Bony lytic lesions
Myeloma or metastasis? The causes of lytic bone lesions, the myeloma screen and imaging that answer it, IMWG criteria, fracture and cord compression risk, and bone-directed therapy.
Tier 1Approach to a presentation
Written with AI assistance and fact-checked against the sources below. For exam study, not clinical decisions. How notes are made
At a glance
- In an adult over 40, a lytic lesion is myeloma or metastatic carcinoma until proven otherwise. Lymphoma, hyperparathyroidism and infection are next.
- Two blood tests answer the myeloma question fast: serum protein electrophoresis with immunofixation and serum free light chains.
- Image the whole skeleton with whole-body low-dose CT (WBLDCT), PET-CT or whole-body MRI. Plain skeletal surveys miss many lesions, and bone scans miss myeloma.
Loading the rest of the note…
Finished reading?
Sources
- International Myeloma Working Group updated criteria for the diagnosis of multiple myelomaRajkumar SV et al., Lancet Oncol 2014;15:e538-48, 2014
- International Myeloma Working Group consensus recommendations on imaging in monoclonal plasma cell disordersHillengass J et al., Lancet Oncol 2019;20:e302-12, 2019
- Treatment of multiple myeloma-related bone disease: recommendations from the Bone Working Group of the International Myeloma Working GroupTerpos E et al., Lancet Oncol 2021;22:e119-30, 2021
- MSAG clinical practice guidelines for newly diagnosed and relapsed or refractory multiple myelomaAU/NZMedical Scientific Advisory Group to Myeloma Australia, January to March 2026
- Denosumab versus zoledronic acid in bone disease treatment of newly diagnosed multiple myeloma: an international, double-blind, double-dummy, randomised, controlled, phase 3 studyRaje N et al., Lancet Oncol 2018;19:370-81, 2018
- Denosumab public summary document, July 2019 PBAC meetingAU/NZPharmaceutical Benefits Advisory Committee, 2019
- Metastatic disease in long bones: a proposed scoring system for diagnosing impending pathologic fracturesMirels H, Clin Orthop Relat Res 1989;(249):256-64, 1989
- Multiple myeloma stakeholder meeting (sponsors) outcome statementAU/NZPharmaceutical Benefits Advisory Committee, 3 February 2026
- Daratumumab, bortezomib, lenalidomide and dexamethasone for multiple myeloma (PERSEUS)Sonneveld P et al., N Engl J Med 2024;390:301-13, 2024
- Last updated
- 14 November 2026
What changed
- 14 November 2026 Turnstile bot check on sign-in and signed-out feedback