Bone involvement in multiple myeloma

From the Reading Room to the Courtroom-The Use of Molecular Radionuclide Imaging in Criminal Trials

Recent years have witnessed an expanded use of single-photon emission CT and PET for a wide range of clinical applications, including imaging of brain abnormalities. As a result, molecular brain imaging is now being more extensively utilized in criminal cases, in particular in the sentencing phase of a trial. This perspective aims to provide a brief overview for the practicing radiologist of this expanded use of single-photon emission CT and PET in criminal cases and will discuss the role of radiology in this field.

Diagnostic value of whole-body ultra-low dose computed tomography in comparison with spinal magnetic resonance imaging in the assessment of disease in multiple myeloma

This study compared the diagnostic value of Whole-Body Ultra Low-Dose computed tomography (WBULDCT) with that of Spinal Magnetic Resonance Imaging (SMRI) in identification of spinal bone marrow involvement in patients with Multiple Myeloma (MM). Thirty-five patients with histologically proven MM underwent WBULDCT and dedicated SMRI. Unenhanced WBULDCT was performed on a 256-slice scanner, with 120 kV and 40 mAs. SMRI was performed on a 1·5T magnet, with T1-turbo spin echo and T2-short tau inversion recovery sequences on sagittal plane. WBULDCT was compared with SMRI in terms of lesion detection, pattern and bone marrow involvement. The overall concordance between WBULDCT and SMRI in lesion detection was 76·7%, detecting (25/35) or excluding (8/35) involvement of the axial skeleton, while in 2/35 patients WBULDCT and SMRI were discordant in terms of axial skeleton involvement. The concordance in spinal distribution of lesions was 61·6% on cervical, 71·5% on dorsal, 86·4% on lumbar and 94·4% on sacral, while for the pattern of disease, it was 56·1% for the focal and 88·7% for the combined pattern. Cohen's kappa index was 0·85 (P < 0·001) assessing an excellent agreement. WBULDCT represents a useful diagnostic tool in the detection of spinal involvement of MM patients, offering detailed information about extra-axial involvement, which could be potentially missed with dedicated SMRI.

Neuroethical responsibilities

Neuroscience represents a dynamic area of biomedical research where neuroethical responsibilities for researchers are emerging. This paper is the companion piece to the French-language one also published in this issue of the Canadian Journal of Neurological Sciences. It serves as a review of recent advances in neuroethics through the lens of three cases: (1) incidental finding of anomalies in neuroimaging research; (2) creation of neurotechnologies that can lead to cognitive enhancement, and (3) responsible communication of research results. We propose and discuss a multidimensional framework of neuroethical responsibilities to help tackle these issues. The framework reiterates the fundamental role of scientific integrity, puts in the foreground social responsibilities pertaining to the eventual use of neuroscience knowledge, and highlights self-reflection in research and training of researchers.

Responsabilités Neuroéthiques

Neuroscience represents a dynamic area of biomedical research where neuroethical responsibilities for researchers are emerging. This paper is the companion piece to the English-language one also published in this issue of the Canadian Journal of Neurological Sciences. It serves as a review of recent advances in neuroethics through the lens of three cases: (1) incidental finding of anomalies in neuroimaging research; (2) creation of neurotechnologies that can lead to cognitive enhancement, and (3) responsible communication of research results. We propose and discuss a multidimensional framework of neuroethical responsibilities to help tackle these issues. The framework reiterates the fundamental role of scientific integrity, puts in the foreground social responsibilities pertaining to the eventual use of neuroscience knowledge, and highlights self-reflection in research and training of researchers.

Biologic and therapeutic determinants of bone mineral density in multiple myeloma

The net impact of malignancy and anti-tumor therapy on bone resorption in myeloma is poorly understood because conventional skeletal radiographs are relatively insensitive for the diagnosis and monitoring of bone disease. We performed determinations of bone mineral density (BMD) at the lumbar spine, femoral neck and radial diaphysis by dual energy X ray absorptiometry (DEXA) in 168 consecutive patients with myeloma seen at our institution. Follow up studies were performed in 41 of these patients. A detailed analysis of patient and disease characteristics was performed to identify the determinants of BMD. Compared to normal age and sex matched controls, mean (+/- SE) BMD was significantly decreased at the lumbar spine (Z score -0.4 +/- 0.10) and femoral neck (Z score -1.0 +/- 0.10), but was surprisingly above normal at the radial diaphysis (Z score +0.35 +/- 0.10), a cortical bone site devoid of hematopoietic marrow, suggesting a differential bone preserving effect at this site. Lack of correlation between the BMD findings and the presence or extent of radiographically evident osteolytic lesions suggested the presence of a systemic bone disease. On multivariate analysis, duration of disease >12 months (p = 0.003) and female sex (p = 0.01) were independently associated with a lower BMD at the femoral neck/lumbar spine. On follow up DEXA (n = 41), BMD increased at > or = 1 site in 9 of 20 patients receiving bisphosphonates and in only 2 of 21 patients not receiving such therapy (p = 0.02). Similarly a decline in BMD at > or = 1 site was seen in 9 of 21 patients not receiving bisphosphonates, irrespective of the disease response status. Interval pamidronate therapy (p = 0.0007) and a low serum beta-2-microglobulin (< 2.5 mg/l) (p = 0.04) were the two most significant variables associated with an increase in BMD on multivariate analysis. These data suggest that myeloma is associated with a systemic bone disease with progressive generalized cancellous bone loss and a bone preserving effect on the radial cortical bone. The early use of bisphosphonates may improve myeloma related bone disease.

The role of bisphosphonates for the treatment of bone disease in multiple myeloma

Palliative therapy is often a major objective for clinicians while treating advanced cancer. This is particularly true in multiple myeloma (MM), where bone involvement markedly influences the quality of life of patients. Bisphosphonates (BP) are a new class of drugs regulating bone turnover, which exert their activity mainly by inhibiting osteoclast bone resorption. Three BP (etidronate, ETD; clodronate, CDN; pamidronate, PMD) have so far been investigated in the clinical setting for treating bone disease in patients with MM. The results of these trials, including our own experience, are reviewed here. Although all three BP were effective in lowering hypercalcemia of MM patients, PMD, a second generation BP, clearly had the most substantial long term clinical benefits regarding bony complications, pain and quality of life. CDN also showed some activity in reducing the development of new lytic lesions, while no significant beneficial effect was seen in patients using ETD. Interestingly, some studies have reported an improved survival in subsets of MM patients receiving BP and this is in agreement with recent evidence of possible direct anti-neoplastic activities of these drugs mediated through reduction of IL-6 production and stimulation of neoplastic cell apoptosis.

Secondary osteoporosis. Diagnostic considerations

This article discusses the important secondary causes of osteoporosis that contribute significantly to bone loss and that seem to increase fracture risk, including hypogonadism, endogenous and exogenous thyroxine excess, hyperparathyroidism, malignancies, gastrointestinal diseases, medications, vices, and connective tissue diseases.

Development of vertebral fractures in patients with multiple myeloma: does MRI enable recognition of vertebrae that will collapse?

PURPOSE

We assessed the relationship between the presence and size of focal marrow abnormalities detected with MRI in vertebral bodies and the subsequent occurrence of vertebral fractures at follow-up in patients with multiple myeloma (MM).

METHOD

We reviewed 179 follow-up MR examinations of the thoracic and lumbar spine prospectively obtained in 37 patients with Stage 3 MM. For each of 131 vertebral bodies that fractured during follow-up, the status of the vertebral bone marrow was assessed on the last MR study obtained at a mean time interval of 4 months prior to fracture occurrence. When focal lesions were observed before fracture in vertebral bodies that later collapsed, their size was compared with that of the contemporary lesions observed in vertebrae that did not collapse.

RESULTS

Of 131 fractures, 82 (63%) appeared in vertebrae previously free of focal bone marrow abnormality at MRI and 49 (37%) appeared in vertebrae in which focal lesions were present on the previous MR study. The size of the lesions that preceded fractures (median 15 mm; range 6-50 mm) was not statistically different from the size of the contemporary lesions (median 15 mm; range 5-60 mm) that did not lead to fracture (p > 0.30).

CONCLUSION

This study in patients with MM suggests a lack of correlation between the preexistence of focal vertebral marrow lesions detected with MRI and the subsequent development of vertebral fractures.

Acute management of cancer-related hypercalcemia

OBJECTIVE

To review the pathogenesis and pharmacologic treatment of acute hypercalcemia associated with malignancy.

DATA SOURCES

A MEDLINE search (1966 to 1995) of the English-language literature pertaining to acute hypercalcemia was performed. Additional literature was obtained from reference lists of articles identified through the search.

STUDY SELECTION AND DATA EXTRACTION

All articles discussing the etiology and medical management of cancer-related acute hypercalcemia were considered in this review. Clinical trials reporting efficacy and safety of antihypercalcemic agents were also included. Information selected in the review was based on the discretion of the authors.

DATA SYNTHESIS

Hypercalcemia is a life-threatening disorder associated with malignancy. It occurs in approximately 10-20% of patients with cancer. A variety of medications have been used in the management of hypercalcemia including bisphosphonates, calcitonin, furosemide, gallium nitrate, glucocorticoids, NaCl 0.9%, and plicamycin. Each of these agents has been reviewed with consideration of pharmacologic mechanism of action, evaluation of clinical trials, recommended dosages, efficacy, safety, cost, and role in treating cancer-related acute hypercalcemia.

CONCLUSIONS

Immediate management of cancer-related acute hypercalcemia to prevent death and provide symptomatic relief is warranted. Severity determined by symptoms, calcium concentrations, and the overall status of the patient are important considerations in selecting appropriate therapy. Although the specific role of individual agents may vary, hydration remains the cornerstone of therapy. NaCl 0.9%, calcitonin, and pamidronate disodium have established roles as dominant first-line agents for the management of acute hypercalcemia associated with malignancy.

Pseudohypercalcemia in an Elderly Patient with Multiplemyeloma: Report of a Case and Review of Literature

Hypercalcemia, a common complication of multiple myeloma, is primarily caused by increased bone resorption. The increase in total calcium is usually associated with an increase in the ionized calcium (Ca(I)), and the hypercalcemia is frequently symptomatic. Rarely, pseudohypercalcemia in multiple myeloma is caused by binding of calcium to the abnormal immunoglobulin. In this setting, the Ca(I) is normal. We describe a 90-year-old woman with an IgA-k myeloma who had substantial increases in the total calcium but normal levels of Ca(I). Clinicians should recognize this unusual phenomenon to avoid unnecessary and potentially toxic therapy.

Evolution of bone densitometry in patients with myeloma treated with conventional or intensive therapy

BACKGROUND

Demineralization is a common hallmark of multiple myeloma (MM) that can be evaluated by dual-energy X-ray absorptiometry (DEXA). The evolution of lumbar and whole body bone density were investigated by DEXA in patients with MM treated by conventional or intensive therapy supported by autologous blood stem cell transplantation.

METHODS

Sixty six patients younger than 66 years with MM were randomly assigned to either conventional (30 patients, Group A) or intensive therapy supported by autologous blood stem cell transplantation (36 patients, Group B). For all patients, lumbar bone mineral density (BMD) was measured by DEXA at diagnosis and 13.2 +/- 4.2 months after the initiation of treatment. Whole body examinations were performed in 45 patients; in addition to whole body BMD, independent BMD values were recorded for various skeletal sites.

RESULTS

At diagnosis, mean lumbar Z score (lumbar mean BMD value) was low (-1.24 +/- 1.45) without any significant difference between the 2 groups. Under treatment, lumbar BMD increased 0.7% in Group A and 4.6% in Group B (P = 0.02). This difference was mainly related to nonresponders in group A who featured a lumbar BMD change of -3.9%, whereas patients in remission in both groups displayed a 4.1% increase (P < 0.001). There was a correlation between the variation of lumbar BMD and the decrease of the serum or urinary monoclonal component (r = 0.34, P = 0.006). After intensive therapy, increase of lumbar BMD was higher in men than in women (7.2% vs. 1%, P = 0.005) perhaps because of variations in hormonal status in women. Unexpectedly, whole body BMD decreased in responders (-3%) because of a decrease in appendicular BMD outweighing the increase in axial BMD. This suggests a redistribution from cortical to cancellous bone in patients with MM responsive to chemotherapy.

CONCLUSION

Bone densitometry is a marker of treatment response that may be particularly useful in nonsecretory and light chain MM. Moreover, it provides new information on bone remodeling in patients treated for MM, which may have therapeutic consequences.