Neurological aspects of multiple myeloma and related disorders

Practical management of disease-related manifestations and drug toxicities in patients with multiple myeloma

Multiple myeloma (MM) is a very heterogeneous disease with multiple symptoms and clinical manifestations. MM affects mainly elderly patients and is difficult to manage in the presence of comorbidities, polypharmacy, frailty and adverse events of disease-targeted drugs. The rapid changes in MM treatment resulting from constant innovations in this area, together with the introduction of numerous new drugs with distinct mechanisms of action and toxicity profiles, have led to an increased complexity in the therapeutic decision-making and patient management processes. The prolonged exposure to novel agents, sometimes in combination with conventional therapies, makes this management even more challenging. A careful balance between treatment efficacy and its tolerability should be considered for every patient. During treatment, a close monitoring of comorbidities, disease-related manifestations and treatment side effects is recommended, as well as a proactive approach, with reinforcement of information and patient awareness for the early recognition of adverse events, allowing prompt therapeutic adjustments. In this review, we discuss various issues that must be considered in the treatment of MM patients, while giving practical guidance for monitoring, prevention and management of myeloma-related manifestations and treatment-related toxicities.

Patient-reported symptoms and diagnostic journey in Multiple Myeloma

Introduction

Late presentation of multiple myeloma (MM) heightens the risk of complication risks, including end-organ damage. This study aimed to: 1) detail the diagnostic journey of MM patients, encompassing symptoms, initial diagnoses, and healthcare professionals met; 2) establish the median duration from symptom onset to MM diagnosis; and 3) examine factors linked to timely MM diagnosis within 12 weeks.

Methods

A total of 300 adults self-reporting MM were analysed from the Rare and Undiagnosed Diseases cohort Study (RUDY). The RUDY study is a web-based platform, where participants provide dynamic consent and self-report their MM diagnosis and information about their diagnostic journey. This includes the estimated date of initial potential first symptoms, descriptions of these symptoms, the healthcare professionals they consulted, and other diagnoses received before the MM diagnosis. Descriptive statistics, combinatorial analyses and logistic regression analyses were used to describe and examine the diagnostic journey of individuals with MM.

Results

Overall, 52% of the participants reported other diagnoses before MM diagnosis, with musculoskeletal disorders (47.8%), such as osteoporosis, costochondritis, or muscle strains, being the most common. The most prevalent initial reported symptom was back pain/vertebral fractures (47%), followed by chest/shoulder pain, including rib pain and fractures (20%), and fatigue/tiredness (19.7%). 40% of participants were diagnosed by direct referral from primary care to haematology without seeing other healthcare professionals whilst 60% consulted additional specialists before diagnosis. The median time from symptom onset to MM diagnosis was 4 months (IQR 2-10 months, range 0-172). Seeing an Allied Healthcare Professional such as a physiotherapist, chiropractor or an osteopath (OR = 0.25, 95% CI [0.12, 0.47], p <0.001), experiencing infection symptoms (OR = 0.32, 95% CI [0.13, 0.76], p = 0.013), and having chest or shoulder pain (OR = 0.45, 95% CI [0.23, 0.86], p = 0.020) were associated with a lower likelihood of being diagnosed with MM within 12 weeks. Older age (OR = 1.04, 95% CI [1.02, 1.07], p = 0.001) was associated with a higher likelihood of diagnosis within 12 weeks.

Discussion

Developing resources for allied health professionals may improve early recognition of MM.

Orofacial symptoms suggestive of malignant lesions and the role of imaging: literature review and case presentation

Among the patients seeking dental treatment, some may present with symptoms that cannot be resolved by dental treatment alone. Patients with orofacial symptoms associated with malignant diseases, which require medical treatment, often visit dental clinics for their initial consultation. Delays in making a definitive diagnosis worsen the patient's prognosis. Therefore, dental clinicians should also be aware of the signs and symptoms associated with malignant diseases. The chief complaints of these patients include numb chin syndrome (NCS), painless swelling of the palate and neck, trismus and temporomandibular disorders, and an enlarged tongue. This article aimed to review these orofacial symptoms and related diseases and describe representative cases of these diseases to obtain a definitive diagnosis via imaging. Panoramic radiograph is widely used in general dentistry, and this article reaffirmed the importance of panoramic radiograph anatomical landmarks in diagnosing the cases presented in this paper.

Multiple myeloma presenting as a cervical intraforaminal tumor: A case report and review of literature

Multiple myeloma (MM) is a hematological malignancy with characteristic clonal plasma cell proliferation and production of monoclonal immunoglobulins. Although it can often metastasize to the bony spine, completely extravertebral and extra-/intradural manifestations are exceedingly rare. In this case report, we describe a 51-year-old male patient with cervical extradural and intraforaminal MM who was surgically treated in our department. Clinical findings and radiological images were retrieved from medical records and an imaging system. This unusual localization of MM and similar cases in the literature are reviewed in detail. The patient underwent tumor resection via a ventral approach, and postoperative MRI demonstrated a sufficient decompression of neural structures. No new neurological deficits were observed at subsequent follow-ups. Although 7 cases of extramedullary extradural manifestations of multiple myeloma have been described in the literature so far, this is the first case of intraforaminal extramedullary multiple myeloma located in the cervical spine and treated by surgery.

Effectiveness of a vitamin D regimen in deficient multiple myeloma patients and its effect on peripheral neuropathy

PURPOSE

Peripheral neuropathy (PN) is common in multiple myeloma (MM) patients. More insight has been gained concerning the role of vitamin D in preventing PN. However, studies evaluating the effects of vitamin D₃ supplementation on PN are lacking. The aims of this study are to (1) evaluate the effectiveness of a vitamin D₃ regimen on achieving adequate vitamin D levels in deficient MM patients and to (2) exploratively evaluate the effect of vitamin D₃ supplementation on PN.

METHODS

Thirty-nine MM patients with inadequate (< 75 nmol/L [= 30 ng/mL]) 25-hydroxyvitamin D (25(OH)D) levels were included in this multicenter, prospective, single-arm study, of whom 35 patients completed the study. They received oral vitamin D₃ for 6 months according to a dose escalation regimen that consisted of one or two loading doses of 200,000 international units (IU), and maintenance doses of 800, 1600, or 3200 IU/day depending on the 25(OH)D level. A validated questionnaire was used to measure PN.

RESULTS

Median 25(OH)D increased from 38 (IQR 32-52) nmol/L at baseline to 77 (IQR 72-87) nmol/L after 6 months (P < 0.001). Adequate 25(OH)D levels were achieved by 66% of the subjects, and 34% were within the range of 50-75 nmol/L. Furthermore, in 37% of the participants, PN severity decreased (P = 0.007).

CONCLUSION

The use of substantially higher vitamin D₃ doses than recommended in current guidelines resulted in a significant increase in vitamin D levels in MM patients. Furthermore, evaluation of PN showed a significant decrease in PN grading. However, this exploratory evaluation needs further confirmatory research.

Involvement of Small Non-Coding RNA and Cell Antigens in Pathogenesis of Extramedullary Multiple Myeloma

Extramedullary multiple myeloma (EMD) is an aggressive disease; malignant plasma cells lose their dependence in the bone marrow microenvironment and migrate into tissues. EMD is a negative prognostic factor of survival. Using flow cytometry and next-generation sequencing, we aimed to identify antigens and microRNAs (miRNAs) involved in EMD pathogenesis. Flow cytometry analysis revealed significant differences in the level of clonal plasma cells between MM and EMD patients, while the expression of CD markers was comparable between these two groups. Further, miR-26a-5p and miR-30e-5p were found to be significantly down-regulated in EMD compared to MM. Based on the expression of miR-26a-5p, we were able to distinguish these two groups of patients with high sensitivity and specificity. In addition, the involvement of deregulated miRNAs in cell cycle regulation, ubiquitin-mediated proteolysis and signaling pathways associated with infections or neurological disorders was observed using GO and KEGG pathways enrichment analysis. Subsequently, a correlation between the expression of analyzed miRNAs and the levels of CD molecules was observed. Finally, clinicopathological characteristics as well as CD antigens associated with the prognosis of MM and EMD patients were identified. Altogether, we identified several molecules possibly involved in the transformation of MM into EMD.

Spinal Lesions as Clinical Manifestations of Plasma Cell Neoplasia

(1) Background: Plasma cell neoplasia can be separated into independent subtypes including multiple myeloma (MM) and solitary plasmacytoma of the bone (SBP). The first clinical signs patients present with are skeletal pain, most commonly involving ribs and vertebrae. (2) Methods: Retrospective analysis of 114 patients (38 female, 76 male) receiving spinal surgery from March 2006 until April 2020. Neurological impairments and surgical instability were the criteria for intervention in this cohort. Analysis was based on demographic data, Spinal Instability Neoplastic Score (SINS), location of the lesion, spinal levels of tumor involvement, surgical treatment, histopathological workup, adjuvant therapy, functional outcome, and overall survival (OS). (3) Results: The following surgical procedures were performed: posterior stabilization only in 9 patients, posterior stabilization and decompression without vertebral body replacement in 56 patients, tumor debulking and decompression only in 8 patients, anterior approach in combined approach without vertebral body replacement and without biopsy and/or without kyphoplasty in 33 patients, 3 patients received biopsies only, and 5 patients received kyphoplasty only. The histopathology diagnoses were MM in 94 cases and SBP in 20 cases. Median OS was 72 months (53.4–90.6 months). Preoperative KPSS was 80% (range 40–100%), the postoperative KPSS was 80% (range 50–100%). (4) Conclusions: Surgery for patients with plasma cell neoplasia is beneficial in case of neurological impairment and spinal instability. Moreover, we were able to show that patients with MM and a low number of spinal levels to be supplied have a better prognosis as well as a younger age at the time of the surgical intervention.

Baseline peripheral neuropathy was associated with age and a prognostic factor in newly diagnosed multiple myeloma patients

Multiple myeloma (MM) is an incurable plasma cell hematological malignancy. Bortezomib has become the primary drug in the treatment of patients with MM. However, its negative effects, especially peripheral neuropathy (PN), affect the patients’ life quality and treatment continuity. However, there are few studies on baseline PN of MM, and little is known of the impact of baseline PN on the prognosis of MM patients. Therefore, we reviewed the clinical data of newly diagnosed MM patients in our center, explored the influencing factors of baseline PN, and evaluated PN’s influence on the prognosis of MM patients undergoing induction therapy with bortezomib. According to the inclusion and exclusion criteria, 155 MM patients were eligible for the retrospective study. The multivariate regression analysis, generalized additive fitting smooth curve, the receiver operating characteristic curve (ROC) and K-M curve were conducted in this study. We found that baseline PN in patients with MM was age-related; MM patients with baseline PN have more severe bortezomib induced PN (BiPN) during the four courses of induction therapy with bortezomib as the primary regimen and worse PN outcome after induction therapy. Additionally, the progression-free survival (PFS) and overall survival (OS) of MM patients with baseline PN were worse than those of the MM patients without baseline PN.

Schnitzler syndrome and Schnitzler-like syndromes

Schnitzler syndrome is a rare disease of adult-onset with main features including chronic urticarial rash, recurrent fever, arthralgia or arthritis, monoclonal gammopathy of undetermined significance (MGUS), and marked systemic inflammation. Schnitzler syndrome is often underdiagnosed. Patients with Schnitzler syndrome may present to dermatologists and allergists for urticaria, hematologists for MGUS, or rheumatologists for arthritis. It is important to recognize Schnitzler syndrome for its remarkable response to interleukin (IL)-1 blockade. Besides, many cases of Schnitzler-like syndromes do not meet the diagnostic criteria of classical Schnitzler syndrome but display excellent response to IL-1 inhibitors. The overly produced IL-1 is the result of a somatic mosaic gain of function mutation of NLRP3 (nucleotide-binding oligomerization domain [NOD]-like receptor [NLR] family pyrin domain containing 3) gene in some patients with Schnitzler-like syndromes. Inflammasome activation is evident in patients with classical Schnitzler syndrome although no NLRP3 gene mutation is identified. Collectively, Schnitzler syndrome and Schnitzler-like syndromes represent a spectrum of IL-1 mediated adult-onset autoinflammatory diseases.

High prevalence of peripheral neuropathy in multiple myeloma patients and the impact of vitamin D levels, a cross-sectional study

PURPOSE

Peripheral neuropathy (PN) is common in patients with multiple myeloma (MM). We hypothesized that the relationship between hypovitaminosis D and PN described in diabetes mellitus patients may also be present in MM patients.

METHODS

To study this potential association, we assessed the incidence of hypovitaminosis D (vitamin D < 75 nmol/L [= 30 ng/mL]) in smouldering and active MM patients in two Dutch hospitals. Furthermore, a validated questionnaire was used to distinguish different PN grades.

RESULTS

Of the 120 patients included between January 2017 and August 2018, 84% had an inadequate vitamin D level (median vitamin D level 49.5 nmol/L [IQR 34-65 nmol/L]; mean age: 68 years [SD ± 7.7]; males: 58%). PN was reported by 69% of patients (n = 83); however, of these 83 patients, PN was not documented in the medical records of 52%. An association was found between lower vitamin D levels and higher incidence of PN in the total population (P = 0.035), and in the active MM patients (P = 0.016).

CONCLUSION

This multi-centre cohort study showed that PN and hypovitaminosis D are common in MM patients, and addressing low vitamin D levels in the treatment of MM patients might be beneficial in reducing the risk of PN. More attention for PN is warranted, as PN is underreported by clinicians. Further research is needed to fully understand the implications of vitamin D in the development of PN in patients with MM.

CLINICAL TRIAL REGISTRATION

Netherland Trial Register NL5835, date of registration July 28, 2016.

[Myelomatous meningitis: a case report]

We present the case of a 67-year-old woman with meningeal carcinomatosis who was treated with chemotherapy for refractory multiple myeloma, and was in remission. She was admitted to our hospital because of tonic seizures and disturbance of consciousness. Monoclonal CD 138-positive plasma cells were detected in her cerebrospinal fluid. Cranial MRI showed gadolinium enhancement of diffuse meninges and cranial nerves. We diagnosed the patient with systemic epilepsy due to meningeal carcinomatosis and administered antiepileptic drugs and intrathecal chemotherapy; however, she showed little improvement, and she passed away on hospital day 74 because of disease progression. Multiple myeloma is known to be associated with neurological symptoms such as peripheral neuropathy, myelopathy, and radiculopathy; however, central nervous system involvement in multiple myeloma is uncommon. We should consider central nervous system involvement in multiple myeloma, such as meningeal carcinomatosis, given the importance of early detection and therapeutic intervention.

Optic nerve head plasmacytoma as a manifestation of multiple myeloma

Extramedullary disease in multiple myeloma is uncommon and associated with a poorer prognosis. Extramedullary disease involving the orbit is even more unusual, with optic nerve involvement being rare. We describe an optic nerve head plasmacytoma in a 45-year-old female in the setting of systemic relapsed, refractory IgA kappa multiple myeloma. The case highlights the importance of keeping extramedullary disease spread in the differential for vision loss in a patient with a history of multiple myeloma. In addition, it describes an unusual location for presentation of extramedullary disease, the optic nerve head, which has rarely been described.

Comparing neuropathy in multiple myeloma and AL amyloidosis

Peripheral neuropathy (PN) is frequent in patients with monoclonal gammopathy due to plasma cell dyscrasia, but little is known about the comparative impact of nerve dysfunction in different disorders. We compared clinical and laboratory results between two diagnostic groups. We recruited 76 untreated multiple myeloma (MM) and 27 AL amyloidosis (ALA) patients for evaluation of symptoms, clinical findings and nerve conduction studies (NCS). We diagnosed significant PN using total neuropathy scores (TNS > 7) in 17.6% of MM and 48.1% of ALA patients and in 27.7% of MM and 35.7% of ALA patients using NCS findings. TNS score grades were significantly higher in the AL amyloidosis patients (Fisher's exact test: P = .02) but a NCS based PN diagnosis was not significantly different (Fisher's exact test: P = .13). A significantly higher TNS vibration (P = .04) and pin (P = .02) sensory sign and TNS reflex (P = .04) sign score was found in amyloidosis patients. Likewise, quantitative sensory thresholds for vibration was higher in amyloidosis patients (Welsh ANOVA: P = .01). NCS revealed signs of more frequent axonal tibial neuropathy with significantly lower motor response amplitudes (P = .02) and resulting higher TNS scores (P = .002), while sural nerve sensory response amplitudes were without significant difference (P = .86). We found more severe TNS grades of PN in AL amyloidosis patients compared with MM patients. We also found higher sensory symptoms scores and higher thresholds for vibration but similar sensory involvement using NCS. The NCS exclusively showed signs of an axonal neuropathy.

Surgical Management of Multiple Myeloma With Symptomatic Involvement of the Spine

INTRODUCTION

Multiple myeloma (MM) is the most frequent primary malignancy of the spine. We aimed to investigate the clinical presentation, surgical indications and outcomes, complications, survival, and its influencing factors in surgically treated MM patients with symptomatic involvement of the spine (SIS).

METHODS

Retrospective analysis of prospectively collected data. Out of 350 MM patients treated at our institution over a period of 12 years (2006-2018), we identified 24 patients who were surgically treated for SIS. We collected data on demographics, clinical presentation, comorbidities, surgical indications, and outcomes and investigated the factors predisposing to postoperative complications and survival.

RESULTS

The median follow-up duration was 85 months; median overall survival (OS) was 50 months. Clinical presentation at admission included pain (88%), sensory and/or motor deficit (67%), and bowel/bladder dysfunction (25%). Symptomatic pathological fractures were seen in 33%. Predominant surgical indications were rapid neurological deterioration with or without spinal cord compression (SCC), followed by mechanical instability. The majority of our patients benefited from surgery in terms of pain reduction in the short term as well as in the long term. There were 21% patients with surgical-related complications (<3 months). Surgical site infections occurred in 17%, without any obvious factors predisposing to infective complications. Neurological deterioration during hospital stay, especially in the presence of motor deficit and/or bowel/bladder dysfunction, significantly reduced OS.

CONCLUSIONS

Sudden-onset neurological deterioration was the predominant factor leading to surgery. We achieved good short- and long-term pain reduction. Surgery is a valuable option for MM patients with SIS who present with rapid neurological deterioration with or without SCC and/or mechanical instability.

Multiple myeloma with intracranial and spinal intradural metastasis: A case report

Multiple myeloma is a hematopoietic cancer that is multicentric and most commonly involves the spine. Multiple myeloma with extraosseous and intradural involvement is an extremely rare condition. Here we present a rare case of spinal multiple myeloma with intracranial and spinal intradural metastasis causing lumbar spinal nerve compression. We present a 60-year-old woman with progressive weakness of the lower limbs for several weeks. Spinal magnetic resonance imaging (MRI) showed a leptomeningeal tumor with nodularity spreading within the cauda equina. Examination of the brain using MRI showed a lytic skull bone lesion and leptomeningeal enhancement. The patient underwent L3-5 laminectomy. Immunohistological staining confirmed a diagnosis of multiple myeloma of the IgA kappa subtype. After surgery, the patient underwent chemotherapy and rehabilitation exercises. Multiple myeloma has a median survival of 2.5 years, while 75% of patients with spinal involvement die within 1 year of diagnosis. Unfortunately, our patient died 3 months after the diagnosis of multiple myeloma with spinal and intracranial involvement. Intracranial and spinal intradural multiple myeloma invasions are quitely rare. Spine biopsies and cerebrospinal fluid cytology can aid in the diagnosis. Early surgical decompression is necessary, especially when neurological deficits occur.

Neurologic Complications of Lymphoma, Leukemia, and Paraproteinemias

PURPOSE OF REVIEW

This article reviews the spectrum of neurologic complications associated with lymphoma, leukemia, and paraproteinemic disorders. While leptomeningeal metastasis is the most common complication of lymphoma and leukemia and peripheral neuropathy is the most common complication of paraproteinemic disorders, clinicians need to be familiar with the diverse neurologic complications of these disorders.

RECENT FINDINGS

Lymphomatous nervous system involvement can be difficult to diagnose, especially when it is the presenting symptom. CSF cytology and flow cytometry, as well as the imaging pattern, assist in diagnosis. Neurologic complications are less common in Hodgkin lymphoma; however, some unique paraneoplastic syndromes are associated with Hodgkin lymphoma, including primary central nervous system angiitis, limbic encephalitis, and cerebellar degeneration. Recent reports suggest that anti-metabotropic glutamate receptor 5 (mGluR5) antibodies are associated with limbic encephalitis and that anti-Tr antibodies are associated with cerebellar degeneration in Hodgkin lymphoma. Polyneuropathy, organomegaly, endocrinopathy, monoclonal plasma cell disorder, and skin changes (POEMS) syndrome is often misdiagnosed as chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). A lambda protein, thrombocytosis, and elevated vascular endothelial growth factor (VEGF) can all be helpful clues in diagnosis. Early recognition is important, as the neuropathy responds to radiation therapy or chemotherapy.

SUMMARY

Neurologic involvement can occur throughout the disease course in lymphoma and leukemia, including at presentation, with systemic progression, and at relapse. In paraproteinemias, the peripheral neuropathy phenotype, monoclonal protein type, and associated autonomic and systemic features aid in identification of an underlying plasma cell disorder.

Intracranial Calcification Masquerading as Hemorrhage in a Patient with Multiple Myeloma Presenting with Facial Neuropathy

Multiple myeloma is an immunoglobulin-producing plasma cell neoplasm that commonly affects the bones, kidneys, the hematopoietic system, and rarely the nervous system. Peripheral nervous system involvement in the form of cranial neuropathy, radiculopathy, and polyneuropathy are common. Compressive myelopathy constitutes the majority of central nervous system disorders followed by cerebrovascular disorders, intracranial plasmacytomas, and leptomeningeal myelomatosis. Cerebrovascular complications such as acute ischemic stroke and transient ischemic attack are not uncommon. Intracerebral hemorrhage, although infrequent, can be secondary to refractory hypertension from renal failure and intratumoral hemorrhage in intracerebral plasmacytomas. Metastatic calcifications in lungs, liver, and skin with high levels of serum calcium and phosphate are seen in patients with multiple myeloma, but intracerebral calcifications are not common. We report an unusual case of intracranial calcification masquerading as acute intracerebral hemorrhage in a patient presenting with acute facial weakness. 

Multiple Myeloma of the Central Nervous System: 13 Cases and Review of the Literature

Central nervous system involvement is a rare complication of multiple myeloma with extremely poor prognosis as it usually fails to respond to therapy. We present 13 cases diagnosed at two centers in Budapest and review the current literature. The majority of our cases presented with high-risk features initially; two had plasma cell leukemia. Repeated genetic tests showed clonal evolution in 3 cases. Treatments varied according to the era, and efficacy was poor as generally reported in the literature. Only one patient is currently alive, with 3-month follow-up, and the patient responded to daratumumab-based treatment. Recent case reports show promising effectivity of pomalidomide and marizomib.

Evaluation of the Relevance of Surgery in Patients with Multiple Myeloma Harboring Symptomatic Spinal Involvement: A Retrospective Case Series

BACKGROUND

Multiple myeloma spinal involvement can lead to bone fractures and neurologic impairment that can severely alter quality of life. The role of surgery is controversial, given its high morbidity, and the lack of evidence. We hereby aim to evaluate efficacy and safety of surgery in the management of symptomatic spinal lesions in patients with multiple myeloma.

METHODS

We included all patients operated on for a myeloma-related spinal lesion in our institution between 2007 and 2015. Demographic, clinical, and surgical data were collected as well as hematologic profiles. We retrospectively assessed the surgical success of the procedures, if at 3 months the patient fulfilled the following 4 criteria: pain relief, ability to walk, spinal stability, and no relevant morbidity.

RESULTS

Thirty-six men and 19 women, with a median age of 62 years, were included. Seventeen patients underwent an emergency intervention, whereas 38 patients underwent elective surgery. At 3 months, 88.2% and 96.1%, respectively, of patients experienced pain relief and were able to walk. Spinal stability was considered satisfactory for 94.1% of patients. We reported 8 major complications in 8 patients. Altogether, 34 patients (61.8%) fulfilled all criteria for surgical success. An International Staging System score of 1 and the absence of previous chemotherapy were significantly associated with surgical success.

CONCLUSIONS

Management of myeloma-related spine lesions requires a multidisciplinary approach. Surgery rapidly provides both decompression and stabilization. Using a strict patient-specific evaluation, we reported rewarding functional results, with acceptable morbidity. Surgery for multiple myeloma vertebral lesions seems to be a valuable option for carefully selected patients.

Multiple myeloma and central nervous system involvement: experience of a Brazilian center

Introduction

The estimated involvement of the central nervous system in patients with multiple myeloma is rare at about 1%. The infiltration can be identified at the time multiple myeloma is diagnosed or during its progression. However, it is more common in refractory disease or during relapse.

Methods

This retrospective cohort study reviewed data from medical records of patients followed up at the Gammopathy Outpatient Clinic of Santa Casa de Misericórdia de São Paulo from January 2008 to December 2016.

Results

Twenty patients were included, with a median follow-up of 33.5 months after central nervous system infiltration. The prevalence was 7%. The median age at diagnosis of multiple myeloma was 56.1 years, with 70% of participants being female. Sixteen patients had central nervous system infiltration at diagnosis of multiple myeloma. Seventeen patients had exclusive osteodural lesions and three had infiltrations of the leptomeninge, of which one had exclusive involvement and two had associated osteodural lesions. The median overall survival was 40.3 months after central nervous system involvement. The median overall survival in the group with central nervous system infiltration at relapse was 7.4 months. The patients with leptomeningeal involvement had a median overall survival of 5.8 months.

Conclusion

Central nervous system infiltration is a rare condition, but it should be considered as a possibility in patients with multiple myeloma and neurological symptoms. The best treatment regimen for this condition remains unknown and, in most cases, the prognosis is unfavorable.

Mieloma múltiplo em cão com apresentação clínica atípica de paralisia facial bilateral: relato de caso

RESUMO Objetivou-se com o presente trabalho relatar um caso de mieloma múltiplo (MM) em uma cadela com apresentação clínica atípica de rigidez da musculatura facial. Foram realizados hemogramas seriados, exames bioquímicos, sumário de urina, sorologia para leishmaniose, radiografias de crânio, citologia de medula óssea e eletroforese de proteínas séricas. O infiltrado plasmocitário em medula óssea >20%, a gamopatia monoclonal e as lesões compatíveis com lise óssea, observados no mielograma, eletroforese de proteínas e exame radiográfico, respectivamente, foram determinantes para conclusão diagnóstica de MM. A doença pode ter uma apresentação clínica variável em cães e representar um desafio ao diagnóstico na clínica de animais de companhia, principalmente em áreas endêmicas de doenças infecciosas que se manifestam com apresentações clínicas e laboratoriais semelhantes.

Diagnosis and management of neuropathies associated with plasma cell dyscrasias

Neuropathies associated with plasma cell dyscrasias are a major cause of morbidity for patients managed by medical oncologists. Because of similarities in clinical presentation and on nerve conduction studies, identifying the underlying disease leading to a paraproteinemic neuropathy can often be difficult. In addition, the degree of neurologic deficit does not strictly correlate with the extent of abnormalities on common clinical laboratory testing. Fortunately, with increasing understanding into the biologic mechanisms of underlying hematologic diseases, additional biomarkers have recently been developed, thus improving our diagnostic capacity. Neuropathies associated with plasma cells dyscrasias are seen with Monoclonal gammopathy of undetermined significance (MGUS) particularly IgM subtype, followed by IgG and IgA MGUS, multiple myeloma, Waldenström's macroglobulinemia, amyloid, Castleman's disease, and POEMS syndrome. The mechanisms of neuronal injury associated with plasma cell dyscrasia vary based on underlying diagnosis and include malignant infiltration, immune-mediated antibody deposition, or local compression of nerve roots. The polyneuropathies are frequently demyelinating, although axonal and mixed neuropathies can also be seen. As demonstrated by the cases included in this review, patients frequently present with symmetric sensory disturbance, followed by progressive motor weakness. Unfortunately, because of the complexity of diagnostic testing, patients are frequently examined late, often after receiving several ineffective therapies. The aim of this case-based review is to provide clinicians with insight on how to properly recognize these atypical neuropathies and send the appropriate diagnostic work, increasing the likelihood of accurately classify the patient's underlying hematologic disorder.

Overall Survival in Spine Myeloma Metastases: Difficulties in Predicting With Prognostic Scores

STUDY DESIGN

Fifty-one patients with spinal multiple myeloma (MM) metastases were operated and followed between January 2004 and July 2014.

OBJECTIVE

The aim of this study was to consider the efficiency of surgical prognosis scores in the management of spinal metastases myelomas.

SUMMARY OF BACKGROUND DATA

The spine is the most common site of bone metastases in MM. Surgery in spine metastases MM is a matter of debate and its impact on the increase of a patient's survival time is not clear. Several surgical survival scores have been developed to determine the best treatment in these patients.

METHODS

We studied 51 patients operated for spinal MM metastases between January 2004 and July 2014. We determined the Tokuhashi and Tomita survival scores and compared them with documented patient survivals. The two scores were also compared with the International Staging System (ISS).

RESULTS

Median survival (MS) was 108 months [standard deviation (SD) 62] for ISS I, 132.2 (SD 40) for ISS II, and 45.5 months (SD 16.3) for ISS III (P = 0.09). According to Tokuhashi survival score, 21 patients (41.2%) will survive <6 months, 6 (11.8%) 6 to 12 months, and 24 (47%) >12 months. According to Tomita et al., 50 patients (98%) will survive >49.9 months and 1 patient (2%) <15 months. Regardless of the ISS grade prognosis, Tokuhashi survival score, and to a lesser extent Tomita score, underestimated the actual survival very significantly [P < 0.0001, Log Rank (Mantel-Cox)].

CONCLUSION

We suggest that spine surgical prognosis scores are not accurate and are not able to predict the survival of patients with spine myeloma metastases. Spine surgeons have to be guided not by the initial ISS stage but rather by spinal instability and neurological status.

LEVEL OF EVIDENCE

N/A.

Neuropathy and efficacy of once weekly subcutaneous bortezomib in multiple myeloma and light chain (AL) amyloidosis

INTRODUCTION

Randomized studies have shown that bortezomib (BTZ) can be given weekly via intravenous (IV) route or twice weekly via subcutaneous (SC) route with lower neuropathy risk and no loss of anti-myeloma efficacy compared to original standard IV twice weekly schedule. Weekly SC should therefore yield the best therapeutic index and is widely used but has not been compared to established administration schedules in the context of a clinical trial.

METHODS

Comprehensive electronic medical record review was done for disease control and neuropathy symptoms of 344 consecutive patients who received their first BTZ-containing regimen for myeloma or AL amyloidosis before or after we changed to SC weekly in December 2010. Univariate and multivariable analyses were carried out that adjusted for age, underlying disease, concurrently used anticancer agents, underlying conditions predisposing to neuropathy, and number of prior regimens compared SC weekly to other schedules.

RESULTS

Fifty-three patients received BTZ SC weekly, 17 SC twice weekly, 127 IV weekly and 147 IV twice weekly. Risk for neuropathy of any grade was higher with other schedules compared to SC weekly (44.3% vs. 26.9%, p = 0.001) while response rate was similar (72.1% vs. 76.6%, respectively, p = 0.15). Multivariable analyses upheld higher neuropathy risk (Odds ratio 2.45, 95% CI 1.26-4.76, p = 0.008) while the likelihood of not achieving a response (= partial response or better) was comparable (Odds ratio 1.25, 95% CI 0.58-2.71, p = 0.56) for other schedules compared to SC weekly, respectively. Lower neuropathy risk translated into longer treatment duration when BTZ was started SC weekly (p = 0.001).

CONCLUSIONS

Weekly SC BTZ has activity comparable to other schedules and causes low rates of neuropathy.

Investigation and management of IgM and Waldenström-associated peripheral neuropathies: recommendations from the IWWM-8 consensus panel

Paraproteinaemic neuropathies are a heterogeneous group of disorders most frequently associated with IgM monoclonal gammopathies including Waldenström macroglobulinaemia (WM). Their consequences are significant for affected patients, and their management challenging for their physicians. The variability in clinical presentation and time course hamper classification and management. The indications for invasive investigations such as cerebrospinal fluid analysis, nerve conduction tests and sensory nerve biopsies are unclear, and the optimum way to measure clinical response to treatment unknown. When to intervene and and how to treat, also present challenges to physicians. As part of its latest deliberations at the International Workshops on WM (IWWM) in London, UK (August 2014), the IWWM8 panel have proposed a consensus approach to the diagnosis and management of peripheral neuropathies associated with IgM monoclonal gammopathies, including WM. Importantly, a consensus regarding the use of clinical outcome measures and recommended models of care for this group of patients is discussed, as well as appropriate treatment interventions.

[Clinical characteristics of pain syndrome in patients with multiple myeloma]

AIM

To study pain syndrome characteristics in the trunk and extremities of patients with multiple myeloma (MM).

MATERIAL AND METHODS

The study involved 120 patients with MM, aged from 34 to 83 years. The duration of disease was 2-37 months.

RESULTS AND CONCLUSION

The pain syndrome of trunk and extremity localization was revealed in 94% patients, its intensity according to the VAS was 65.5±25.4 mm. At all stages of disease, moderate to severe pain, predominantly related to polyneuropathy (PNP), radiculopathy and osteodestruction, was more frequent. Radicular pain syndrome was revealed in 46% of all MM patients, and in the majority of cases (92%), there were bone destruction lesions. The character of pain in MM should be specified to optimize further management of the patient.

Intracranial Involvement by Plasma Cell Neoplasms

OBJECTIVES

Intracranial plasma cell neoplasms (PCNs) arising from the skull, dura, or brain parenchyma are rare tumors and there is only a limited experience in the literature with these lesions.

METHODS

We performed a retrospective clinicopathologic study of fourteen cases of intracranial PCN at our institution encountered over a 26-year-period.

RESULTS

The fourteen patients ranged in age from 30-74 years (median 66 years) and included seven males. For eight patients, their intracranial lesions were the initial presentation of multiple myeloma (MM). Three patients had prior history of MM; their intracranial tumors showed blastic plasma cell morphology, and all three died secondary to MM. The remaining three patients did not or have not developed MM.

CONCLUSIONS

PCNs rarely arise in the intracranial compartment. Intracranial PCN may be the initial presentation of MM. Anecdotally, blastic morphology appears to manifest more aggressive behavior.

Managing treatment-related peripheral neuropathy in patients with multiple myeloma

Peripheral neuropathy is one of the most important complications of multiple myeloma treatment. Neurological damage can be observed at the onset of the disease, due to the effect of monoclonal protein or radicular compression, but more often is treatment related. Vinca alkaloids in the past era, and more recently, thalidomide and bortezomib are mainly responsible. Degeneration of dorsal root ganglion is common, prevalently related to angiogenesis inhibition and cytokine modulation in the case of thalidomide and inhibition of the ubiquitin proteasome system in the case of bortezomib. Sensory neuropathy and neuropathic pain are more common; motor neuropathy and autonomic damage are less frequently observed. Neurotoxicity often affects patient's quality of life and requires dose modification or withdrawal of therapy, with a possible effect on the overall response. A prompt recognition of predisposing factors (such as diabetes mellitus, alcohol abuse, vitamin deficiencies, or viral infections) and appearance of signs and symptoms, through a periodic neurological assessment with appropriate scales, is extremely important. Effective management of treatment at the emergence of peripheral neuropathy can minimize the incidence and severity of this complication and preserve therapeutic efficacy. Dose adjustment could be necessary during treatment; moreover, gabapentin or pregabalin, tricyclic antidepressants, serotonin and norepinephrine reuptake inhibitors, carbamazepine, and opioid-type analgesics are suggested according to the pain severity. Some authors reported that patients who develop peripheral neuropathy during their multiple myeloma treatments presented a particular gene expression profile; therefore, future studies could be helpful for a better understanding of possible biological pathways underlying neurotoxicity.

Local radiotherapy for palliation in multiple myeloma patients with symptomatic bone lesions

Purpose

To evaluate the clinical outcomes of symptomatic bone lesions in patients with multiple myeloma (MM) who received local radiotherapy (LRT).

Materials and Methods

Fifty-one patients with 87 symptomatic bone lesions treated via LRT were analyzed. LRT was delivered at a median total dose of 21 Gy (range, 12 to 40 Gy) in a median of 7 fractions (range, 4 to 20 fractions). The clinical outcomes of LRT and the factors affecting treatment response were assessed.

Results

After a median follow-up time of 66.7 weeks, symptom relief was achieved for 85 of 87 lesions (97.7%). The median time to symptom relief was 7 days from the start of LRT (range, 1 to 67 days). The duration of in-field failure-free survival ranged from 1.1 to 450.9 weeks (median, 66.7 weeks). The radiation dose or use of previous and concurrent chemotherapy was not significantly associated with in-field failure for LRT (p = 0.354, 0.758, and 0.758, respectively).

Conclusion

Symptomatic bone lesions in patients with MM can be successfully treated with LRT. A higher radiation dose or the use of concurrent chemotherapy may not influence the in-field disease control. A relatively low radiation dose could achieve remission of symptoms in patients with MM.

Numb chin syndrome as first symptom of diffuse large B-cell lymphoma

Numb chin syndrome is a rare sensory neuropathy of the mental nerve characterized by numbness, hypoesthesia, paraesthesia, and very rarely pain. Dental causes, especially iatrogenic ones, maxillofacial trauma, or malignant neoplasm are etiologic factors for this rare syndrome. Many malignant and metastatic neoplasms are causing this syndrome, like primary osteosarcoma, squamous cell carcinoma, and mandibular metastasis of primary carcinoma of breast, lung, thyroid, kidney, prostate, and nasopharynx. Haematological malignancies like acute lymphocytic leukaemia, Hodgkin and non-Hodgkin lymphoma, and myeloma can cause this neuropathy. The authors report a case of a 71-year-old woman in which the numb chin syndrome was the first symptom of the diffuse large B-cell lymphoma, which caused infiltration and reabsorption of the alveolar ridge and lower mandibular cortex. A biopsy of the mass was performed on fragments of tissue collected from the mandibular periosteum, medullary and cortical mandibular bone, and inferior alveolar nerve.

Hypericin-mediated photodynamic therapy induces apoptosis of myoloma SP2/0 cells depended on caspase activity in vitro

BACKGROUND

Photodynamic therapy (PDT) is becoming a promising therapeutic modality for hematological malignancies. Hypericin is a natural photosensitizer possessing anti-depressant, anti-virus and anti-cancer activities. The present study was designed to explore the effect and mechanism of hypericin-mediated PDT on the mouse multiple myeloma (MM) cells in vitro.

METHODS

The mouse myeloma SP2/0 cells were incubed with different concentrations of hypericin and then illuminated with different light doses. The inhibitory effect of hypericin-mediated PDT on tumor cell proliferation was assayed by 3-(4, 5-dimethylthiazol-2-yl)-2, 5-diphenyltetrazolium bromide (MTT) method. The apoptosis related morphological changes of SP2/0 cells were observed by microscopy. The biochemical hallmarks of apoptosis such as DNA fragments, mitochondrial membrane potential changes were assessed. The expression of apoptosis related proteins were investigated by western blotting.

RESULTS

Hypericin-mediated PDT induced the proliferation inhibition and apoptosis of tumor cells in a dose dependent manner. Tumor cells showed obvious morphological changes of apoptosis and necrosis and DNA fragmentation after treated by hypericin mediated PDT (0.025 ~ 0.05 μM). The mitochondria membrane potential in SP2/0 cells was decreased significantly after incubated with the 0.025 μM and 0.5 μM hypericin (P < 0.05). The expression level of caspase-3 was decreased, while caspase activity was elevated with the increasing drug dosage. The apoptosis of SP2/0 cells was blocked by a pan-caspase inhibitor Z-VAD-FMK and caspase-3 inhibitor Ac-DEVD-CHO.

CONCLUSION

Hypericin-mediated PDT induced apoptosis mainly dependent on caspase related pathways. Hypericin-mediated PDT may be a potential and alternative therapy for MM.

Bortezomib- and thalidomide-induced peripheral neuropathy in multiple myeloma: clinical and molecular analyses of a phase 3 study

A subanalysis of the GIMEMA-MMY-3006 trial was performed to characterize treatment-emergent peripheral neuropathy (PN) in patients randomized to thalidomide-dexamethasone (TD) or bortezomib-TD (VTD) before and after double autologous transplantation (ASCT) for multiple myeloma (MM). A total of 236 patients randomized to VTD and 238 to TD were stratified according to the emergence of grade ≥2 PN. Gene expression profiles (GEP) of CD138+ plasma cells were analyzed in 120 VTD-treated patients. The incidence of grade ≥2 PN was 35% in the VTD arm and 10% in the TD arm (P < 0.001). PN resolved in 88 and 95% of patients in VTD and TD groups, respectively. Rates of complete/near complete response, progression-free and overall survival were not adversely affected by emergence of grade ≥2 PN. Baseline characteristics were not risk factors for PN, while GEP analysis revealed the deregulated expression of genes implicated in cytoskeleton rearrangement, neurogenesis, and axonal guidance. In conclusion, in comparison with TD, incorporation of VTD into ASCT was associated with a higher incidence of PN which, however, was reversible in most of the patients and did not adversely affect their outcomes nor their ability to subsequently receive ASCT. GEP analysis suggests an interaction between myeloma genetic profiles and development of VTD-induced PN.

Therapy-related peripheral neuropathy in multiple myeloma patients

This review discusses the most common issues concerning multiple myeloma (MM)-related peripheral neuropathy (PN). This is an important MM complication, observed in up to 54% of newly diagnosed patients, caused by the disease itself or its treatment. Although its aetiology is largely unknown, a number of mechanisms are suspected. It is important to know the neurological status of a patient, as many new antimyeloma medicines can trigger or exacerbate any pre-existing neuropathy. Examples include thalidomide-induced and bortezomib-induced PN (TiPN and BiTN, respectively), which are key MM treatment options. TiPN is usually sensory and sensorimotor, whereas BiPN is typically sensory. The mechanisms of chemotherapy-induced neurotoxicity in MM are well known; thalidomide seems to induce PN through its antiangiogenic properties, whereas bortezomib neurotoxicity is connected with disrupted calcium homeostasis. TiPN incidence ranges from 25% to 75%, and its prevalence and severity appears to be dose-dependent. BiPN incidence is almost 40% and is dose-related as well. Poor (25%) reversibility of TiPN prompted the recommendations for dose and exposure reduction, whereas BiPN cases are mostly reversible (64%). Peripheral sensory neuropathy is very rare in patients receiving bendamustine monotherapy. Because of this favourable toxicity profile, bendamustine may be considered a promising option for combination therapies in pre-existing PN in myeloma patients. Considering the lack of curative therapy for treatment-emergent PN, prevention is a key management strategy in MM patients. All patients should be evaluated for PN before the administration of a neurotoxic drug, and those under treatment should be closely monitored by a neurologist.

Schnitzler syndrome: an under-diagnosed clinical entity

Schnitzler syndrome is considered to be a rare disorder characterized by a monoclonal IgM protein and chronic urticaria that is associated with considerable morbidity. We hypothesized that the syndrome may be under-recognized and patients may be deprived of highly effective therapy in the form of anakinra. We performed a retrospective search of the dysproteinemia database at Mayo Clinic as well as the medical records of all patients with chronic urticaria to determine the true incidence of the disease. We compared patients with the diagnosis of Schnitzler syndrome and those who met the criteria but in whom the syndrome was not recognized. Comparisons between groups were performed and survival curves determined. We identified 16 patients with diagnosed Schnitzler syndrome and an additional 46 patients who met diagnostic criteria. The monoclonal protein was IgMκ in 94% of patients. Therapy with anakinra in 4 patients led to rapid and complete resolution of symptoms. The median overall survival for this syndrome is over 12.8 years. Progression to lymphoma was only observed in 8% of patients; this is lower than previous reports. Schnitzler syndrome may be present in up to 1.5% of patients with a monoclonal IgM in their serum and likely under-recognized as a clinical syndrome.

Evolving role of FDG PET/CT in multiple myeloma imaging and management

OBJECTIVE

Multiple myeloma is the most common cause of primary malignancy in bones. Radiography has been the imaging reference standard for decades. However, the growing use of CT, MRI, and PET technology has led to earlier diagnosis of multiple myeloma, more accurate therapy assessment, and better prediction of patient outcome. This article is focused on the evolving role of (18)F-FDG PET/CT in multiple myeloma diagnosis, therapy assessment, and prognosis.

CONCLUSION

FDG PET/CT is a valuable imaging modality in diagnosis, therapy assessment, and prognosis of multiple myeloma.