Bone disease in multiple myeloma and precursor disease: novel diagnostic approaches and implications on clinical management

Abstract

The manifestations of bone involvement in patients with multiple myeloma (MM) can have devastating clinical effects and increase mortality. Recent studies demonstrate that patients with the precursor conditions smoldering MM (SMM) and monoclonal gammopathy of undetermined significance (MGUS) show evidence of bone disease and increased risk of fractures. The understanding of the pathogenesis of bone disease in MM has expanded in recent years. The traditional skeletal survey will probably be replaced by newer and more sensitive imaging techniques, which may have a prognostic impact and change our definition of MGUS and SMM. Bisphosphonates are recommended to prevent skeletal events in patients with MM, and have also been studied in SMM and MGUS. This article summarizes the current knowledge of bone disease in plasma cell disorders, and discusses the current standard and future role of novel imaging techniques, as well as the evidence and current guidelines for bisphosphonates in MM, SMM and MGUS.

Figure 1. An 82-year-old female with IgA monoclonal gammopathy of undetermined significance and a vertebral fracture in L5

Figure 2. ¹⁸F-fluorodeoxyglucose-PET/computed tomography imaging in a patient with smoldering multiple myeloma

A 65-year-old male with smoldering multiple myeloma. The patient had no lesions on skeletal survey. (A) CT scan of the patient's right lower extremity that shows a lytic lesion in the right distal femur. (B) PET image that demonstrates increased ¹⁸F-fluorodeoxyglucose (FDG) uptake in the PET image at the corresponding region. The ¹⁸F-FDG-PET also shows two additional areas of increased uptake probably representing early lytic changes. (C) A composite image derived from the CT scan and FDG-PET images. Reprinted with permission from [100].