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Radiologische Diagnostik des multiplen Myeloms

Radiological diagnostics of multiple myeloma

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Zusammenfassung

Klinisches/methodisches Problem

Die Aufgabe der bildgebenden Diagnostik beim multiplen Myelom (MM) ist die zuverlässige Erfassung der Tumorlast im Skelett sowie auch der extraskelettalen Manifestationen und der assoziierten Komplikationen (z. B. Wirbelkörperfrakturen, Frakturgefahr).

Radiologische Standardverfahren

Projektionsradiographie (Skelettstatus) zur Erfassung von Osteolysen, Osteoporose oder Frakturen.

Methodische Innovationen

Die Ganzkörper-CT stellt hochsensitiv die Osteolysen, die Ganzkörper-MRT das Ausmaß der Knochenmarkinfiltration dar. Die Positronenemissionstomographie(PET)-CT kann zusätzlich die aktiven Myelomläsionen detektieren und wichtige Informationen für den Therapieverlauf geben.

Leistungsfähigkeit

Nach den Ergebnissen mehrerer Studien sind die Schnittbildverfahren dem Röntgenskelettstatus überlegen. Die Ganzkörper-MRT ist sowohl für den Nachweis fokaler Läsionen als auch einer diffusen Infiltration signifikant sensitiver als die Ganzkörper-CT. Die PET-CT zeigt eine vergleichbare Sensitivität mit der Ganzkörper-MRT.

Bewertung

Aufgrund der höheren Sensitivität bei der Detektion von Myelomläsionen sollten die Ganzkörper-CT und die Ganzkörper-MRT die Projektionsradiographie ersetzen.

Empfehlung für die Praxis

Bei Verdacht auf ein MM sollte bei der initialen Diagnostik eine Ganzkörper-CT durchgeführt werden. Werden hier keine Herde gefunden, sollte, falls verfügbar, eine Ganzkörper(GK)-MRT oder zumindest eine MRT der Wirbelsäule und des Beckens durchgeführt werden. Falls eine GK-MRT in der initialen Diagnostik durchgeführt wurde, sollte bei fokalen Herden eine ergänzende Ganzkörper-CT erfolgen, um das Ausmaß der Osteolysen zu erfassen und das Frakturrisiko abzuschätzen. Bei der monoklonalen Gammopathie unklarer Signifikanz (MGUS), beim solitären und beim „smoldering“ Myelom sollte, falls verfügbar, die GK-MRT eingesetzt werden, da hiervon die Prognose und das Therapiekonzept bei vorhandenen Infiltraten betroffen sind.

Abstract

Clinical/methodical issue

Robust and reliable imaging methods are required to estimate the skeletal tumor load in multiple myeloma, as well as for the diagnosis of extraskeletal manifestations. Imaging also plays an essential role in the assessment of fracture risk and of vertebral fractures.

Standard radiological methods

The conventional skeletal survey has been the gold standard in the imaging of multiple myeloma for many years.

Methodical innovations

Other modalities which have been investigated and are in use are whole-body computed tomography (WBCT), 18F-fluorodeoxyglucose positron emission tomography computed tomography (FDG PET-CT) and whole-body magnetic resonance imaging (WBMRI). These techniques are able to depict both mineralized bone and the bone marrow with a high sensitivity for myeloma lesions.

Performance

Several studies have shown that cross-sectional imaging is superior to the skeletal survey in the detection of myeloma lesions and WBMRI has been shown to be significantly more sensitive than WBCT for the detection of focal myeloma lesions as well as for diffuse infiltration. The FDG PET-CT technique has a sensitivity comparable to WBMRI.

Achievements

Due to the higher sensitivity in the detection of myeloma lesions WBCT and WBMRI should replace the skeletal survey.

Practical recommendations

A WBCT should be performed if there is suspicion of multiple myeloma. If no focal lesions are found WBMRI or at least MRI of the spine and pelvis should be additionally performed if available. If WBMRI has been initially performed and focal lesions are present, an additional WBCT may be performed to assess the extent of bone destruction and fracture risk. In cases of monoclonal gammopathy of undetermined significance (MGUS), solitary and smoldering myeloma, a WBMRI, if available, should be performed in addition to WBCT.

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Einhaltung ethischer Richtlinien

Interessenkonflikt. A. Baur-Melnyk, M. D’Anastasi, S. Grandl, M.F. Reiser geben an, dass kein Interessenkonflikt besteht. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

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Authors and Affiliations

  1. Institut für Klinische Radiologie, Klinikum der Ludwig-Maximilians-Universität München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland

    M. D’Anastasi, S. Grandl, M.F. Reiser &  A. Baur-Melnyk

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  1. M. D’Anastasi
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  2. S. Grandl
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  3. M.F. Reiser
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  4. A. Baur-Melnyk
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Correspondence to A. Baur-Melnyk.

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D’Anastasi, M., Grandl, S., Reiser, M. et al. Radiologische Diagnostik des multiplen Myeloms. Radiologe 54, 556–563 (2014). https://doi.org/10.1007/s00117-013-2628-9

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