A 70-year-old woman comes to the office due to back pain, fatigue, and inability to carry out her daily work. The pain began 6 months ago and has slowly intensified. The patient had a hip fracture 3 months ago but has no other medical conditions. She is a lifetime nonsmoker and drinks alcohol on social occasions. She currently takes no medications. The patient has no extremity weakness or paresthesia. She has mild constipation; urination is normal. Initial laboratory results are as follows: Dipstick urinalysis is normal. The patient undergoes a bone marrow biopsy, which shows 20% plasma cells. While discussing the options for further investigation and treatment, the patient says that, since her initial visit, she has had pain in her left shoulder and right flank after a minor fall. Which of the following is the best next step in management?

Question

A 70-year-old woman comes to the office due to back pain, fatigue, and inability to carry out her daily work.  The pain began 6 months ago and has slowly intensified.  The patient had a hip fracture 3 months ago but has no other medical conditions.  She is a lifetime nonsmoker and drinks alcohol on social occasions.  She currently takes no medications.  The patient has no extremity weakness or paresthesia.  She has mild constipation; urination is normal.  Initial laboratory results are as follows:  Dipstick urinalysis is normal. The patient undergoes a bone marrow biopsy, which shows 20% plasma cells.  While discussing the options for further investigation and treatment, the patient says that, since her initial visit, she has had pain in her left shoulder and right flank after a minor fall.  Which of the following is the best next step in management?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf69_6b1e_8f63_257b769f4f45_MD0005_00 Patients with multiple myeloma (MM) require evaluation of the skeletal system to determine the size, number, and location of bone lesions, which helps predict symptomatic progression. Although plain radiographs (skeletal survey) were used in the past, cross-sectional imaging with whole-body CT, MRI, or positron emission tomography scan is now recommended because these studies are far more sensitive. In most centers, whole-body low-dose CT scan without contrast is the preferred screening modality due to its relatively low cost and the ease and speed of testing. (Choice A) Patients with MM who have bone fractures frequently have elevated alkaline phosphatase levels. However, this finding is not a reliable marker of total bone tumor burden. (Choice B) Technetium-99m bone scanning detects areas of bone remodeling due to integration of radiolabeled phosphate analogues. Therefore, this study is primarily used to evaluate for blastic bone lesions. Because MM causes lytic lesions, technetium-99m bone scans are not typically helpful in the evaluation of this disease. (Choice D) A skeletal survey uses plain radiographs of the spine, humeri, femurs, skull, and pelvis to evaluate for lytic lesions. Although skeletal survey can be used when no other imaging modalities are available or possible, it is not the preferred modality for evaluation of bone lesions in patients with MM due to low sensitivity. Educational objective: Patients with multiple myeloma require evaluation of the skeletal system to assess for bone involvement. Whole-body cross-sectional evaluation with low-dose CT scan without contrast, MRI, or positron emission tomography scan is preferred. Skeletal survey is less sensitive and is only recommended when whole-body cross sectional imaging is not possible or available.

A 70-Year-Old Woman Comes to the Office Due to Back