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Agaronnik ND, Giberson-Chen C, Bono CM. Using advanced imaging to measure bone density, compression fracture risk, and risk for construct failure after spine surgery. Spine J 2024; 24:1135-1152. [PMID: 38437918 DOI: 10.1016/j.spinee.2024.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 01/22/2024] [Accepted: 02/23/2024] [Indexed: 03/06/2024]
Abstract
Low bone mineral density (BMD) can predispose to vertebral body compression fractures and postoperative instrumentation failure. DEXA is considered the gold standard for measurement of BMD, however it is not obtained for all spine surgery patients preoperatively. There is a growing body of evidence suggesting that more routinely acquired spine imaging studies such as computed tomography (CT) and magnetic resonance imaging (MRI) can be opportunistically used to measure BMD. Here we review available studies that assess the validity of opportunistic screening with CT-derived Hounsfield Units (HU) and MRI-derived vertebral vone quality (VBQ) to measure BMD of the spine as well the utility of these measures in predicting postoperative outcomes. Additionally, we provide screening thresholds based on HU and VBQ for prediction of osteopenia/ osteoporosis and postoperative outcomes such as cage subsidence, screw loosening, proximal junctional kyphosis, and implant failure.
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Affiliation(s)
| | - Carew Giberson-Chen
- Harvard Combined Orthopaedic Residency Program, 55 Fruit Street, Yawkey Building, Suite 3A, Boston, MA 02114
| | - Christopher M Bono
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115; Harvard Combined Orthopaedic Residency Program, 55 Fruit Street, Yawkey Building, Suite 3A, Boston, MA 02114; Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Yawkey Building, Suite 3A, Boston, MA 02114.
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Kaufmann J, Täubl AU, Nikolaidou E, Rühle A, Hopprich A, Wollschläger D, Mayer A, Nicolay NH, Schmidberger H, Bostel T. Excellent long-term pain response and local control following postoperative radiotherapy in patients with multiple myeloma. Strahlenther Onkol 2024; 200:633-641. [PMID: 38289360 PMCID: PMC11186884 DOI: 10.1007/s00066-024-02198-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 01/03/2024] [Indexed: 06/21/2024]
Abstract
PURPOSE Multiple myeloma is associated with osteolytic bone lesions, often requiring surgery of the spine and postoperative radiotherapy (RT). Although common, data for clinical and informed decision-making are sparse. In this monocentric retrospective study, we aim to report the outcome of patients who underwent spinal surgery and postoperative RT due to multiple myeloma. METHODS A total of 54 patients with multiple myeloma who underwent prior spinal surgery and postoperative RT at our institution between 2009 and 2020 were analyzed. Spinal instability neoplastic score (SINS) and Bilsky score, posttherapeutic adverse events, clinical data, and outcomes were collected and analyzed. The primary endpoint of this study was overall survival (OS), secondary endpoints were progression-free survival (PFS), pain response, local control, and skeletal-related events (SRE). RESULTS The 3‑ and 5‑year overall survival (OS) was 74.9% (95% confidence interval [CI]: 63.5-88.4%) and 58% (95% CI: 44.5-75.6%), respectively. Median survival was not reached and 75% survival was 34.3 months (95% CI: 28.7-95.4 months). Median follow-up was 63 months (95% CI: 49-94 months). The number of patients with good to adequate performance status (Karnofsky performance score [KPS] ≥ 70) significantly increased after surgery (p < 0.01). We observed no grade 3/4 toxicity and only 13 (24%) grade 1/2 adverse events. Two patients (4%) experienced SRE. Overall, 92% of patients reported reduced pain after radiotherapy, with 66% reporting complete pain response. There was no difference in pain response between patients with different Bilsky scores. Bisphosphonate therapy and lower Bilsky score at the start of RT were associated with improved OS in univariate analysis (all p < 0.05). Multivariate Cox regression confirmed a Bilsky score of 2 or 3 as an independent negative prognostic factor (HR 3.89; 95 CI 1.4-10.7; p < 0.01). We observed no in-field recurrences. CONCLUSION In this study, we were able to show that the current standard of RT after spinal surgery of osteolytic lesions is safe. In addition, we observed a very low rate of SRE (4%) and no in-field recurrences, demonstrating the local efficacy of RT in multiple myeloma patients. Higher Bilsky scores were associated with worse OS in multivariate analysis, but had no effect on pain response.
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Affiliation(s)
- Justus Kaufmann
- Department of Radiation Oncology, University Medical Center Mainz, Mainz, Germany.
| | - Annika Ute Täubl
- Department of Radiation Oncology, University Medical Center Mainz, Mainz, Germany
| | - Eirini Nikolaidou
- Department of Radiation Oncology, University Medical Center Mainz, Mainz, Germany
- Department for Radiation Oncology, Charité-Universitätsmedizin Berlin, 13353, Berlin, Germany
| | - Alexander Rühle
- Department of Radiotherapy and Radiation Oncology, University Hospital Leipzig, 04103, Leipzig, Germany
| | - Anne Hopprich
- Department of Radiation Oncology, University Medical Center Mainz, Mainz, Germany
| | - Daniel Wollschläger
- Institute for Medical Biostatistics, Epidemiology and Informatics, University Medical Center Mainz, Mainz, Germany
| | - Arnulf Mayer
- Department of Radiation Oncology, University Medical Center Mainz, Mainz, Germany
- Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Nils Henrik Nicolay
- Department of Radiotherapy and Radiation Oncology, University Hospital Leipzig, 04103, Leipzig, Germany
| | - Heinz Schmidberger
- Department of Radiation Oncology, University Medical Center Mainz, Mainz, Germany
| | - Tilman Bostel
- Department of Radiation Oncology, University Medical Center Mainz, Mainz, Germany
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Zijlstra H, Te Velde JP, Striano BM, Groot OQ, de Groot TM, Raje N, Patel C, Husseini J, Delawi D, Kempen DHR, Verlaan JJ, Schwab JH. Remineralization Rate of Lytic Lesions of the Spine in Multiple Myeloma Patients Undergoing Radiation Therapy. Global Spine J 2024:21925682241260651. [PMID: 38856741 DOI: 10.1177/21925682241260651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/11/2024] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE In general, Multiple Myeloma (MM) patients are treated with systemic therapy including chemotherapy. Radiation therapy can have an important supportive role in the palliative management of MM-related osteolytic lesions. Our study aims to investigate the degree of radiation-induced remineralization in MM patients to gain a better understanding of its potential impact on bone mineral density and, consequently, fracture prevention. Our primary outcome measure was percent change in bone mineral density measured in Hounsfield Units (Δ% HU) between pre- and post-radiation measurements, compared to non-targeted vertebrae. METHODS We included 119 patients with MM who underwent radiotherapy of the spine between January 2010 and June 2021 and who had a CT scan of the spine at baseline and between 3-24 months after radiation. A linear mixed effect model tested any differences in remineralization rate per month (βdifference) between targeted and non-targeted vertebrae. RESULTS Analyses of CT scans yielded 565 unique vertebrae (366 targeted and 199 non-targeted vertebrae). In both targeted and non-targeted vertebrae, there was an increase in bone density per month (βoverall = .04; P = .002) with the largest effect being between 9-18 months post-radiation. Radiation did not cause a greater increase in bone density per month compared to non-targeted vertebrae (βdifference = .67; P = .118). CONCLUSION Our results demonstrate that following radiation, bone density increased over time for both targeted and non-targeted vertebrae. However, no conclusive evidence was found that targeted vertebrae have a higher remineralization rate than non-targeted vertebrae in patients with MM.
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Affiliation(s)
- Hester Zijlstra
- Department of Orthopedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jens P Te Velde
- Department of Orthopedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Brendan M Striano
- Department of Orthopedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Olivier Q Groot
- Department of Orthopedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Tom M de Groot
- Department of Orthopedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Noopur Raje
- Department of Hematology/Oncology, Center for Multiple Myeloma, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Chirayu Patel
- Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Jad Husseini
- Department of Radiology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Diyar Delawi
- Department of Orthopedic Surgery, St. Antonius Hospital, Utrecht, Nieuwegein, The Netherlands
| | | | - Jorrit-Jan Verlaan
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Joseph H Schwab
- Department of Orthopedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
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Role of Spinal Instability Neoplastic Score in Management of Spinal Plasmocytomas. World Neurosurg 2022; 161:e303-e307. [DOI: 10.1016/j.wneu.2022.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 02/01/2022] [Indexed: 11/21/2022]
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König L, Herfarth K. [Benefits of radiotherapy for patients with solitary plasmacytoma or multiple myeloma]. Radiologe 2021; 62:30-34. [PMID: 34762165 DOI: 10.1007/s00117-021-00935-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Treatment options for patients with solitary plasmacytoma (SP) or multiple myeloma (MM) should be discussed in an interdisciplinary context. This systematic review focuses on the importance of radiotherapy in MM and SP. OBJECTIVE Summary of local radio-oncological treatment options for patients with SP and MM. MATERIALS AND METHODS Based on a systematic literature search, the current evidence on the topic was analyzed and summarized. RESULTS Patients with SP should be primarily treated with radiotherapy with or without surgery. Irradiation concepts may vary depending on risk factors and manifestation (solitary bone plasmacytoma vs. solitary extramedullary plasmacytoma). Although local control rates are high after radiotherapy, progression to multiple myeloma frequently occurs. In patients with MM, radiation is mainly used in palliative settings for pain relief, prevention of fractures or in patients who suffer from neurological symptoms due to spinal cord compression. Irradiation dose and fractionation should be selected based on treatment indication and general condition of the patient. CONCLUSION Although most patients receive systemic treatment at initial diagnosis, approximately 40% of patients with MM will require radiation during the course of their disease. While radiation is mainly used for palliation in patients with MM, it represents the primary and curative treatment option in patients with SP.
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Affiliation(s)
- Laila König
- Abteilung RadioOnkologie und Strahlentherapie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland.
| | - Klaus Herfarth
- Abteilung RadioOnkologie und Strahlentherapie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland
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