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Khan AA, Morrison A, Hanley DA, Felsenberg D, McCauley LK, O'Ryan F, Reid IR, Ruggiero SL, Taguchi A, Tetradis S, Watts NB, Brandi ML, Peters E, Guise T, Eastell R, Cheung AM, Morin SN, Masri B, Cooper C, Morgan SL, Obermayer-Pietsch B, Langdahl BL, Al Dabagh R, Davison KS, Kendler DL, Sándor GK, Josse RG, Bhandari M, El Rabbany M, Pierroz DD, Sulimani R, Saunders DP, Brown JP, Compston J. Diagnosis and management of osteonecrosis of the jaw: a systematic review and international consensus. J Bone Miner Res 2015; 30:3-23. [PMID: 25414052 DOI: 10.1002/jbmr.2405] [Citation(s) in RCA: 818] [Impact Index Per Article: 90.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 11/03/2014] [Accepted: 11/05/2014] [Indexed: 11/08/2022]
Abstract
This work provides a systematic review of the literature from January 2003 to April 2014 pertaining to the incidence, pathophysiology, diagnosis, and treatment of osteonecrosis of the jaw (ONJ), and offers recommendations for its management based on multidisciplinary international consensus. ONJ is associated with oncology-dose parenteral antiresorptive therapy of bisphosphonates (BP) and denosumab (Dmab). The incidence of ONJ is greatest in the oncology patient population (1% to 15%), where high doses of these medications are used at frequent intervals. In the osteoporosis patient population, the incidence of ONJ is estimated at 0.001% to 0.01%, marginally higher than the incidence in the general population (<0.001%). New insights into the pathophysiology of ONJ include antiresorptive effects of BPs and Dmab, effects of BPs on gamma delta T-cells and on monocyte and macrophage function, as well as the role of local bacterial infection, inflammation, and necrosis. Advances in imaging include the use of cone beam computerized tomography assessing cortical and cancellous architecture with lower radiation exposure, magnetic resonance imaging, bone scanning, and positron emission tomography, although plain films often suffice. Other risk factors for ONJ include glucocorticoid use, maxillary or mandibular bone surgery, poor oral hygiene, chronic inflammation, diabetes mellitus, ill-fitting dentures, as well as other drugs, including antiangiogenic agents. Prevention strategies for ONJ include elimination or stabilization of oral disease prior to initiation of antiresorptive agents, as well as maintenance of good oral hygiene. In those patients at high risk for the development of ONJ, including cancer patients receiving high-dose BP or Dmab therapy, consideration should be given to withholding antiresorptive therapy following extensive oral surgery until the surgical site heals with mature mucosal coverage. Management of ONJ is based on the stage of the disease, size of the lesions, and the presence of contributing drug therapy and comorbidity. Conservative therapy includes topical antibiotic oral rinses and systemic antibiotic therapy. Localized surgical debridement is indicated in advanced nonresponsive disease and has been successful. Early data have suggested enhanced osseous wound healing with teriparatide in those without contraindications for its use. Experimental therapy includes bone marrow stem cell intralesional transplantation, low-level laser therapy, local platelet-derived growth factor application, hyperbaric oxygen, and tissue grafting.
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Coleman R, Body JJ, Aapro M, Hadji P, Herrstedt J. Bone health in cancer patients: ESMO Clinical Practice Guidelines. Ann Oncol 2014; 25 Suppl 3:iii124-37. [PMID: 24782453 DOI: 10.1093/annonc/mdu103] [Citation(s) in RCA: 347] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
There are three distinct areas of cancer management that make bone health in cancer patients of increasing clinical importance. First, bone metastases are common in many solid tumours, notably those arising from the breast, prostate and lung, as well as multiple myeloma, and may cause major morbidity including fractures, severe pain, nerve compression and hypercalcaemia. Through optimum multidisciplinary management of patients with bone metastases, including the use of bone-targeted treatments such as potent bisphosphonates or denosumab, it has been possible to transform the course of advanced cancer for many patients resulting in a major reduction in skeletal complications, reduced bone pain and improved quality of life. Secondly, many of the treatments we use to treat cancer patients have effects on reproductive hormones, which are critical for the maintenance of normal bone remodelling. This endocrine disturbance results in accelerated bone loss and an increased risk of osteoporosis and fractures that can have a significant negative impact on the lives of the rapidly expanding number of long-term cancer survivors. Finally, the bone marrow micro-environment is also intimately involved in the metastatic processes required for cancer dissemination, and there are emerging data showing that, at least in some clinical situations, the use of bone-targeted treatments can reduce metastasis to bone and has potential impact on patient survival.
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Affiliation(s)
- R Coleman
- Weston Park Hospital, Cancer Research-UK/Yorkshire Cancer Research Sheffield Cancer Research Centre, Sheffield, UK
| | - J J Body
- CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - M Aapro
- Multidisciplinary Oncology Institute, Genolier, Switzerland
| | - P Hadji
- Department of Gynecology, Endocrinology and Oncology, Philipps-University of Marburg, Marburg, Germany
| | - J Herrstedt
- Department of Oncology, Odense University Hospital, Odense, Denmark
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Jackson GH, Morgan GJ, Davies FE, Wu P, Gregory WM, Bell SE, Szubert AJ, Navarro Coy N, Drayson MT, Owen RG, Feyler S, Ashcroft AJ, Ross FM, Byrne J, Roddie H, Rudin C, Boyd KD, Osborne WL, Cook G, Child JA. Osteonecrosis of the jaw and renal safety in patients with newly diagnosed multiple myeloma: Medical Research Council Myeloma IX Study results. Br J Haematol 2014; 166:109-17. [PMID: 24673708 DOI: 10.1111/bjh.12861] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Accepted: 01/22/2014] [Indexed: 11/28/2022]
Abstract
Bisphosphonates are recommended in patients with osteolytic lesions secondary to multiple myeloma. We report on the safety of bisphosphonate therapy with long-term follow-up in the Medical Research Council Myeloma IX study. Patients with newly diagnosed multiple myeloma were randomised to zoledronic acid (ZOL; 4 mg intravenously every 21-28 d) or clodronate (CLO; 1600 mg/d orally) plus chemotherapy. Among 1960 patients (5.9-year median follow-up), both bisphosphonates were well tolerated. Acute renal failure events were similar between groups (ZOL 5.2% vs. CLO 5.8% at 2 years; incidence plateaued thereafter). The overall incidence of confirmed osteonecrosis of the jaw (ONJ) was low, but higher with ZOL (ZOL 3.7% vs. CLO 0.5%; P < 0.0001). ONJ events were generally low grade and most occurred between 8 and 30 months (median time to ONJ, 23.7 months). Among 10 patients with ONJ recovery data, four patients in the ZOL group completely recovered, two patients improved, and three patients experienced no improvement; one CLO patient experienced no improvement. Dental surgery or trauma preceded ONJ in six ZOL patients. The incidence of renal adverse events was similar for ZOL and CLO. ONJ incidence remained low and was lower with CLO compared to ZOL. We have seen no further ONJ cases to date.
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Olsen OE, Wader KF, Misund K, Våtsveen TK, Rø TB, Mylin AK, Turesson I, Størdal BF, Moen SH, Standal T, Waage A, Sundan A, Holien T. Bone morphogenetic protein-9 suppresses growth of myeloma cells by signaling through ALK2 but is inhibited by endoglin. Blood Cancer J 2014; 4:e196. [PMID: 24658374 PMCID: PMC3972702 DOI: 10.1038/bcj.2014.16] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Revised: 02/10/2014] [Accepted: 02/12/2014] [Indexed: 12/28/2022] Open
Abstract
Multiple myeloma is a malignancy of plasma cells predominantly located in the bone marrow. A number of bone morphogenetic proteins (BMPs) induce apoptosis in myeloma cells in vitro, and with this study we add BMP-9 to the list. BMP-9 has been found in human serum at concentrations that inhibit cancer cell growth in vitro. We here show that the level of BMP-9 in serum was elevated in myeloma patients (median 176 pg/ml, range 8–809) compared with healthy controls (median 110 pg/ml, range 8–359). BMP-9 was also present in the bone marrow and was able to induce apoptosis in 4 out of 11 primary myeloma cell samples by signaling through ALK2. BMP-9-induced apoptosis in myeloma cells was associated with c-MYC downregulation. The effects of BMP-9 were counteracted by membrane-bound (CD105) or soluble endoglin present in the bone marrow microenvironment, suggesting a mechanism for how myeloma cells can evade the tumor suppressing activity of BMP-9 in multiple myeloma.
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Affiliation(s)
- O E Olsen
- KG Jebsen Center for Myeloma Research, Norwegian University of Science and Technology, Trondheim, Norway
| | - K F Wader
- 1] KG Jebsen Center for Myeloma Research, Norwegian University of Science and Technology, Trondheim, Norway [2] Department of Oncology, St Olav's University Hospital, Trondheim, Norway
| | - K Misund
- KG Jebsen Center for Myeloma Research, Norwegian University of Science and Technology, Trondheim, Norway
| | - T K Våtsveen
- KG Jebsen Center for Myeloma Research, Norwegian University of Science and Technology, Trondheim, Norway
| | - T B Rø
- 1] KG Jebsen Center for Myeloma Research, Norwegian University of Science and Technology, Trondheim, Norway [2] Department of Pediatrics, St Olav's University Hospital, Trondheim, Norway
| | - A K Mylin
- Department of Haematology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - I Turesson
- Department of Hematology and Coagulation Disorders, Skane University Hospital, Malmö, Sweden
| | - B F Størdal
- KG Jebsen Center for Myeloma Research, Norwegian University of Science and Technology, Trondheim, Norway
| | - S H Moen
- KG Jebsen Center for Myeloma Research, Norwegian University of Science and Technology, Trondheim, Norway
| | - T Standal
- 1] KG Jebsen Center for Myeloma Research, Norwegian University of Science and Technology, Trondheim, Norway [2] CEMIR (Centre of Molecular Inflammation Research), Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - A Waage
- 1] KG Jebsen Center for Myeloma Research, Norwegian University of Science and Technology, Trondheim, Norway [2] Department of Hematology, St Olav's University Hospital, Trondheim, Norway
| | - A Sundan
- 1] KG Jebsen Center for Myeloma Research, Norwegian University of Science and Technology, Trondheim, Norway [2] CEMIR (Centre of Molecular Inflammation Research), Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - T Holien
- KG Jebsen Center for Myeloma Research, Norwegian University of Science and Technology, Trondheim, Norway
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Campisi G, Fedele S, Fusco V, Pizzo G, Di Fede O, Bedogni A. Epidemiology, clinical manifestations, risk reduction and treatment strategies of jaw osteonecrosis in cancer patients exposed to antiresorptive agents. Future Oncol 2014; 10:257-75. [PMID: 24490612 DOI: 10.2217/fon.13.211] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
ABSTRACT: Osteonecrosis of the jaws (ONJ) is an adverse side event of bisphosphonates and denosumab, antiresorptive agents that effectively reduce the incidence of skeletal-related events in patients with metastatic bone cancer and multiple myeloma. Available data suggest that 0–27.5% of individuals exposed to antiresorptive agents can develop ONJ. There is increasing evidence that avoidance of surgical trauma and infection to the jawbones can minimize the risk of ONJ, but there are still a significant number of individuals who develop ONJ in the absence of these risk factors. Bone necrosis is almost irreversible and there is no definitive cure for ONJ with the exclusion, in certain cases, of surgical resection. However, most ONJ individuals are affected by advanced incurable cancer and are often managed with minimally invasive nonsurgical interventions in order to control jawbone infections and painful symptoms. This article summarizes current knowledge of ONJ epidemiology, manifestations, risk-reduction and therapeutic strategies. Further research is needed in order to determine individual predisposition to ONJ and clarify the effectiveness of available treatments.
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Affiliation(s)
- Giuseppina Campisi
- Unit of Oral Medicine, Department of Surgical, Oncological & Oral Sciences, University of Palermo, Palermo, Italy
| | - Stefano Fedele
- University College London, UCL Eastman Dental Institute, & NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - Vittorio Fusco
- Unit of Oncology, Department of Oncology & Hematology, Azienda Ospedaliera di Alessandria (City Hospital), Alessandria, Italy
| | - Giuseppe Pizzo
- Unit of Oral Medicine, Department of Surgical, Oncological & Oral Sciences, University of Palermo, Palermo, Italy
| | - Olga Di Fede
- Unit of Oral Medicine, Department of Surgical, Oncological & Oral Sciences, University of Palermo, Palermo, Italy
| | - Alberto Bedogni
- Unit of Oral & Maxillofacial Surgery, Department of Surgery, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
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Terpos E, Berenson J, Raje N, Roodman GD. Management of bone disease in multiple myeloma. Expert Rev Hematol 2014; 7:113-25. [DOI: 10.1586/17474086.2013.874943] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Palumbo A, Rajkumar SV, San Miguel JF, Larocca A, Niesvizky R, Morgan G, Landgren O, Hajek R, Einsele H, Anderson KC, Dimopoulos MA, Richardson PG, Cavo M, Spencer A, Stewart AK, Shimizu K, Lonial S, Sonneveld P, Durie BGM, Moreau P, Orlowski RZ. International Myeloma Working Group consensus statement for the management, treatment, and supportive care of patients with myeloma not eligible for standard autologous stem-cell transplantation. J Clin Oncol 2014; 32:587-600. [PMID: 24419113 DOI: 10.1200/jco.2013.48.7934] [Citation(s) in RCA: 273] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE To provide an update on recent advances in the management of patients with multiple myeloma who are not eligible for autologous stem-cell transplantation. METHODS A comprehensive review of the literature on diagnostic criteria is provided, and treatment options and management of adverse events are summarized. RESULTS Patients with symptomatic disease and organ damage (ie, hypercalcemia, renal failure, anemia, or bone lesions) require immediate treatment. The International Staging System and chromosomal abnormalities identify high- and standard-risk patients. Proteasome inhibitors, immunomodulatory drugs, corticosteroids, and alkylating agents are the most active agents. The presence of concomitant diseases, frailty, or disability should be assessed and, if present, treated with reduced-dose approaches. Bone disease, renal damage, hematologic toxicities, infections, thromboembolism, and peripheral neuropathy are the most frequent disabling events requiring prompt and active supportive care. CONCLUSION These recommendations will help clinicians ensure the most appropriate care for patients with myeloma in everyday clinical practice.
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Affiliation(s)
- Antonio Palumbo
- Antonio Palumbo and Alessandra Larocca, University of Torino, Torino; Michele Cavo, Seràgnoli Institute of Hematology, Bologna University School of Medicine, Bologna, Italy; S. Vincent Rajkumar, Mayo Clinic, Rochester, MN; Jesus F. San Miguel, University Hospital of Salamanca, Salamanca, Spain; Ruben Niesvizky, Weill Cornell Medical College, New York, NY; Gareth Morgan, Royal Marsden Hospital, London, United Kingdom; Ola Landgren, National Cancer Institute, Bethesda, MD; Roman Hajek, University of Ostrava School of Medicine and University Hospital Ostrava, Ostrava, Czech Republic; Hermann Einsele, University of Wurzburg, Wurzburg, Germany; Kenneth C. Anderson and Paul G. Richardson, Dana-Farber Cancer Institute, Boston, MA; Meletios A. Dimopoulos, University of Athens School of Medicine, Athens, Greece; Andrew Spencer, Alfred Hospital, Melbourne, Victoria, Australia; A. Keith Stewart, Mayo Clinic, Scottsdale, AZ; Kazuyuki Shimizu, Aichi Gakuin Hospital, Nagoya, Japan; Sagar Lonial, Emory University, Atlanta, GA; Pieter Sonneveld, Erasmus Medical Centre, Rotterdam, the Netherlands; Brian G.M. Durie, Cedars-Sinai Comprehensive Cancer Center, Los Angeles, CA; Philippe Moreau, University Hospital, Nantes, France; and Robert Z. Orlowski, MD Anderson Cancer Center, Houston, TX
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Ludwig H, Miguel JS, Dimopoulos MA, Palumbo A, Garcia Sanz R, Powles R, Lentzsch S, Ming Chen W, Hou J, Jurczyszyn A, Romeril K, Hajek R, Terpos E, Shimizu K, Joshua D, Hungria V, Rodriguez Morales A, Ben-Yehuda D, Sondergeld P, Zamagni E, Durie B. International Myeloma Working Group recommendations for global myeloma care. Leukemia 2013; 28:981-92. [DOI: 10.1038/leu.2013.293] [Citation(s) in RCA: 139] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 09/17/2013] [Accepted: 09/23/2013] [Indexed: 12/31/2022]
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Terpos E, Morgan G, Dimopoulos MA, Drake MT, Lentzsch S, Raje N, Sezer O, García-Sanz R, Shimizu K, Turesson I, Reiman T, Jurczyszyn A, Merlini G, Spencer A, Leleu X, Cavo M, Munshi N, Rajkumar SV, Durie BGM, Roodman GD. International Myeloma Working Group recommendations for the treatment of multiple myeloma-related bone disease. J Clin Oncol 2013; 31:2347-57. [PMID: 23690408 DOI: 10.1200/jco.2012.47.7901] [Citation(s) in RCA: 235] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
PURPOSE The aim of the International Myeloma Working Group was to develop practice recommendations for the management of multiple myeloma (MM) -related bone disease. METHODOLOGY An interdisciplinary panel of clinical experts on MM and myeloma bone disease developed recommendations based on published data through August 2012. Expert consensus was used to propose additional recommendations in situations where there were insufficient published data. Levels of evidence and grades of recommendations were assigned and approved by panel members. RECOMMENDATIONS Bisphosphonates (BPs) should be considered in all patients with MM receiving first-line antimyeloma therapy, regardless of presence of osteolytic bone lesions on conventional radiography. However, it is unknown if BPs offer any advantage in patients with no bone disease assessed by magnetic resonance imaging or positron emission tomography/computed tomography. Intravenous (IV) zoledronic acid (ZOL) or pamidronate (PAM) is recommended for preventing skeletal-related events in patients with MM. ZOL is preferred over oral clodronate in newly diagnosed patients with MM because of its potential antimyeloma effects and survival benefits. BPs should be administered every 3 to 4 weeks IV during initial therapy. ZOL or PAM should be continued in patients with active disease and should be resumed after disease relapse, if discontinued in patients achieving complete or very good partial response. BPs are well tolerated, but preventive strategies must be instituted to avoid renal toxicity or osteonecrosis of the jaw. Kyphoplasty should be considered for symptomatic vertebral compression fractures. Low-dose radiation therapy can be used for palliation of uncontrolled pain, impending pathologic fracture, or spinal cord compression. Orthopedic consultation should be sought for long-bone fractures, spinal cord compression, and vertebral column instability.
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Affiliation(s)
- Evangelos Terpos
- Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece.
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Decreasing frequency of osteonecrosis of the jaw in cancer and myeloma patients treated with bisphosphonates: the experience of the oncology network of piedmont and aosta valley (north-Western Italy). ISRN ONCOLOGY 2013; 2013:672027. [PMID: 23533811 PMCID: PMC3600177 DOI: 10.1155/2013/672027] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Accepted: 01/18/2013] [Indexed: 11/21/2022]
Abstract
Background. Data concerning frequency of Osteonecrosis of Jaws (ONJ) are mostly based on single center experiences.
Patients and Methods. Since 2005 a multidisciplinary study group collected data of cases of ONJ in patients treated with Bisphosphonates (BP) and observed in oncology and hematology centers of a regional network. Results. By December 2008, 221 cases were registered. We report details of 200 cases, identified after cross-checking reports from centres of medical oncology, haematology, and oral care. Primary neoplasm was breast cancer (39%), myeloma (32%), prostate cancer (16%), and other types of cancer (8%). In about 50% of the cases a history of dental extraction was present. Zoledronic acid was administered (alone or with other BP) to 178 patients (89%). Median time from first infusion to ONJ diagnosis was 21.0 (zoledronic acid only) and 39.0 months (pamidronate only). The number of ONJ cases per year was 3 in 2003, 21 in 2004, 58 in 2005, 60 in 2006, 37 in 2007, and 21 in 2008. Conclusion. The number of new ONJ cases in cancer and myeloma patients increased until 2006 and then reduced. The possible reasons of this trend (introduction of zoledronic acid; increase of ONJ awareness; diffusion of preventive dental measures; late modifications of BP prescription) are herein discussed.
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Tosi P. Diagnosis and treatment of bone disease in multiple myeloma: spotlight on spinal involvement. SCIENTIFICA 2013; 2013:104546. [PMID: 24381787 PMCID: PMC3870870 DOI: 10.1155/2013/104546] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Accepted: 11/14/2013] [Indexed: 05/07/2023]
Abstract
Bone disease is observed in almost 80% of newly diagnosed symptomatic multiple myeloma patients, and spine is the bone site that is more frequently affected by myeloma-induced osteoporosis, osteolyses, or compression fractures. In almost 20% of the cases, spinal cord compression may occur; diagnosis and treatment must be carried out rapidly in order to avoid a permanent sensitive or motor defect. Although whole body skeletal X-ray is considered mandatory for multiple myeloma staging, magnetic resonance imaging is presently considered the most appropriate diagnostic technique for the evaluation of vertebral alterations, as it allows to detect not only the exact morphology of the lesions, but also the pattern of bone marrow infiltration by the disease. Multiple treatment modalities can be used to manage multiple myeloma-related vertebral lesions. Surgery or radiotherapy is mainly employed in case of spinal cord compression, impending fractures, or intractable pain. Percutaneous vertebroplasty or balloon kyphoplasty can reduce local pain in a significant fraction of treated patients, without interfering with subsequent therapeutic programs. Systemic antimyeloma therapy with conventional chemotherapy or, more appropriately, with combinations of conventional chemotherapy and compounds acting on both neoplastic plasma cells and bone marrow microenvironment must be soon initiated in order to reduce bone resorption and, possibly, promote bone formation. Bisphosphonates should also be used in combination with antimyeloma therapy as they reduce bone resorption and prolong patients survival. A multidisciplinary approach is thus needed in order to properly manage spinal involvement in multiple myeloma.
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Affiliation(s)
- Patrizia Tosi
- Hematology Unit, Department of Oncology and Hematology, Infermi Hospital, Viale Settembrini 2, 47100 Rimini, Italy
- *Patrizia Tosi:
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Poon M, Zeng L, Zhang L, Hsiao J, Wong E, Lam H, Bedard G, Chow E. Incidence of skeletal morbidity rates over time in patients with multiple myeloma-related bone disease as reported in randomized trials employing bone-modifying agents. J Comp Eff Res 2013; 2:69-76. [DOI: 10.2217/cer.12.69] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: The purpose of this review was to investigate if advances in bone-targeted therapies have decreased the incidence of skeletal morbidity rates over time in patients with multiple myeloma-related bone disease. Methods: A literature search was conducted over the OvidSP platform in MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials to identify Phase III results from bone-targeted therapy trials in patients with multiple myeloma. The skeletal morbidity rate was the end point of interest, and for each study, a mean year of enrollment ([start of enrollment + end of enrollment]/2) was calculated. Results: A total of eight study arms were identified, with only two placebo arms; therefore, a weighted linear regression was not feasible and only intervention treatment arms were analyzed. A statistically significant downward trend in the skeletal morbidity rate was observed in all intervention arms. Conclusion: The incidence of skeletal morbidity rates has decreased significantly over time in patients with multiple myeloma.
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Affiliation(s)
- Michael Poon
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Center, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Liang Zeng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Center, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Liying Zhang
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Center, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Janey Hsiao
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Center, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Erin Wong
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Center, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Henry Lam
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Center, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Gillian Bedard
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Center, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Edward Chow
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Center, University of Toronto, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
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What is the evidence for the use of bisphosphonate therapy in newly diagnosed multiple myeloma patients lacking bone disease? Hematology 2012. [DOI: 10.1182/asheducation.v2012.1.350.3806855] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
A 55-year-old man without prior medical problems presented to the emergency room with a 2-month history of progressive fatigue. Initial workup showed a hemoglobin level of 9.0 g/dL and an increased total protein level of 12.6 g/dL. Further testing revealed a normal serum calcium and creatinine, an IgG kappa paraprotein of 5.4 g/dL, and a Bence Jones proteinuria of 450 mg of kappa light chain in 24 hours. The bone marrow showed 60% plasma cells with normal cytogenetics and t(4;14), but no other associated genetic abnormalities by FISH. Skeletal survey and MRI of the spine were negative for myeloma bone disease. The patient's oncologist recently began therapy with lenalidomide, bortezomib, and dexamethasone and recommended the initiation of zoledronic acid monthly. The patient questions the benefit of this drug because he has no bone disease.
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Osborne TR, Ramsenthaler C, Siegert RJ, Edmonds PM, Schey SA, Higginson IJ. What issues matter most to people with multiple myeloma and how well are we measuring them? A systematic review of quality of life tools. Eur J Haematol 2012; 89:437-57. [PMID: 22985406 DOI: 10.1111/ejh.12012] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2012] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Treatment advances in multiple myeloma have increased expected survival from months to years for some patients. Alongside improved survival emerges a need to better understand and measure health-related quality of life (HRQOL), both in research and clinical settings. OBJECTIVES (i) Identify HRQOL tools validated for use in myeloma; (ii) identify issues important to HRQOL from the point of view of patients with myeloma; (iii) describe the measurement properties of each HRQOL tool; (iv) evaluate the content validity of HRQOL tools in terms of their ability to capture all issues important to patients and (v) explore the suitability of each HRQOL tool for use in different settings. METHOD Systematic literature review of six databases with no limits by date or language. RESULTS Thirty-nine studies reported validation of 13 HRQOL instruments. Seven studies identified issues important to HRQOL from the patients' perspective. No instrument was comprehensive to all issues important to patients. The EORTC-QLQ-C30 and MY24 have undergone the most comprehensive psychometric validation. Most validation occurred in trial patients and not clinically representative groups. No studies evaluated clinical utility of tools alongside routine practice. CONCLUSION The best existing HRQOL tools are designed predominantly for use in research. Reliable, valid and responsive tools exist for this purpose, but may miss issues important to patients. The design of HRQOL measures should be guided by intended utility, whether for research or clinical practice, and further validation of HRQOL tools in clinically representative groups is needed. Development and validation of HRQOL tools for clinical use may be of value.
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Affiliation(s)
- Thomas R Osborne
- Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, King's College London, and King's College Hospital, London, UK.
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Terpos E, Kastritis E, Dimopoulos MA. Prevention and Treatment of Myeloma Bone Disease. Curr Hematol Malig Rep 2012; 7:249-57. [DOI: 10.1007/s11899-012-0135-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Mhaskar R, Redzepovic J, Wheatley K, Clark OAC, Miladinovic B, Glasmacher A, Kumar A, Djulbegovic B. Bisphosphonates in multiple myeloma: a network meta-analysis. Cochrane Database Syst Rev 2012:CD003188. [PMID: 22592688 DOI: 10.1002/14651858.cd003188.pub3] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Bisphosphonates are specific inhibitors of osteoclastic activity and used in the treatment of patients with multiple myeloma (MM). While bisphosphonates are shown to be effective in reducing vertebral fractures and pain, their role in improving overall survival (OS) remains unclear. This is an update of a Cochrane review first published in 2002 and previously updated in 2010. OBJECTIVES To assess the evidence related to benefits and harms associated with use of various types of bisphosphonates (aminobisphosphonates versus nonamino bisphosphonates) in the management of patients with MM. Our primary objective was to determine whether adding bisphosphonates to standard therapy in MM improves OS and progression-free survival (PFS), and decreases skeletal-related morbidity. Our secondary objectives were to determine the effects of bisphosphonates on pain, quality of life, incidence of hypercalcemia, incidence of bisphosphonate-related gastrointestinal toxicities, osteonecrosis of jaw and hypocalcemia. SEARCH METHODS We searched MEDLINE, LILACS, EMBASE (December 2009 to October 2011) and the Cochrane Controlled Trials Register (all years, latest Issue September 2011) to identify all randomized trials in MM up to October 2011 using a combination of text and MeSH terms. We also handsearched relevant meeting proceedings (December 2009 to October 2011). SELECTION CRITERIA Any randomized controlled trial (RCT) assessing the role of bisphosphonates and observational studies or case reports examining bisphosphonate-related osteonecrosis of the jaw in patients with MM were eligible for inclusion. DATA COLLECTION AND ANALYSIS Two review authors extracted the data. Data were pooled and reported as hazard ratio (HR) or risk ratio (RR) under a random-effects model. Statistical heterogeneity was explored using metaregression. MAIN RESULTS In this update, we included 2 studies (2464 patients) that were not part of our last Cochrane review published in 2010. In this review we included 16 RCTs comparing bisphosphonates with either placebo or no treatment and 4 RCTs with a different bisphosphonate as a comparator. The 20 included RCTs enrolled 6692 patients. Overall methodological quality of reporting was moderate. Thirty per cent (6/20) of trials reported the method of generating the randomization sequence. Forty per cent (8/20) of trials had adequate allocation concealment. Withdrawals and dropouts were described in 60% (12/20) of trials. Pooled results showed no direct effect of bisphosphonates on OS compared with placebo or no treatment (HR 0.96, 95% CI 0.82 to 1.13; P = 0.64). However, there was a statistically significant heterogeneity among the included RCTs (I(2) = 55%, P = 0.01) for OS. To explain this heterogeneity we performed a metaregression assessing the relationship between bisphosphonate potency and improvement in OS, which found indicating an OS benefit with zoledronate (P = 0.058). This provided a further rationale for performing network meta-analyses of the various types of bisphosphonates that were not compared head to head in RCTs. Results from network meta-analyses showed superior OS with zoledronate compared with etidronate (HR 0.43, 95% CI 0.16 to 0.86) and placebo (HR 0.61, 95% CI 0.28 to 0.98). However, there was no difference between zoledronate and other bisphosphonates. Pooled analysis did not demonstrate a beneficial effect of bisphosphonates compared with placebo or no treatment in improving PFS (HR 0.70, 95% CI 0.41 to 1.19; P = 0.18) There was no heterogeneity among trials reporting PFS estimates (I(2) = 35%, P = 0.20).Pooled analysis demonstrated a beneficial effect of bisphosphonates compared with placebo or no treatment on prevention of pathological vertebral fractures (RR 0.74, 95% CI 0.62 to 0.89; I(2) = 7%), skeletal-related events (SRE) (RR 0.80, 95% CI 0.72 to 0.89; I(2) = 2%) and amelioration of pain (RR 0.75, 95% CI 0.60 to 0.95; I(2) = 63%). The network meta-analysis did not show any difference in the incidence of osteonecrosis of the jaw (5 RCTs, 3198 patients) between bisphosphonates. Rates of osteonecrosis of the jaw in observational studies (9 studies, 1400 patients) ranged from 0% to 51%. The pooled results (6 RCTs, 1689 patients) showed no statistically significant increase in frequency of gastrointestinal symptoms with the use of bisphosphonates compared with placebo or no treatment (RR 1.23, 95% CI 0.95 to 1.60; P = 0.11).The pooled results (3 RCTs, 1002 patients) showed no statistically significant increase in frequency of hypocalcemia with the use of bisphosphonates compared with placebo or no treatment (RR 2.19, 95% CI 0.49 to 9.74). The network meta-analysis did not show any differences in the incidence of hypocalcemia, renal dysfunction and gastrointestinal toxicity between the bisphosphonates used. AUTHORS' CONCLUSIONS Use of bisphosphonates in patients with MM reduces pathological vertebral fractures, SREs and pain. Assuming a baseline risk of 20% to 50% for vertebral fracture without treatment, between 8 and 20 MM patients should be treated to prevent vertebral fracture(s) in one patient. Assuming a baseline risk of 31% to 76% for pain amelioration without treatment, between 5 and 13 MM patients should be treated to reduce pain in one patient. With a baseline risk of 35% to 86% for SREs without treatment, between 6 and 15 MM patients should be treated to prevent SRE(s) in one patient. Overall, there were no significant adverse effects associated with the administration of bisphosphonates identified in the included RCTs. We found no evidence of superiority of any specific aminobisphosphonate (zoledronate, pamidronate or ibandronate) or nonaminobisphosphonate (etidronate or clodronate) for any outcome. However, zoledronate appears to be superior to placebo and etidronate in improving OS.
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Affiliation(s)
- Rahul Mhaskar
- Center for Evidence Based Medicine and Health Outcomes Research, University of South Florida, Tampa, Florida, USA
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Kleber M, Udi J, Metzke B, Terpos E, Roodmann GD, Morgan G, Dispenzieri A, Einsele H, Wäsch R, Engelhardt M. Challenging the current approaches to multiple myeloma- and other cancer-related bone diseases: from bisphosphonates to targeted therapy. Leuk Lymphoma 2012; 53:1057-61. [PMID: 22149167 DOI: 10.3109/10428194.2011.644548] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
An international myeloma meeting entitled "Challenging the current approaches to multiple myeloma- and other cancer-related bone diseases: from bisphosphonates to targeted therapy" was held in Freiburg, Germany in July 2011 to discuss novel insights into and approaches to myeloma bone disease and other bone-seeking tumors. This review briefly summarizes the most prominent data of the meeting and current literature on our understanding of bone disease, the role of imaging techniques, operative interventions and systemic bone-seeking treatment, all of which should further improve our future therapeutic choices.
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Affiliation(s)
- Martina Kleber
- Department of Hematology and Oncology, University Medical Center Freiburg, Freiburg, Germany
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Rudic JS, Giljaca V, Krstic MN, Bjelakovic G, Gluud C. Bisphosphonates for osteoporosis in primary biliary cirrhosis. Cochrane Database Syst Rev 2011:CD009144. [PMID: 22161446 DOI: 10.1002/14651858.cd009144.pub2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Bisphosphonates are widely used for treatment of postmenopausal osteoporosis. Patients with primary biliary cirrhosis often have osteoporosis - either postmenopausal or secondary to the liver disease. No systematic review or meta-analysis has assessed the effects of bisphosphonates for osteoporosis in patients with primary biliary cirrhosis. OBJECTIVES To assess the beneficial and harmful effects of bisphosphonates for osteoporosis in primary biliary cirrhosis. SEARCH METHODS The Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, LILACS, clinicaltrials.gov, the WHO International Clinical Trials Registry Platform, and full text searches were conducted until November 2011. Manufacturers and authors were contacted for additional studies during the conductance of the review. SELECTION CRITERIA All randomised clinical trials of bisphosphonates in primary biliary cirrhosis compared with placebo or no intervention, or another bisphosphonate, or any other drug. DATA COLLECTION AND ANALYSIS Two authors extracted data. RevMan Analysis was used for statistical analysis of dichotomous data with risk ratio (RR) or risk difference (RD) and of continuous data with mean difference (MD) or standardised mean difference (SMD), all with 95% confidence intervals (CI). Methodological components were used to assess risk of systematic errors (bias). Trial sequential analysis was also used to control for random errors (play of chance). MAIN RESULTS Six trials were included. Three trials with 106 participants, of which two trials with high risk of bias, did not demonstrate significant effects of bisphosphonates (etidronate or alendronate) versus placebo or no intervention regarding mortality (RD 0.00; 95% CI -0.12 to 0.12, I² = 0%), fractures (RR 0.87; 95% CI 0.29 to 2.66, I² = 0%), or adverse events (RR 1.00; 95% CI 0.49 to 2.04). Two trials with 62 participants with high risk of bias compared one bisphosphonate (etidronate or alendronate) versus another (alendronate or ibandronate) and found no significant difference regarding mortality (RD -0.03; 95% CI -0.14 to 0.07, I² = 0%), fractures (RR 0.95; 95% CI 0.18 to 5.06, I² = 0%), or adverse events (RR 1.00; 95% CI 0.49 to 2.04, I² = 0%). Bisphosphonates had no significant effect on liver-related mortality, liver transplantation, or liver-related morbidity compared with placebo or no intervention, or another bisphosphonate. Bisphosphonates had no significant effect on bone mineral density compared with placebo or no intervention, or another bisphosphonate. Bisphosphonates compared with placebo or no intervention seem to decrease the urinary amino telopeptides of collagen I (NTx) concentration (MD -16.93 nmol bone collagen equivalents/mmol creatinine; 95% CI -23.77 to -10.10; 2 trials with 88 patients; I² = 0%) and serum osteocalcin (SMD -0.81; 95% CI -1.22 to -0.39; 3 trials with 100 patients; I² = 34 %) concentration. The former result was supported by trial sequential analysis, but not the latter. Alendronate compared with another bisphosphonate (ibandronate) had no significant effect on serum osteocalcin concentration (MD -3.61 ng/ml, 95% CI -9.41 to 2.18; 2 trials with 47 patients; I² = 82%) in a random-effects meta-analysis, but it significantly decreased serum osteocalcin (MD -4.40 ng/ml, 95% CI -6.75 to -2.05; 2 trials with 47 patients; I² = 82%), the procollagen type I N-terminal propeptide (MD -8.79 ng/ml, 95% CI -15.96 to -1.63; 2 trials with 47 patients; I² = 38%), and NTx concentration (MD -14.07 nmol bone collagen equivalents/mmol creatinine, 95% CI -24.23 to -3.90; 2 trials with 46 patients; I²=0%) in a fixed-effect model. The latter two results were not supported by trial sequential analyses. There was no statistically significant difference in the number of patients having bisphosphonates withdrawn due to adverse events compared with placebo or no intervention (RD -0.04; 95% CI -0.21 to 0.12; 2 trials with 46 patients; I² = 0%), or another bisphosphonate (RR 0.56; 95% CI 0.14 to 2.17; 2 trials with 62 patients; I² = 0%). One trial with 32 participants and with high risk of bias compared etidronate versus sodium fluoride without finding significant difference regarding mortality, fractures, adverse events, or bone mineral density. Etidronate compared with sodium fluoride significantly decreased serum osteocalcin, urinary hydroxyproline, and parathyroid hormone concentration. AUTHORS' CONCLUSIONS We did not find evidence to support or refute the use of bisphosphonates for patients with primary biliary cirrhosis. The data seem to indicate a possible positive intervention effect of bisphosphonates on decreasing urinary amino telopeptides of collagen I concentration compared with placebo or no intervention with no risk of random error. There is need for more randomised clinical trials assessing the effects of bisphosphonates for osteoporosis on patient-relevant outcomes in primary biliary cirrhosis.
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Affiliation(s)
- Jelena S Rudic
- Department of Hepatology, Clinic of Gastroenterology, Clinical Centre of Serbia, Koste Todorovica 2, Belgrade, Serbia, 11000
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Optimising the use of bone-targeted agents in patients with metastatic cancers: a practical guide for medical oncologists. Support Care Cancer 2011; 19:1687-96. [PMID: 21785900 DOI: 10.1007/s00520-011-1230-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Accepted: 07/04/2011] [Indexed: 01/25/2023]
Abstract
Bone metastases can be associated with a significant worsening of patient morbidity and mortality. Bisphosphonates have been extensively researched and shown to delay the onset and reduce the incidence of complications from bone metastases. The most commonly used bisphosphonates are intravenous pamidronate, intravenous ibandronate, intravenous zoledronic acid and oral/intravenous clodronate. Several bone-targeted agents with innovative mechanisms of action are currently being developed. These include receptor activator of nuclear factor-kB ligand (RANKL) inhibitors, CCR1 inhibitors, Src inhibitors, DKK1-neutralising antibodies, activin antagonists and endothelin-1 inhibitors. In an era of individualised medicine, oncologists are being faced with an increasing number of questions when dealing with bone-targeted agents. These questions not only include the choice of which drug to use (i.e. bisphosphonates or RANKL inhibitor) but also the best treatment strategy to use. This review will provide medical oncologists with a practical guide to the use of bone-targeted agents.
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Kristinsson SY, Minter AR, Korde N, Tan E, Landgren O. Bone disease in multiple myeloma and precursor disease: novel diagnostic approaches and implications on clinical management. Expert Rev Mol Diagn 2011; 11:593-603. [PMID: 21745013 PMCID: PMC3199399 DOI: 10.1586/erm.11.44] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The manifestations of bone involvement in patients with multiple myeloma (MM) can have devastating clinical effects and increase mortality. Recent studies demonstrate that patients with the precursor conditions smoldering MM (SMM) and monoclonal gammopathy of undetermined significance (MGUS) show evidence of bone disease and increased risk of fractures. The understanding of the pathogenesis of bone disease in MM has expanded in recent years. The traditional skeletal survey will probably be replaced by newer and more sensitive imaging techniques, which may have a prognostic impact and change our definition of MGUS and SMM. Bisphosphonates are recommended to prevent skeletal events in patients with MM, and have also been studied in SMM and MGUS. This article summarizes the current knowledge of bone disease in plasma cell disorders, and discusses the current standard and future role of novel imaging techniques, as well as the evidence and current guidelines for bisphosphonates in MM, SMM and MGUS.
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Affiliation(s)
- Sigurdur Y Kristinsson
- Department of Medicine, Division of Hematology, Karolinska University Hospital Solna, SE-171 76, Stockholm, Sweden.
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Terpos E, Dimopoulos MA, Berenson J. Established role of bisphosphonate therapy for prevention of skeletal complications from myeloma bone disease. Crit Rev Oncol Hematol 2011; 77 Suppl 1:S13-23. [PMID: 21353176 DOI: 10.1016/s1040-8428(11)70004-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Patients with advanced multiple myeloma (MM) often have increased osteolytic activity of osteoclasts and impaired osteogenesis by osteoblasts, resulting in osteolytic bone lesions that increase the risk of skeletal-related events (SREs) including pathologic fracture, the need for radiotherapy or surgery to bone, and spinal cord compression. Such SREs are potentially life-limiting, and can reduce patients' functional independence and quality of life. Bisphosphonates (e.g., oral clodronate and intravenous pamidronate and zoledronic acid) can inhibit osteoclast-mediated osteolysis, thereby reducing the risk of SREs, ameliorating bone pain, and potentially prolonging survival in patients with MM. Extensive clinical experience demonstrates that bisphosphonates are generally well tolerated, and common adverse events are typically mild and manageable. Studies are ongoing to optimize the timing and duration of bisphosphonate therapy in patients with bone lesions from MM.
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Affiliation(s)
- Evangelos Terpos
- Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece.
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Terpos E, Moulopoulos LA, Dimopoulos MA. Advances in imaging and the management of myeloma bone disease. J Clin Oncol 2011; 29:1907-15. [PMID: 21483016 DOI: 10.1200/jco.2010.32.5449] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Osteolytic disease is a major complication of multiple myeloma that may lead to devastating skeletal-related events (SREs). Conventional radiography remains the gold standard for the evaluation of bone disease in patients with myeloma. However, whole-body magnetic resonance imaging (MRI) is recommended in patients with normal conventional radiography and should be performed as part of staging in all patients with a solitary plasmacytoma of bone. Urgent MRI is also the diagnostic procedure of choice to assess suspected cord compression, whereas computed tomography can guide tissue biopsy. Positron emission tomography with computed tomography can provide complementary information to MRI, but its use in multiple myeloma must be better defined by further studies. The incorporation of abnormal MRI findings into the definition of symptomatic myeloma also needs to be clarified. Bisphosphonates remain the cornerstone for the management of myeloma bone disease. Intravenous pamidronate and zoledronic acid are equally effective in reducing SREs, whereas zoledronic acid seems to offer survival benefits in symptomatic patients. Caution is needed to avoid adverse events, such as renal impairment and osteonecrosis of the jaw. Novel antiresorptive agents, such as denosumab, have given encouraging results, but further studies are needed before their approval for managing myeloma bone disease. Combination approaches with novel antimyeloma agents, such as bortezomib (which has anabolic effects on bone) with bisphosphonates or with drugs that enhance osteoblast function, such as antidickkopf-1 agents, antisclerostin drugs, or sotatercept, may favorably alter our way of managing myeloma bone disease in the near future.
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Affiliation(s)
- Evangelos Terpos
- Department of Clinical Therapeutics, University of Athens School of Medicine, Alexandra General Hospital, 80 Vas. Sofias Ave, 11528, Athens, Greece.
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Lipton A. Bones, breasts, and bisphosphonates: rationale for the use of zoledronic acid in advanced and early breast cancer. BREAST CANCER-TARGETS AND THERAPY 2011; 3:1-7. [PMID: 24367171 DOI: 10.2147/bctt.s16774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Bisphosphonates inhibit osteoclast-mediated bone resorption, thereby inhibiting the release of growth factors necessary to promote cancer cell growth, differentiation, and tumor formation in bone. These agents have demonstrated efficacy for delaying the onset and reducing the incidence of skeletal-related events in the advanced breast cancer setting, and have been shown to prevent cancer therapy-induced bone loss in the early breast cancer setting. Emerging clinical data indicate that the role of bisphosphonates in advanced and early breast cancer is evolving. Retrospective analyses and recent clinical trial data show that zoledronic acid may improve outcomes in some patients with breast cancer. Data from ABCSG-12 and ZO-FAST suggest that zoledronic acid may improve disease-free survival in the adjuvant breast cancer setting in postmenopausal women or women with endocrine therapy-induced menopause, and recent data from a predefined subset of the AZURE trial added to the anticancer story. However, the overall negative AZURE trial also raises questions about the role of bisphosphonates as an anticancer agent in patients with breast cancer. Overall, these data suggest that the addition of zoledronic acid to established anticancer regimens may have potential anticancer benefits in specific patient populations, although more studies are required to define its role.
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Affiliation(s)
- Allan Lipton
- Milton S. Hershey Medical Center, Pennsylvania State University, Hershey, PA, USA
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Gertz MA. The role of bisphosphonate therapy in the global management of multiple myeloma. Leuk Lymphoma 2011; 52:736-7. [DOI: 10.3109/10428194.2011.554586] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Minter AR, Simpson H, Weiss BM, Landgren O. Bone disease from monoclonal gammopathy of undetermined significance to multiple myeloma: pathogenesis, interventions, and future opportunities. Semin Hematol 2011; 48:55-65. [PMID: 21232659 PMCID: PMC6863044 DOI: 10.1053/j.seminhematol.2010.11.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Manifestations of bone disease-osteopenia, osteolytic lesions, and fractures-are the hallmark of multiple myeloma (MM) and occur clinically in the vast majority of patients. These abnormalities can have devastating clinical effects by increasing both the morbidity and mortality of patients. Bone disease is usually found when patients are diagnosed with active MM; however, recent data suggest that it is present in early myelomagenesis, including patients with myeloma precursor disease, monoclonal gammopathy of undetermined significance (MGUS). The primary mechanisms of abnormal bone remodeling are increased osteoclastic activity, which occurs in close proximity to active myeloma cells, and decreased activity of the surrounding osteoblasts. Better understanding of the pathogenesis of bone disease in MM will allow us to enhance our current therapeutic options in the treatment of bone disease. In patients with active MM and at least one lytic lesion, intravenous bisphosphonates have been shown to decrease skeletal-related events and pain, improve performance status, and maintain quality of life. Emerging evidence suggests that intervention at earlier stages of disease may prevent skeletal-related events at time of progression, but there is no evidence that bisphosphonates in this setting change the natural history of the disease.
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Affiliation(s)
- Alex R. Minter
- Medical Oncology Branch, Center for Cancer Research,
National Cancer Institute, National Institutes of Health, Bethesda, MD
- Walter Reed Army Medical Center, Washington, DC
| | - Haley Simpson
- Medical Oncology Branch, Center for Cancer Research,
National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Brendan M. Weiss
- Medical Oncology Branch, Center for Cancer Research,
National Cancer Institute, National Institutes of Health, Bethesda, MD
- Walter Reed Army Medical Center, Washington, DC
| | - Ola Landgren
- Medical Oncology Branch, Center for Cancer Research,
National Cancer Institute, National Institutes of Health, Bethesda, MD
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Harousseau JL. Ten Years of Improvement in the Management of Multiple Myeloma: 2000-2010. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2010; 10:424-42. [DOI: 10.3816/clml.2010.n.076] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Terpos E, Dimopoulos MA. Intravenous pamidronate for myeloma bone disease: can the dose be lowered? Lancet Oncol 2010; 11:913-4. [PMID: 20863760 DOI: 10.1016/s1470-2045(10)70227-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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