Distinguishing Osteoporosis from Multiple Myeloma

Key Distinguishing Features

Ordinary osteoporosis is characterized by diffuse bone loss without focal destructive lesions, affecting trabecular bone uniformly, according to the International Osteoporosis Foundation 1
The presence of discrete lytic (punched-out) lesions visible on imaging is a characteristic of multiple myeloma bone disease, as stated by the European Society for Medical Oncology 1, 2
Multiple myeloma bone disease presents in approximately 90% of symptomatic myeloma patients, with increased osteoclastic activity and suppressed osteoblastic function, as reported by the American Society of Hematology 1, 2
Normal alkaline phosphatase or elevated bone-specific ALP is typically seen in osteoporosis, whereas in myeloma, ALP is typically normal or low despite lytic lesions, according to the National Comprehensive Cancer Network 3

If discrete lytic lesions are present, the European Society for Medical Oncology recommends ordering serum free light chain assay immediately, performing serum and urine protein electrophoresis with immunofixation, checking complete blood count, calcium, creatinine, and albumin, and proceeding with bone marrow biopsy 3, 4
If only diffuse osteopenia without lytic lesions is present, the International Myeloma Society suggests considering myeloma workup if osteoporosis occurs in males or premenopausal women, and obtaining MRI of spine (or whole-body MRI if available) to detect marrow involvement 1, 2, 4

The American College of Radiology recommends whole-body low-dose CT (WBLD-CT) as the gold standard for detecting lytic lesions, which detects 60% more relevant findings than conventional X-rays 2, 5
MRI is superior for detecting bone marrow infiltration before lytic destruction occurs, as stated by the European Society of Radiology 1, 2