Leitlinien zum multiplen Myelom und ihre aktuellen Anpassungen: Konsequenzen für die Bildgebung

Zusammenfassung

Hintergrund Seit 2014 haben sich die diagnostischen Kriterien für das multiple Myelom und seine nicht therapiepflichtigen Vorstufen geändert. Zudem wurden neue Empfehlungen zur Modalität der Bildgebung und zum Therapieansprechen vorgeschlagen. Dieser Übersichtsartikel soll einen Überblick über aktuelle Definitionen, diagnostische Optionen und neue, für den Radiologen relevante Empfehlungen zum Vorgehen bei Plasmazellerkrankungen bieten.

Methode Eine Pubmed-Suche bezüglich Leitlinien zum multiplen Myelom wurde durchgeführt und hinsichtlich der aktuellsten Veröffentlichungen internationaler Fachgesellschaften und Expertenreviews gefiltert. Die Empfehlungen der „International Myeloma Working Group“ (IMWG), des „National Comprehensive Cancer Networks“ (NCCN, USA), der Europäischen Gesellschaft für Medizinische Onkologie (ESMO) sowie des Europäischen Myelom-Netzwerks (EMN) wurden zusammengefasst.

Ergebnisse und Schlussfolgerung Der konventionelle Skelettstatus nach dem „Pariser Schema“ sollte zunehmend durch die Schnittbildgebung ersetzt werden. Zur Differenzierung eines durch Osteolysen oder Knochenmarkbeteiligung therapiepflichtigen multiplen Myeloms von seinen Vorstufen wird eine initiale Diagnostik mittels Ganzkörper-Niedrigdosis-CT und ggf. Ganzkörper-MRT empfohlen. 2 oder mehr fokale Myelom-verdächtige Herdbefunde zeigen nun auch bei intaktem mineralisiertem Knochen ein symptomatisches Myelom an. Zur Verlaufsbeurteilung gibt es bisher keine klare Empfehlung. Die Beurteilung eines fokalen Befalls vor und nach Therapie mittels ¹⁸F-FDG-PET/CT ist Bestandteil der neuen Guidelines zur Detektion einer minimalen Resterkrankung, die somit die Rolle der PET/CT neu definieren könnten.

Kernaussagen: 

• Die Ganzkörper-Niedrigdosis-CT wird als neuer Standard zur Detektion von Osteolysen durch internationale Fachgesellschaften befürwortet.

• Fokale Läsionen in der MRT zeigen auch bei intaktem mineralisiertem Knochen ein therapiepflichtiges Myelom an.

• Die IMWG empfiehlt mindestens eine Schnittbildgebung in der initialen Diagnostik: Ganzkörper-Niedrigdosis-CT, MRT oder PET/CT je nach Verfügbarkeit und Finanzierungsmöglichkeiten.

• Das diagnostische Potenzial der ¹⁸F-FDG-PET/CT beim Follow-Up wird i. R. der Definition einer minimalen Resterkrankung nach Therapie unterstrichen; die Umsetzung in Deutschland ist wegen ihres eingeschränkten Einsatzes in der Routine unsicher.

Zitierweise

• Mosebach J, Thierjung H, Schlemmer H et al. Multiple Myeloma Guidelines and Their Recent Updates: Implications for Imaging. Fortschr Röntgenstr 2019; 191: 998 – 1009

Key words

marrow - skeletal-appendicular - skeletal-axial - CT - PET-CT - MR imaging

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