Surgical management of spinal fractures and neurological involvement in patients with myeloma

In vivo antitumor efficacy of 17-AAG loaded PMMA in a human multiple myeloma xenograft mouse model

Multiple myeloma (MM) is a monoclonal malignancy characterized by abnormal proliferation of plasma cells. The disease clinically manifests as anemia, hypercalcemia, renal insufficiencies, and osteolytic damage. Osteolytic damage goes with severe bone pain, spinal instability, and pathological fracture, symptoms that are collectively referred to as multiple myeloma bone disease (MMBD). Polymethylmethacrylate (PMMA) bone cement is widely used for bone repair after MMBD surgery, owing to its excellent biomechanical properties and fast curing. To date, however, efficacy of drug-loading PMMA in inhibition of tumor growth and angiogenesis remains unknown. Here, we report that 17-AAG-loaded PMMA bone cement inhibits MM growth in vivo and suppresses tumor diffusion to peripheral tissues. In addition, 17-AAG-loaded PMMA promotes MM apoptosis by downregulating Bax and active Caspase-3.

Preliminary establishment of a spinal stability scoring system for multiple myeloma

BACKGROUND

Multiple myeloma is an incurable malignant plasma cell disorder that represents the most common primary malignant bone tumor. It commonly involves bone metastasis in multiple vertebral bodies, and the Spinal Instability Neoplastic Score scoring system may not be fully applicable to multiple myeloma (MM) patients.

AIM

To evaluate the spinal stability of patients with MM spinal involvement to guide their clinical treatment.

METHODS

By using the Delphi method, we collected and extracted information through a series of questionnaires and improved it via feedback. We also preliminarily established a spinal stability scoring system for multiple myeloma.

RESULTS

Fifteen clinicians completed a second round of questionnaires and compared their answers with those of the first round of questionnaires to identify significant comments or changes that required group discussions. As a result, no further feedback was used to improve the scoring system. After integrating the information from the expert consultation questionnaire, we established the initial scoring system for MM spine stability and used the scoring system to assess a series of representative clinical cases. The MM spinal stability scoring system was created by calculating the scores of the six separate components: location, pain, number of segments, physiological curvature, comorbidities, and neurological function. The minimum value was “0”, and the maximum value was “24”. A score of “0–10” indicated “spine stability”, a score of “11–17” indicated “potential instability”, and a score of “18–24” indicated “spine instability”. Patients with a score of “11–24” need an intervention such as surgery.

CONCLUSION

The initial establishment of the MM spine stability scoring system provides a vital theoretical basis for the evaluation of spine stability in individuals with MM.

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.

PKP/PVP combine chemotherapy in the treatment of multiple myeloma patients with vertebral pathological fractures: minimum 3-year follow-up of 108 cases

Background

Multiple myeloma (MM) is a blood system malignant tumor, which often leads to osteolytic bone destruction, and the vertebral column is the primary site of involvement. However, the efficacy and prognosis of percutaneous kyphoplasty/vertebroplasty (PKP/PVP) for simple vertebral pathological fractures in patients with multiple myeloma are not yet unified. The primary objective of this study was to investigate the efficacy and prognosis of PKP/PVP in the treatment of multiple myeloma patients with vertebral pathological fractures.

Methods

A total of 108 patients with MM from Beijing Chao-Yang Hospital from 2007 to 2013 were enrolled. Of these, 52 patients underwent PKP/PVP surgery and chemotherapy (surgery group) and 56 received only chemotherapy (chemotherapy group). The age, gender, International Staging System (ISS), fracture location, segment, visual analog scale (VAS), Oswestry Disability Index (ODI), comprehensive treatment satisfaction, stem cell transplantation, overall survival (OS), mortality rate, and the cause of death of patients were recorded; the mean follow-up time was 42.46 months.

Results

The average age of patients in surgery and chemotherapy groups was 60.8 years and 58.1 years, and the mean survival time was 41.98 months and 43.30 months, respectively. The VAS score at 1 month and last follow-up after treatment in surgery group were significantly lower than those in the chemotherapy group (P < 0.05); the ODI at 1 month after treatment in the surgery group was significantly lower than that in the chemotherapy group (P < 0.05); no significant difference was observed in the 3-year mortality rate between surgery and chemotherapy groups. The number of patients who developed activity disorder in the surgery group was significantly less than that in the chemotherapy group (P < 0.05). The OS of patients in ISS stage III was significantly less than that in ISS stages I and II (P < 0.05).

Conclusions

PKP/PVP surgery can greatly relieve the pain caused by fractures, reduce the risk of being completely bedridden and pulmonary infection, and improve the quality of life of patients; however, it did not affect mortality rate and overall survival time in patients.

Trial registration

As this was a retrospective study, it did not require ethical approval; all patients had signed informed consent when they received treatment, and all treatment options were voluntary.

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.

Lumbar subtotal corpectomy non-fusion model produced using a novel prosthesis

OBJECTIVE

In this study, we aimed to design a movable artificial lumbar complex (MALC) prosthesis for non-fusion reconstruction after lumbar subtotal corpectomy and to establish an in vitro anterolateral lumbar corpectomy non-fusion model for evaluating the biomechanical stability, preservation of segment movements and influence on adjacent inter-vertebral movements of this prosthesis.

METHODS

Imaging was performed on a total of 26 fresh goat lumbar spine specimens to determine which of the specimens did not meet the requirements (free of deformity and fractures); the residual specimens were randomly divided into an intact group, a fusion group and a non-fusion group. Bone mineral density (BMD) was tested and compared among the three groups. Biomechanical testing was conducted to obtain the range of motion (ROM) in flexion-extension, lateral bending at L2-3, L3-4 and L4-5 and axial rotation at L2-5 in the three groups.

RESULTS

Two specimens were excluded due to vertebral fractures. BMD showed no statistical significance among three groups (P > 0.05). The stability of the prosthesis did not differ significantly during flexion, extension, and lateral bending at L2-3, L3-4, and L4-5 and axial torsion at L2-5 between the intact group and the non-fusion group (P > 0.05). Segment movements of the specimens in the non-fusion group revealed significantly decreased L2-3 ROM and significantly increased L3-4 and L4-5 ROM in flexion and lateral bending compared with the fusion group (P < 0.05).

CONCLUSIONS

Reconstruction with a MALC prosthesis after lumbar subtotal corpectomy not only produced instant stability but also effectively preserved segment movements, without any abnormal gain of mobility in adjacent inter-vertebral spaces. However, additional studies, including in vivo animal experiments as well as biocompatibility and biomechanical tests of human body specimens are needed.

Metastatic epidural spinal cord compression

INTRODUCTION

Metastatic epidural spinal cord compression (MESSC) is a frequent event in patients affected by solid tumor metastases. Current available approaches for MESCC include corticosteroids, radiotherapy and surgery. In the last few years, surgery has evolved from decompression by laminectomy alone, with the introduction of instrumentation systems by metalware (screws and hooks), and this has been associated to an improvement of clinical results compared to radiotherapy alone. Areas covered: In this narrative review, we outline the phases of management of cancer patients affected by MESSC, and discuss the timing of treatments, their impact on the Quality of life (QoL), and the relative benefits and harms of surgery and radiotherapy. Expert commentary: Despite the fact that clinical and surgical trials will be required to determine the most appropriate surgical technique and timing of surgery, we do expect a newer and more important role for radiotherapy in the management of MESCC patients in the next future. In particular, the implementation of radiotactic stereosurgery as adjuvant to decompressive surgery is expected to increase in the next few years, above all in those patients that can be candidate to the so called separation surgery.