TREATMENT OF BONE DISEASE

 

 

The following picture of a CT scan (my personal archive) illustrates several skeletal events that may occur in the course of multiple myeloma:
  1 - Multiple lytic lesions in the visualized bones
  2 - Several compression fractures in the spine
  3 - Kyphotic deformity of the upper thoracic spine (arrow)
  4 - Bone cement from vertebroplasty at L4 and L5
  5 - Marked expansion of the sternum, which is completely replaced by myeloma
Patient had also several healed rib fractures, and a pathologic fracture in a humerus (not shown), requiring surgery with intramedullary rod placement.

 

 

 

The presence of osteopenia or osteoporosis should be evaluated by a dual-energy X-ray absorptiometry (DEXA) scan. This technique assesses the bone mineral density (BMD) in lumbar spine, femoral neck, and distal radius.

Skeletal-related events (SREs) in multiple myeloma can be defined as:
  - pathologic fracture
  - spinal cord compression
  - need for bone radiation therapy
  - need for bone surgery

 

 


Radiotherapy

 

MM is very sensitive to radiation.
RT is useful for:
 - Palliating pain in localized bone lesions
 - Preventing fractures in large osteolytic bone lesions
 - Spinal cord compression
 - Extramedullary plasmacytomas
 - Involvement of vital organs
 - Solitary plasmacytoma (it may be curative)

Radiotherapy usually requires 2-4 weeks to take effect.

 

 

Current role of radiation therapy for multiple myeloma.
Front Oncol. 2015 Feb 18;5:40.
Talamo G, Dimaio C, Abbi KK, Pandey MK, Malysz J, Creer MH, Zhu J, Mir MA, Varlotto JM.
Retrospective study of 449 consecutive myeloma patients. Treatment with RT was indicated in 149 (34%) of them. Most common indications for RT:
  - Palliation of bone pain (109 pts, 42%)
  - Prevention/treatment of pathological fractures (73 pts, 28%)
  - Spinal cord compression (26 pts, 10%)
  - Involvement of vital organs or extramedullary disease (25 pts, 10%)

 

 


Surgery

 

Surgery of the spine with decompression is indicated for the treatment of spinal cord compression.
Fractures or impending fractures of long bones are treated with fixation and intramedullary rod placement.

 

The following x-rays show a compression fracture at T8 and surgical fixation of the spine after laminectomy for spinal cord compression (my personal archive). Spinal cord compression is an oncologic emergency.

 

         

 

 

Surgical placement of an intramedullary rod for an expansile lytic lesion in the diaphysis of the right humerus (my personal archive):

 

 

 

Surgical placement of an intramedullary rod for a large lytic lesion in the distal diaphysis of the right femur with high risk of pathologic fracture (my personal archive):

 

 

 

Surgical therapy of skeletal complications in multiple myeloma.
Int Orthop. 2011 Aug;35(8):1209-13.
Utzschneider S, Schmidt H, Weber P, Schmidt GP, Jansson V, Dürr HR.

 

 


VERTEBROPLASTY and Kyphoplasty

 

Vertebroplasty and kyphoplasty provide a significant and durable pain relief for patients with intractable spinal pain secondary to osteolytic vertebral compression fractures.
Pain relief is expected within 24 hours after the procedure.

Vertebroplasty involves the percutaneous injection of polymethyl-methacrylate (PMMA), a highly viscous bone cement, in the vertebral body.

Kyphoplasty involves the insertion of an inflatable balloon, which creates a cavity in the vertebral body that can be filled with PMMA. The introduction of inflatable bone tamps into the vertebral body restores the vertebral body to its original height.

Possible complications include the extravasation of PMMA into the spinal canal and neural foramina, pulmonary embolism, and infections.

 

Bone cement injected in a fractured vertebral body after vertebroplasty - x-ray (my personal archive):

 

 

 

Pulmonary embolism of polymethyl methacrylate during percutaneous vertebroplasty and kyphoplasty.
AJR Am J Roentgenol. 2004 Oct;183(4):1097-102.
Choe DH, Marom EM, Ahrar K, Truong MT, Madewell JE.
This study reviewed the findings of CXR taken after percutaneous vertebroplasty procedures in 64 patients. Pulmonary emboli of cement in lungs were noted in 3 of 65 (4.6%) vertebroplasty or kyphoplasty. The findings at the CXR were multiple radiodense opacities with a tubular and branching shape. All patients with cement pulmonary embolism to lungs were asymptomatic. Pulmonary embolism of cement was not correlated with the type of procedure performed, kyphoplasty vs vertebroplasty.

Percutaneous vertebroplasty and kyphoplasty in patients with multiple myeloma.
Eur J Haematol. 2006 Feb;76(2):180-1.
Bartolozzi B, Nozzoli C, Pandolfo C, Antonioli E, Guizzardi G, Morichi R, Bosi A.

The role of vertebral augmentation in multiple myeloma: International Myeloma Working Group Consensus Statement.
Leukemia. 2008 Aug;22(8):1479-84.
Hussein MA, Vrionis FD, Allison R, Berenson J, Berven S, Erdem E, Giralt S, Jagannath S, Kyle RA, LeGrand S, Pflugmacher R, Raje N, Rajkumar SV, Randall RL, Roodman D, Siegel D, Vescio R, Zonder J, Durie BG; International Myeloma Working Group.

Vertebral augmentation in the treatment of pathologic compression fractures in 792 patients with multiple myeloma.
Leukemia. 2013 Dec;27(12):2391-3.
Erdem E, Samant R, Malak SF, Culp WC, Brown A, Peterson L, Lensing S, Barlogie B.
This is a retrospective review of 2693 vertebral augmentation procedures in 792 patients with multiple myeloma and spinal compression fractures. Vertebroplasty was the procedure used in 83% of cases. Results:
  - Distribution: T1-T10 37%, T11-L2 39%, L3-sacrum 24%
  - Pain levels reduced, from a pre-procedure average score of 6.9, to a post-procedure average score of 4.2 (using a 0-10 pain level scale).
  - Use of narcotic analgesics reduced from a baseline of 70% to 48% after the procedure.

 

VERTEBROPLASTY

A technique to circumvent subcutaneous cement tracts during percutaneous vertebroplasty.
AJNR Am J Neuroradiol. 2004 Oct;25(9):1595-6.
Kaufmann TJ, Wald JT, Kallmes DF.

Vertebroplasty in multiple myeloma: outcomes in a large patient series.
AJNR Am J Neuroradiol. 2008 Apr;29(4):642-8.
McDonald RJ, Trout AT, Gray LA, Dispenzieri A, Thielen KR, Kallmes DF.
This study reviewed clinical outcomes in 67 multiple myeloma patients treated with vertebroplasty. The authors observed a significant improvements in all of the outcome measures after the vertebroplasty:
  - 82% of patients had a significant improvement in subjective rest pain
  - 89% of patients had a significant improvement in subjective activity pain
  - 65% of patients required fewer narcotics after vertebroplasty
  - 70% of patients had improved mobility

Percutaneous vertebroplasty in multiple myeloma: prospective long-term follow-up in 106 consecutive patients.
Cardiovasc Intervent Radiol. 2012 Feb;35(1):139-45.
Anselmetti GC, Manca A, Montemurro F, Hirsch J, Chiara G, Grignani G, Carnevale Schianca F, Capaldi A, Rota Scalabrini D, Sardo E, Debernardi F, Iussich G, Regge D.

 

KYPHOPLASTY

Kyphoplasty in the treatment of osteolytic vertebral compression fractures as a result of multiple myeloma.
J Clin Oncol. 2002 May 1;20(9):2382-7.
Dudeney S, Lieberman IH, Reinhardt MK, Hussein M.
This study evaluates the efficacy of 55 consecutive kyphoplasty procedures in 18 myeloma patients with osteolytic vertebral compression fractures. Kyphoplasty restored, on average, 34% of height lost at the time of fracture. It led to a significant clinical improvement of bony pain and physical function. The authors found no major complications related directly to use of this technique.  Asymptomatic cement leakage occurred at 2 levels (4%).

Kyphoplasty for patients with multiple myeloma is a safe surgical procedure: results from a large patient cohort.
Clin Lymphoma Myeloma. 2009 Oct;9(5):375-80.
Huber FX, McArthur N, Tanner M, Gritzbach B, Schoierer O, Rothfischer W, Krohmer G, Lessl E, Baier M, Meeder PJ, Kasperk C.
This study evaluates the outcomes of 190 kyphoplasty procedures in 76 patients with multiple myeloma. The authors observed one case of pulmonary embolism, due to leakage of the bone cement.

 

 


Giampaolo Talamo, M.D.