Unstable Pathologic Vertebral Fractures in Multiple Myeloma : Propensity Score Matched Cohort Study between Reconstructive Surgery with Adjuvant Radiotherapy and Radiotherapy Alone

Abstract

Objective : Although radiotherapy (RT) is recommended for multiple myeloma (MM) involving spine, the treatment of choice between reconstructive surgery with RT and RT alone for pathologic vertebral fractures (PVFs) associated with structural instability or neurologic compromises remains controversial. The purpose of this study was to evaluate the clinical efficacies of reconstructive surgery with adjuvant RT for treatment of MM with PVFs by comparing with matched cohorts treated with RT alone. Methods : Twenty-eight patients underwent reconstructive surgery followed by RT between 2008 and 2015 in a single institution, for management of PVFs associated with structural instability of the spine and/or neurologic compromises (group I). Twentyeight patients were treated with RT alone (group II) after propensity score matching in a 1-to-1 format based on instability of the spine, as well as age and performance. Clinical outcomes including the overall survival rates, duration of independent ambulation, neurological status, and numeric rating scale (NRS) for back pain were compared. Results : Clinical and radiological features before treatment were similar in both groups. The median survival period was similar between the two groups. However, the mean duration of independent ambulation was significantly longer in group I (88.8 months; 95% confidence interval [CI], 66.0-111.5) than in group II (39.4 months; 95% CI, 25.2-53.6) (log rank test; p=0.022). Deterioration of Frankel grade (21.4% vs. 60.7%, p=0.024) and NRS for back pain (2.7±2.2 vs. 5.0±2.7, p=0.000) at the last follow-up were higher in the group II. Treatment-related complications were similar in both groups. Conclusion :In patients with unstable PVFs due to MM, reconstructive surgery may yield superior clinical outcomes compared with RT alone in maintaining independent ambulation and neurological status, as well as pain control despite similar median survival and complications.

When Should Spinal Surgery Be Considered for Spinal Metastasis from Non-Small Cell Lung Cancer?—Propensity Score Matched Study between Surgery with Radiotherapy and Radiotherapy Alone

“…Although a direct comparison of neurologic recovery between the surgery group and RT alone group was not possible due to different neurologic statuses before the treatment, a previous study reported that relief of Frankel grade in the surgery group was superior to that of the radiotherapy group (p = 0.025) in treating spinal metastasis of lung cancer [27]. In the pathologic vertebral fracture in multiple myeloma, we also reported that spinal surgery might provide better clinical outcomes than RT alone in maintaining independent ambulation, neurological status, and pain control despite similar median survival and complications [28].…”

“…This result was consistent with our previous report regarding multiple myeloma. In patients with unstable pathologic vertebral fractures due to multiple myeloma, spinal surgery with adjuvant RT compared with RT alone provided better clinical outcomes in terms of maintaining independent ambulation and neurologic status despite similar median survival and complications [28]. In this regard, surgery for the MSD of lung cancer should be considered for cases of potentially unstable spine and neurological deficits that can be resolved by direct decompression.…”

Which factors are associated with adverse prognosis in multiple myeloma patients after surgery? - preliminary establishment and validation of the nomogram

“…Regression analysis results demonstrated that preoperative KPS and ECOG-PS scores were factors influencing patient prognosis. It is evident that postoperative records better reflect patient prognosis [ 55 ]. However, considering that the purpose of this study was to provide references for preoperative decision-making, the KPS and ECOG-PS values included preoperative records, unavoidably reducing the predictive accuracy of these parameters.…”

“…Nonetheless, KPS showed meaningful statistical results. The lower the KPS and the higher the ECOG-PS score, the worse the prognosis of the patients [ 27 , 55 ]. Currently, ECOG has been proven to be associated with an increased risk of infection in patients with MM and has been incorporated into the infection risk prediction models for MM patients, such as the FIRST and GEM-PETHEMA models [ 56 ].…”