine workup for patients with MGUS unless there are clinical features that increase suspicion.”

For MM, the statement explaines that “MRI is the imaging gold-standard method for the detection of bone marrow involvement in MM (grade A). We stress that MRI detects bone marrow involvement and not bone destruction. MRI of the spine and pelvis can detect approximately 90% of focal lesions in MM, and thus, it can be used in cases where WB-MRI is not available (grade B). MRI is the procedure of choice to evaluate a painful lesion in patients with myeloma, mainly in the axial skeleton, and detect spinal cord compression (grade  A). MRI is particularly useful in the evaluation of collapsed vertebrae, especially when myeloma is not active, where the possibility of osteoporotic fracture is high (grade B).”