You are on page 1of 6

Musculoskeletal Imaging Bredella et al. Use of FDG PET in Assessing Multiple Myeloma

Value of FDG PET in the Assessment of Patients with Multiple Myeloma

FDG PET in the Assessment of Patients with Multiple Myeloma Miriam A. Bredella 1 , 2

Miriam A. Bredella 1,2 Lynne Steinbach 1 Gary Caputo 2 George Segall 3 Randall Hawkins 2

Received April 8, 2004; accepted after revision July 14, 2004.

1 Department of Radiology, Massachusetts General Hospital, 15 Parkman St., WACC 515, Boston, MA 02114. Address correspondence to M. A. Bredella (mbredella@yahoo.com).

2 Department of Radiology, University of California San Francisco, San Francisco, CA 94143-0628.

3 Department of Nuclear Medicine, VA Palo Alto Health Care System, Palo Alto, CA 94304.

AJR 2005;184:1199–1204

0361–803X/05/1844–1199

© American Roentgen Ray Society

AJR:184, April 2005

OBJECTIVE. Our objective was to evaluate if whole-body PET with FDG is able to detect bone marrow involvement in patients with multiple myeloma and to assess its appearance and distribution pattern. MATERIALS AND METHODS. Seventeen whole-body FDG PET scans were per- formed in 13 patients with multiple myeloma. Four patients were referred for evaluation of ex- tent of disease pretherapy and nine patients were referred for assessment of therapy response (chemotherapy, radiation therapy, bone marrow transplant). FDG PET images were evaluated for distribution and uptake pattern. Standardized uptake values were obtained to quantify FDG uptake. Results of other imaging examinations (MRI, CT, radiography), laboratory data, biop- sies, and the clinical course were used for verification of detected lesions. RESULTS. FDG PET was able to detect medullary involvement of multiple myeloma. There were two false-negative results. In one patient, the radiographic skeletal survey showed subcentimeter lytic lesions within the ribs that were not detected on FDG PET and in the other patient, a lytic lesion detected on radiographs showed only mildly increased FDG uptake that was not identified prospectively. There was one false-positive FDG PET result in a patient who had undergone radiation therapy 3 weeks before PET. FDG PET was helpful in differentiating between posttherapeutic changes and residual/recurrent tumor and in assessing response to therapy. FDG PET resulted in upstaging of disease in four patients, which influenced subse- quent management and prognosis. Sensitivity of FDG PET in detecting myelomatous involve- ment was 85% and specificity was 92%. CONCLUSION. FDG PET is able to detect bone marrow involvement in patients with mul- tiple myeloma. FDG PET is useful in assessing extent of disease at time of initial diagnosis, con- tributing to staging that is more accurate. FDG PET is also useful for evaluating therapy response.

M
M

ultiple myeloma is a malignant hematologic disorder character- ized by bone marrow infiltration with neoplastic plasma cells [1,

2]. Multiple myeloma accounts for 10% of all hematologic cancers with an incidence of ap- proximately 4/100,000 per year [3]. The diag- nosis of multiple myeloma is based on specific criteria that include paraproteinemia, plasma cell infiltration of bone marrow, and osteolytic bone destruction. Approximately 5–10% of patients have a solitary plasmacy- toma and two thirds of these patients progress to multiple myeloma, presumably because occult disease is present at initial diagnosis [4, 5]. According to the staging system intro- duced by Durie and Salomon [6], the extent of bone lesions in multiple myeloma signifi- cantly influences therapy. Patients with stage I multiple myeloma, with only limited alter-

ation in blood parameters and not more than one skeletal lesion, are followed clinically without therapy, whereas patients with stage II or III multiple myeloma require chemother- apy [2, 4, 6, 7]. With the development of new therapeutic options for treating multiple my- eloma [1, 4], it becomes increasingly impor- tant to accurately and noninvasively diagnose myelomatous lesions and follow them after treatment. It has been shown that bone scintigraphy is inadequate for the detection of myeloma-as- sociated bone lesions due to minimal osteo- blastic activity and hypovascularity of the lesion [8, 9]. Radiographs are usually ob- tained for staging, but are limited for evaluat- ing early disease (stages I and II), and several studies have shown that multifocal disease may be present despite normal radiographs [10–12]. MRI is more sensitive than radio-

1199

graphs in detecting bone marrow lesions, and studies have shown that MRI of the vertebral column can detect additional lesions in one third of patients considered to have solitary plasmacytoma based on radiographic find- ings; however, the sensitivity of detecting early disease is limited [13, 14]. MRI and ra- diographs often cannot differentiate between treated bone marrow lesions and viable neo- plastic tissue. FDG is an analog of glucose that is radio- labeled with the positron-emitting radionu- clide 18 F. Metabolically active cells take up and phosphorylate FDG, which then is not further metabolized and remains trapped within the cell. The resulting intracellular ac- cumulation of FDG is imaged with PET. High uptake is seen in tumor cells, which have in- creased rates of metabolism compared with normal tissue [15]. FDG PET has been exten- sively used to detect occult malignant and metastatic lesions in patients with carcinoma or lymphoma and has been become a standard tool for staging patients with bronchogenic carcinoma [16–19].

for staging patients with bronchogenic carcinoma [16–19]. Fig. 1.— 55-year-old woman with newly diagnosed multiple

Fig. 1.—55-year-old woman with newly diagnosed multiple myeloma, evaluated pretherapy. Whole-body FDG PET shows multiple foci of increased FDG uptake in bone marrow throughout the body, consistent with myelomatous involvement. Standardized uptake val- ues of lesions ranged from 3.8 to 6.2.

1200

Bredella et al.

The purpose of our study was to evaluate if whole body FDG PET is able to detect bone marrow involvement in patients with multiple myeloma and to assess its appearance and dis- tribution pattern. We also evaluated the per- formance of FDG PET in detecting myelomatous disease compared with other standard imaging methods such as MRI, CT, or radiography and assessed the influence of the additional information obtained by FDG PET on staging and therapy

Materials and Methods We retrospectively studied 13 patients with multiple myeloma, who were referred for im- aging (MRI, CT, radiographs) of the muscu- loskeletal system to evaluate for myelomatous involvement. Patients were diagnosed with multiple myeloma on the basis of the criteria defined by Durie and Salmon [6]. All patients underwent whole-body FDG PET. The patient population included 10 males and three fe- males, aged 41–79 years, with a mean age of 54 years. Four patients were referred for eval- uation of disease extent pretherapy and nine patients were referred for assessment of ther- apy response (chemotherapy, bone marrow transplant, radiation therapy, surgical resec- tion). Three patients underwent serial MRI, CT, radiographs, and FDG PET scans to as- sess response to therapy. All patients underwent whole-body FDG

PET using an ECAT EXACT HR (CTI, Sie- mens Medical Solutions) camera, allowing si- multaneous acquisition of 47 contiguous slices with a slice thickness of 3.375 mm (one bed position, 15.86-cm axial field of view). The pa- tients fasted at least for 4 hr before the study, with plasma glucose levels obtained at the time

of FDG administration. Blood glucose levels at

the time of injection were less than 6.5 mmol/

L in all patients. FDG (3.7 MBq [0.1 mCi]/kg

body weight) was injected IV. Whole-body emission scanning (8 to 12 bed positions; ac- quisition time, 5 min/bed position) was per- formed 45 min after FDG administration. The PET scans were reconstructed by filtered-back projection using a Hanning filter. FDG PET images were evaluated visually by two experi- enced radiologists. The radiologists had results of other imaging studies available to them at the time of PET. Regions of interest (ROIs) were drawn man- ually around areas of increased uptake. The av- erage and peak activity within each tumor was then corrected for radioactive decay and nor- malized for patient weight. The standardized uptake values were calculated based on the fol-

lowing equation: Standardized uptake value (SUV) = tissue concentration (MBq/g)/[in- jected dose (MBq)/body weight(g)]. While the optimal method for drawing ROIs would be using CT or MRI as an anatomic template that projects ROIs onto PET data with coregistered PET/CT or PET/MRI data sets, this was not possible in this study because coregistered data sets were not available. We felt the best ap- proach was to use direct visualization of the ra- diographic and PET results to guide manual definition of ROIs on PET images. In addition, because lesions often had somewhat irregular borders, iscontouring or other semiautomatic ROI definition methods would likely not change the results and could, with relatively low-intensity margins of lesions, actually in- troduce more error and noise into the analysis. Ten patients underwent MRI using a 1.5-T magnet (Signa; GE Healthcare) with the fol- lowing imaging sequences: T1-weighted spin-echo (TR/TE, 600/20), STIR (3,000/ 150), fat-suppressed T2-weighted fast spin- echo (3,000/90), and fat-suppressed T1- weighted spin-echo (600/20) before and after the administration of gadopentetate dimeglu- mine. Section thickness was 4 mm, intersec- tion gap was 1 mm, field of view was 14 cm, and the matrix was 256 × 256 pixels. MR images were evaluated for diffuse or focal bone marrow infiltration that was hy- pointense on T1- and hyperintense on T2- weighted and STIR images. The number, lo- cation, size, signal intensity, and enhance- ment pattern of each lesion were recorded. Four patients underwent CT of the spine, and six patients underwent radiography of the spine, pelvis, ribs, skull, and proximal long bones (skeletal survey). CT images and radio- graphs were evaluated for lytic and perme- ative bone lesions, and the location and size of each lesion were recorded. FDG PET was performed within 6 weeks of MRI, CT, or ra- diographs. The results of the imaging studies, laboratory data, biopsies, and clinical course were used for verification of detected lesions.

Results We evaluated 17 FDG PET, 16 MRI, four CT studies, and six radiographic bone surveys in 13 patients over a period of 2 years. Four patients underwent FDG PET and MRI at baseline before initiation of therapy. One of these patients showed diffuse abnormal increased FDG uptake throughout the spine, ribs, pelvis, and long bones, consistent with diffuse myelomatous involvement (Fig. 1). MRI of the spine in this patient showed abnor-

AJR:184, April 2005

Use of FDG PET in Assessing Multiple Myeloma

Use of FDG PET in Assessing Multiple Myeloma A B C Fig. 2.— 56-year-old woman with

A

Use of FDG PET in Assessing Multiple Myeloma A B C Fig. 2.— 56-year-old woman with

B

Use of FDG PET in Assessing Multiple Myeloma A B C Fig. 2.— 56-year-old woman with

C

Fig. 2.—56-year-old woman with multiple myeloma, pretherapy. A, Coronal FDG PET shows no abnormal FDG uptake and was interpreted as normal. B, Sagittal FDG PET through left upper extremity shows only mildly increased FDG uptake in left humerus (arrow) that was not detected prospectively. C, Radiograph of left humerus shows large lytic lesion (arrow), corresponding to area of abnormal FDG uptake. This was found to represent myelomatous involvement on subsequent biopsy.

mal infiltrative bone marrow signal that was low on T1- and high on T2-weighted images, consistent with myelomatous involvement. One patient showed no abnormal uptake on FDG PET, and radiographs and MRI were deemed normal. There were two false-nega- tive results on FDG PET. In one patient, a skel- etal survey showed subcentimeter lytic lesions within the ribs that were not detected on FDG PET. Subcentimeter radiolucencies in this pa- tient might have been too small to characterize

Fig. 3.—43-year-old man with high-grade plasmacy- toma of right hemipelvis, status postchemotherapy and bone marrow transplant. A, Coronal fat-suppressed T1-weighted MRI with gado- pentetate dimeglumine shows abnormal enhancing soft tissue in right hemipelvis. B, Coronal FDG PET shows abnormal FDG uptake in right hemipelvis with standardized uptake value rang- ing from 4.3 to 5.0.

AJR:184, April 2005

with FDG PET. The other patient showed a large lytic lesion on radiographs, which showed only mildly increased FDG uptake and was not identified prospectively. The lytic le- sion was due to myelomatous involvement as proven by subsequent biopsy (Fig. 2). None of these patients received immunosuppressive therapy before imaging, which could have led to suppressed FDG uptake. Nine patients underwent chemotherapy, radiation therapy, bone marrow transplant,

chemotherapy, radiation therapy, bone marrow transplant, A surgical resection, or a combination of these. In four

A

surgical resection, or a combination of these. In four patients, MRI findings were equivocal in differentiating between post- therapeutic changes and residual/recurrent tumor. Subsequent FDG PET demonstrated increased uptake, consistent with myeloma- tous involvement in two cases, confirmed by biopsy. No abnormal FDG uptake was noted in the remaining two cases. These two patients showed clinical improvement. One patient with initial diagnosis of solitary plas-

two cases. These two patients showed clinical improvement. One patient with initial diagnosis of solitary plas-

B

1201

A D Bredella et al. B E C F Fig. 4.— 41-year-old patient with multiple

A

A D Bredella et al. B E C F Fig. 4.— 41-year-old patient with multiple myeloma

D

Bredella et al.
Bredella et al.

B

A D Bredella et al. B E C F Fig. 4.— 41-year-old patient with multiple myeloma

E

A D Bredella et al. B E C F Fig. 4.— 41-year-old patient with multiple myeloma

C

A D Bredella et al. B E C F Fig. 4.— 41-year-old patient with multiple myeloma

F

Fig. 4.—41-year-old patient with multiple myeloma of C1/C2, status post posterior spinal fusion, chemotherapy, and bone marrow transplant 9 months ago. A, Sagittal fat-suppressed T1-weighted MRI with gadopentetate dimeglumine shows abnormal enhancing soft tissue (arrow) at C1/C2, suspicious for recurrent myeloma. B, Sagittal FDG PET shows no abnormal FDG uptake in cervical spine. Patient was followed clinically and there was no evidence of recurrent tumor over 1 year. Note phys- iologic FDG uptake in the oropharynx (arrow). C, Axial CT image through upper cervical spine obtained for neck pain 8 months later shows lytic lesions at C1/ C2 at site of original tumor (arrow). These findings were thought to represent recurrent tumor. Note posterior spinal fusion hardware. D, Sagittal FDG PET shows no abnormal FDG uptake and patient improved clinically without evidence of recurrent tumor. E, Sagittal fat-suppressed T1-weighted MRI with gadopentetate dimeglumine, obtained 7 months later for alteration in blood parameters that was suspicious for recurrent tumor. There is abnormal enhancing soft tissue at C1/C2 (arrow) that was thought to represent recurrent tumor. F, Sagittal FDG PET obtained same day shows no abnormal FDG uptake in cervical spine; however, new focus of intense FDG uptake (standardized uptake value: 4.3) is noted in left sacroiliac region (arrow) that was found to represent myeloma on subsequent biopsy.

1202

AJR:184, April 2005

Use of FDG PET in Assessing Multiple Myeloma

macytoma, based on MRI and radiographic bone survey, showed multiple FDG-avid foci, suspicious for myelomatous involvement, which influenced staging and subsequent therapy. Extensive medullary and ex- tramedullary involvement was confirmed in this patient on autopsy. One patient with plasmacytoma of the right hemipelvis showed abnormal enhancing soft tissue, consistent with plasmacytoma. This was confirmed on subsequent FDG PET (Fig. 3). One patient who had undergone radiation therapy of the right clavicle three weeks be- fore FDG PET, showed abnormal uptake in the region of the radiated clavicle and sur- rounding musculature. Increased uptake was likely due to postradiation changes; however, residual tumor could not be excluded. Clini- cal follow-up in this patient showed good re- sponse to therapy without evidence of residual tumor. Three patients underwent serial MRI, CT, radiographs, and FDG PET scans to assess re- sponse to chemotherapy and bone marrow transplant. All patients showed persistent ab- normal bone marrow signal on MRI, and ab- normal lytic lesions on CT and radiographs, suspicious for residual tumor. Subsequent FDG PET demonstrated decline in metabolic activity in two patients, which was concor- dant with clinical improvement. In one pa-

tient, a new focus of abnormal uptake was detected on follow-up scan in an area distant to the original tumor, consistent with recur- rent disease (Fig. 4). Results of imaging stud- ies and clinical findings are summarized in Table 1. Sensitivity of FDG PET in detecting myelomatous involvement was 85% and specificity was 92%.

Discussion The presence and extent of bone marrow and extramedullary involvement in patients with multiple myeloma are important factors influencing prognosis and clinical manage- ment [4, 7]. Radiographs are usually obtained for staging of multiple myeloma, but are lim- ited for evaluating early disease [8]. MRI is more sensitive than radiographs in detecting bone marrow involvement; however, substi- tution of radiograph surveys by MRI limited to the spine and pelvis would cause under- staging in 10% of patients [14]. In addition, MRI has limitations in diagnosing stage I dis- ease, and up to 20% of MRI examinations can be normal despite diffuse bone marrow in- volvement [14]. A small number of patients also present with extramedullary manifesta- tions of multiple myeloma, and these lesions are often difficult to detect but have major im- pact on the prognosis [7, 20]. In a recent study by Mahnken et al. [21], MDCT of the spine,

in combination with MRI, was sensitive in detecting myelomatous involvement in pa- tients with stage III disease. However, there are no studies to evaluate the performance of CT in evaluating stage I or II disease. A recent study has shown the ability of FDG PET in differentiating posttherapeutic changes from tumor recurrence in patients with musculoskeletal sarcomas [22]. Case re- ports and two larger studies have shown the potential of FDG PET in detecting bone mar- row involvement in patients with multiple myeloma [7, 23–26]. Our study showed that FDG PET is able to detect bone marrow involvement in patients with multiple myeloma. The ability of PET to evaluate the whole body in a single procedure and the potential to detect medullary and ex- tramedullary lesions in a single examination are important advantages over standard imag- ing techniques such as MRI, CT, or radio- graphs. FDG PET also is helpful in monitoring response to therapy. In the group of patients who underwent serial FDG PET examinations, changes in metabolic activity of myelomatous lesions predicted clinical outcome. In four patients, FDG PET resulted in upstaging of disease and, therefore, more aggressive therapy. One of these patients pre- sented with plasmacytoma and the detection of additional lesions influenced management

TABLE 1

Description of Patients and Studies

 

Patient

Age

Sex

Myeloma Type

Location

Therapy

MRI, CT, Radiographs

PET Standardized Uptake Value

Histology/Clinical

Follow-Up

1

46

F

MM

Ribs

Baseline

Subcentimeter lytic lesions (radiographs)

Normal

Positive

2

55

F

MM

Axial, periph

Baseline

T2, T1, enhancement

3.8–6.2

Positive

skeleton

3

56

F

MM

Humerus

Baseline

Lytic lesion left humerus

Normal

Positive

4

54

M

MM (by lab data)

Baseline

Normal

Normal

Positive

5

43

M

Plasmacytoma

Pelvis

R, BMT

T2, T1, enhancement

4.3–5.0

Positive

6

50

M

Plasmacytoma

Skull base

C, R, S

Lytic lesions (CT, radiographs) T2, T1

Normal

Negative

7

63

M

Plasmacytoma

Pelvis

C

T2, T1, enhancement pelvis

3.2–4.1 (pelvis, spine, scapula)

Positive

(multifocal dx)

8

41

M

MM

C-spine

S, C, BMT

T2, T1, enhancement, Lytic lesions on CT, radiographs

C-spine: normal

C-spine: negative

Pelvis: 4.3–5.0

Pelvis: recurrence

9

64

M

MM

Spine

S, R, C

T2, T1

Normal

Negative

10

79

M

MM

Spine, pelvis

S, R

T2, T1

3.0–4.2

Positive

11

49

M

MM

Ribs

C, BMT

T2

2.9–3.5

Positive

12

56

M

MM

T-spine

S, R, C

T2, T1, lytic lesions (CT)

Normal

Negative

13

53

M

MM

Clavicle

R

Normal radiographs, CT

2.8–3.2

Negative

Note.—MM = multiple myeloma, S = surgical resection, R = Radiation therapy, C = Chemotherapy, BMT = bone marrow transplant, T2 = T2 hyperintensity, T1 = T1 hypointensity, Periph = peripheral, dx = disease, Spine = total spine, C-spine = cervical spine, T-spine = thoracic spine, — = not possible to determine.

AJR:184, April 2005

1203

and outcome. It must be noted that very small lesions may not be detected on FDG PET due to volume averaging in relation to the limited spatial resolution of the PET scanner. In our study, there was a false-negative result on FDG PET due to subcentimeter size of the le- sion. In one case, myelomatous involvement of the humerus showed only mildly increased metabolic activity and was not detected pro- spectively. False-positive results can occur due to inflammatory changes from radiation therapy or post surgery, as in our case, where FDG PET was performed within 3 weeks of radiation therapy. Therefore, FDG PET should not be performed within 2 months fol- lowing therapy. Our study had several limitations. First, there is the small number of patients and retrospec- tive fashion of our study. Second, the radiolo- gists had the results of other imaging studies available at time of interpretation. Another lim- itation is the lack of pathologic correlation in certain patients. We used biopsy in some cases and had to rely on additional imaging studies or clinical course in the other cases. All but one patient was evaluated more than 6 months post- therapy. Previous studies have shown that dif- fuse bone marrow uptake can be seen during or within months after chemotherapy, which can lead to false-positive results. Our study showed that FDG PET is useful in assessing the extent of multiple myeloma at time of initial diagnosis, contributing to more accurate staging. FDG PET is also useful for evaluating therapy response, especially when other imaging techniques (MRI, CT, radiog- raphy) remain abnormal. FDG PET also con- tributes to improve clinical management in patients with solitary plasmacytoma, when a higher sensitivity to detect medullary in- volvement is essential.

1204

Bredella et al.

References

1.

Tian E, Zhan F, Walker R, et al. The role of the Wnt-signaling antagonist DKK1 in the develop- ment of osteolytic lesions in multiple myeloma. N Engl J Med 2003;349:2483–2494

2.

Bartl R, Frisch B, Diem H, et al. Histologic, bio- chemical, and clinical parameters for monitoring multiple myeloma. Cancer 1991;68:2241–2250

3.

Landis SH, Murray T, Bolden S, Wingo PA. Cancer statistics, 1998. CA Cancer J Clin 1998;48:6–29

4.

Barlogie B, Shaughnessy J, Tricot G, et al. Treat- ment of multiple myeloma. Blood 2004;103:20–32

5.

Holland J, Trenkner DA, Wasserman TH, Fineberg B. Plasmacytoma. Treatment results and conversion to myeloma. Cancer 1992;69:1513–1517

6.

Durie BG, Salmon SE. A clinical staging system for multiple myeloma. Correlation of measured myeloma cell mass with presenting clinical features, response to treatment, and survival. Cancer 1975;36:842–854

7.

Durie BG, Waxman AD, D’Agnolo A, Williams CM. Whole-body (18)F-FDG PET identifies high- risk myeloma. J Nucl Med 2002;43:1457–1463

8.

Angtuaco EJ, Fassas AB, Walker R, Sethi R, Bar- logie B. Multiple myeloma: clinical review and diagnostic imaging. Radiology 2004;231:11–23

9.

Bataille R, Chevalier J, Rossi M, Sany J. Bone scin- tigraphy in plasma-cell myeloma. A prospective study of 70 patients. Radiology 1982;145:801–804

10.

Moulopoulos LA, Dimopoulos MA, Smith TL, et al. Prognostic significance of magnetic resonance imaging in patients with asymptomatic multiple myeloma. J Clin Oncol 1995;13:251–256

11.

Mariette X, Zagdanski AM, Guermazi A, et al. Prog- nostic value of vertebral lesions detected by magnetic resonance imaging in patients with stage I multiple myeloma. Br J Haematol 1999;104:723–729

12.

Tertti R, Alanen A, Remes K. The value of magnetic resonance imaging in screening myeloma lesions of the lumbar spine. Br J Haematol 1995;91:658–660

13.

Moulopoulos LA, Dimopoulos MA, Weber D, Fuller L, Libshitz HI, Alexanian R. Magnetic res- onance imaging in the staging of solitary plasma- cytoma of bone. J Clin Oncol 1993;11:1311–1315

14.

Lecouvet FE, Malghem J, Michaux L, et al. Skel- etal survey in advanced multiple myeloma: radio- graphic versus MR imaging survey. Br J Haematol 1999;106:35–39

15. Kissel J, Brix G, Bellemann ME, et al. Pharmacoki- netic analysis of 5-[18F]fluorouracil tissue concentra- tions measured with positron emission tomography in patients with liver metastases from colorectal adeno- carcinoma. Cancer Res 1997;57:3415–3423

16. Glaspy JA, Hawkins R, Hoh CK, Phelps ME. Use of positron emission tomography in oncology. Oncology (Huntingt) 1993;7:41–46, 49–50;dis- cussion 50–42, 55

17. Kostakoglu L, Goldsmith SJ. Fluorine-18 fluorode- oxyglucose positron emission tomography in the staging and follow-up of lymphoma: is it time to shift gears? Eur J Nucl Med 2000;27:1564–1578

18. Kubota K, Yamada S, Kondo T, et al. PET imag- ing of primary mediastinal tumours. Br J Cancer

1996;73:882–886

19. Strauss LG. Positron emission tomography: cur- rent role for diagnosis and therapy monitoring in oncology. Oncologist 1997;2:381–388

20. Kato T, Tsukamoto E, Nishioka T, et al. Early de- tection of bone marrow involvement in extramed- ullary plasmacytoma by whole-body F-18 FDG positron emission tomography. Clin Nucl Med

2000;25:870–873

21. Mahnken AH, Wildberger JE, Gehbauer G, et al. Multidetector CT of the spine in multiple my- eloma: comparison with MR imaging and radiog- raphy. AJR 2002;178:1429–1436

22. Bredella MA, Caputo GR, Steinbach LS. Value of FDG positron emission tomography in conjunc- tion with MR imaging for evaluating therapy re- sponse in patients with musculoskeletal sarcomas. AJR 2002;179:1145–1150

23. Orchard K, Barrington S, Buscombe J, Hilson A, Prentice HG, Mehta A. Fluoro-deoxyglucose positron emission tomography imaging for the de- tection of occult disease in multiple myeloma. Br J Haematol 2002;117:133–135

24. Schirrmeister H, Bommer M, Buck AK, et al. Ini- tial results in the assessment of multiple myeloma using 18F-FDG PET. Eur J Nucl Med Mol Imag- ing 2002;29:361–366

25. Schirrmeister H, Buck AK, Bergmann L, Reske SN, Bommer M. Positron emission tomography (PET) for staging of solitary plasmacytoma. Can- cer Biother Radiopharm 2003;18:841–845

26. Jadvar H, Conti PS. Diagnostic utility of FDG PET in multiple myeloma. Skeletal Radiol

2002;31:690–694

AJR:184, April 2005