Evaluating Treatment Strategies for Spinal Lesions in Multiple Myeloma: A Review of the Literature

Abstract

Background: Vertebral disease is a major cause of morbidity in 70% of patients diagnosed with multiple myeloma (MM). Associated osteolytic lesions and vertebral fractures are well documented in causing debilitating pain, functional restrictions, spinal deformity, and cord compression. Currently, treatment modalities for refractory MM spinal pain include systemic therapy, radiotherapy, cementoplasty (vertebroplasty/kyphoplasty), and radio frequency ablation. Our objectives were to report on the efficacy of existing treatments for MM patients with refractory spinal pain, to determine if a standardized treatment algorithm has been described, and to set the foundation upon which future prospective studies can be designed. Methods: A systematic search of the PubMed database was performed for studies relevant to the treatment of vertebral disease in MM patients. A multitude of search terms in various combinations were used, including but not limited to: ''vertebroplasty,'' ''kyphoplasty,'' ''radiation,'' ''multiple myeloma,'' ''radiotherapy,'' and ''radiosurgery.'' Results: Our preliminary search resulted in 219 articles, which subsequently resulted in 19 papers following abstract, title, full-text, and bibliography review. These papers were then grouped by treatment modality: radiotherapy, cementoplasty, or combination therapy. Significant pain and functional score improvement across all treatment modalities was found in the majority of the literature. While complications of treatment occurred, few were noted to be clinically significant. Conclusions: Treatment options-radiotherapy and/or cementoplasty-for vertebral lesions and pathologic fractures in MM patients demonstrate significant radiographic and clinical improvement. However, there is no consensus in the literature as to the optimal treatment modality as a result of a limited number of studies reporting headto-head comparisons. One study did find significantly improved pain and functional scores with preserved vertebral height in favor of kyphoplasty over radiotherapy. When not contraindicated, we advocate for some form of cementoplasty. Further prospective studies are required before implementation of a standardized treatment protocol. Level of Evidence: 5.

The Role of Vertebral Augmentation Procedures in the Management of Multiple Myeloma

“…Stereotactic radiotherapy has been studied as a treatment modality for MBD, secondary to its tumoricidal effect on MM cells, and to block the migration of neoplastic cells by forming an ablation-shell barrier or by embolization of necrotic tumor cells. 47 The American Society for Radiation Oncology guidelines suggest schemes of a single 8 Gy fraction, 20 Gy in 5 fractions, 24 Gy in 6 fractions, or 30 Gy in 10 fractions, which showed adequate pain relief from painful bone metastasis. 48 However, radiation doses in excess of 24 Gy pose a higher risk of Grade-I radiation toxicity.…”

Vertebroplasty in patients with multiple myeloma with vertebral compression fractures: protocol for a single-blind randomised controlled trial

“…The procedure is considered to be well suited for treatment of patients with malignant spine disease as it can be done under local anaesthesia, provides rapid pain relief 11 12 and prevents prolonged immobilisation. PVP and KP provide stability within the fractured vertebral body by preventing microscopic movement and macroscopic collapse.…”

Surgical Management of Multiple Myeloma and Plasmocytoma of the Spine

“…The vertebral disease is a major cause of morbidity in 70% of patients diagnosed with multiple myeloma. Associated osteolytic lesions and vertebral fractures are well documented in causing debilitating pain, functional restrictions, spinal deformity, and cord compression [10]. Clinically a vertebral plasmocytoma shows up with symptomatology that varies from back pain, with or without minimal correlation with weight bearing [11], to acute back pain with structural instability due to pathological fracture to symptoms leading to neurological compression.…”