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Kong I, Riddell LW, Kohler JM, Nguyen MC, Carraro MN. Atypical Presentation and Diagnosis of Multiple Myeloma: A Case Report. Cureus 2024; 16:e51870. [PMID: 38327916 PMCID: PMC10849065 DOI: 10.7759/cureus.51870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 01/07/2024] [Indexed: 02/09/2024] Open
Abstract
Chronic neck pain is a common, seemingly benign condition that typically does not warrant an urgent workup, in contrast to acute onset neck pain. Vertebral artery dissection (VAD) is a relatively rare presentation of acute onset neck pain and often presents in the context of blunt trauma. Due to the risk of subsequent clot formation and stroke, patients who present with symptoms suggestive of VAD must be promptly screened, most often first with computed tomography angiography (CTA) followed by magnetic resonance imaging (MRI) or magnetic resonance angiography (MRA) for further evaluation. We present a case of a 69-year-old male with a history of chronic neck pain who was seen in the emergency department due to acute, severe neck pain with initial CTA imaging that suggested left VAD. However, follow-up MRI of his cervical spine identified that what seemed to be a left VAD was instead multiple myeloma. This case demonstrates the utility of using multiple imaging modalities, including CT, CTA, MRI, and MRA, in diagnosing an atypical presentation of multiple myeloma and the consequences of physician implicit biases that are often involved when treating patients with chronic pain.
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Affiliation(s)
- Iris Kong
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Allentown, USA
| | - Luke W Riddell
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Allentown, USA
| | - Jacquelyn M Kohler
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Allentown, USA
| | - Michael C Nguyen
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Allentown, USA
| | - Michelle N Carraro
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Allentown, USA
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2
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Zhang B, Zhang L, Bian B, Lin F, Zhu Z, Wang J. Diagnostic value of WB-DWI versus 18F-FDG PET/CT for the detection of multiple myeloma. Indian J Cancer 2023; 60:303-309. [PMID: 37787189 DOI: 10.4103/ijc.ijc_1129_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
Background Whole-body diffusion-weighted imaging (WB-DWI) is commonly used for the detection of multiple myeloma (MM). Comparative data on the efficiency of WB-DWI compared with F-18 fluoro-2-deoxy-d-glucose positron emission tomography-computed tomography (18F-FDG PET/CT) to detect MM is limited. Methods This was a retrospective, single-center study of 22 patients with MM enrolled from January 2018 to December 2019. All patients underwent WB-DWI and 18F-FDG PET/CT. Pathological and clinical manifestations, as well as radiologic follow-up, were used for diagnosis. The overall accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of both methods were compared. The apparent diffusion coefficient (ADC) values of MM lesions and false-positive lesions were estimated. Results A total of 214 MM bone lesions were evaluated. There was no significant difference in the accuracy of WB-DWI and PET/CT (86.92 versus 88.32%). Though WB-DWI had a higher sensitivity (99.26% versus84.56%) and PET-CT had a higher specificity (96.10% versus 64.56%), these differences were not statistically significant. There was a statistically significant difference in PPV (83.33% versus 96.64%) and NPV (98.08% versus 77.89%) of WB-DWI and PET/CT, respectively. The ADC value for MM lesions was significantly lower than that for false-positive lesions (P < 0.001). Receiver operating curve analysis showed that the AUC was 0.846, and when the cut-off value was 0.745 × 10-3 mm2/s, the sensitivity and specificity were 86.3 and 83.4%, respectively, which distinguished MM lesions from non-MM lesions. Conclusion WB-DWI and PET-CT scans have similar overall accuracy for detecting MM lesions. The higher PPV of PET-CT and NPV of WB-DWI make them complementary imaging modalities. The ADC value for MM lesions is significantly lower than that for false-positive lesions. An ADC cutoff value of 0.745 × 10-3 mm2/s results in sensitivity and specificity of 86.3 and 83.4%, respectively.
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Affiliation(s)
- Bei Zhang
- Department of Radiology, First Hospital of Jilin University, Changchun, China
| | - Li Zhang
- Department of Radiology, First Hospital of Jilin University, Changchun, China
| | - Bingyang Bian
- Department of Radiology, First Hospital of Jilin University, Changchun, China
| | - Fang Lin
- Department of Radiology, First Hospital of Jilin University, Changchun, China
| | - Zining Zhu
- Department of Radiology, First Hospital of Jilin University, Changchun, China
| | - Jiping Wang
- Department of Radiology, First Hospital of Jilin University, Changchun, China
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3
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Pusceddu C, Faiella E, Derudas D, Ballicu N, Melis L, Zedda S, Marsico S. Re-expansion of vertebral compression fractures in patients with multiple myeloma with percutaneous vertebroplasty using spinejack implants: a preliminary and retrospective study. Front Surg 2023; 10:1121981. [PMID: 37288134 PMCID: PMC10242080 DOI: 10.3389/fsurg.2023.1121981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 05/04/2023] [Indexed: 06/09/2023] Open
Abstract
Objective To retrospectively evaluate the feasibility and effectiveness of vertebroplasty using Spinejack implantation for the treatment and stabilization of painful vertebral compression fractures, in patients diagnosed with Multiple Myeloma (MM), to allow both an effective pain reduction and a global structural spine stabilization. Materials and Methods From July 2017 and May 2022 thirty-nine patients diagnosed MM, with forty-nine vertebral compression fractures underwent percutaneous Vertebroplasty using Spinejack Implants. We analyzed the feasibility and complications of the procedure, the decrease in pain using visual analogue scale (VAS) and Functional Mobility Scale (FMS). Results The technical success rate was 100%. No procedure-related major complications or death occurred. In the 6-month follow-up, the mean VAS score decreased from 5.4 ± 1.0 to 0.2 ± 0.5 with a mean reduction of 96.3%. FMS decreased from 2.3 ± 0.5 vs. 1.2 ± 0.4 with a mean reduction of -47.8%. There were no major complications related to incorrect positioning of the Expandable Titanium SpineJack Implants. In five patients, a cement leak was observed with no associated clinical manifestations. The average length of hospital stay was 6-8 Hours6.6 ± 1.2 h. No new bone fractures or local disease recurrence occurred during a median contrast-enhanced CT follow-up of 6 months. Conclusions Our results suggest that vertebroplasty, using Spinejack implantation for the treatment and stabilization of painful vertebral compression fractures, secondary to Multiple Myeloma is a safe and effective procedure with long - term pain relief and restoration of vertebral height.
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Affiliation(s)
- Claudio Pusceddu
- Division of Interventional Radiology, Department of Oncological Radiology, Ocological Hospital “A. Businco”, Regional Referral Center for Oncologic Diseases, Cagliari, Italy
| | - Eliodoro Faiella
- Department of Radiology, Sant'Anna Hospital, San Fermo Della Battaglia, Italy
| | | | - Nicola Ballicu
- Division of Interventional Radiology, Department of Oncological Radiology, Ocological Hospital “A. Businco”, Regional Referral Center for Oncologic Diseases, Cagliari, Italy
| | - Luca Melis
- Department of Oncological Radiology, Oncological Hospital “A. Businco”, Regional Referral Center for Oncological Diseases, Cagliari, Italy
| | - Stefano Zedda
- Division of Interventional Radiology, Department of Oncological Radiology, Ocological Hospital “A. Businco”, Regional Referral Center for Oncologic Diseases, Cagliari, Italy
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Mansour M, Haider Z, Al Khiami L, Sioufi MST, Takieddin A, Al Shamat AA, Alwaw R, Musleh M. A rare multiple myeloma complication as a spinal cord metastasis: A case report. Clin Case Rep 2023; 11:e7069. [PMID: 36911628 PMCID: PMC9995807 DOI: 10.1002/ccr3.7069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 02/04/2023] [Accepted: 02/22/2023] [Indexed: 03/11/2023] Open
Abstract
Multiple myeloma is a hematological cancer mostly located in the marrow of the vertebrae, pelvis, and thighs. Although the presence of extramedullary disease in the central nervous system is rare, herein, we report a complicated case of multiple myeloma in the spinal cord.
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Affiliation(s)
- Marah Mansour
- Faculty of Medicine Tartous University Tartous Syria
| | - Zeinab Haider
- Faculty of Medicine Al andalus University for Medical Sciences Qadmus Syria
| | - Lin Al Khiami
- Faculty of Medicine Damascus University Damascus Syria
| | | | | | | | - Ricarda Alwaw
- Department of Neurology Al Assad University Hospital Damascus Syria
| | - Mais Musleh
- Department of Hematology Al Assad University Hospital Damascus Syria
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Dao A, McDonald MM, Savage PB, Little DG, Schindeler A. Preventing osteolytic lesions and osteomyelitis in multiple myeloma. J Bone Oncol 2022; 37:100460. [DOI: 10.1016/j.jbo.2022.100460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 10/16/2022] [Accepted: 10/27/2022] [Indexed: 11/05/2022] Open
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Lecouvet FE, Vekemans MC, Van Den Berghe T, Verstraete K, Kirchgesner T, Acid S, Malghem J, Wuts J, Hillengass J, Vandecaveye V, Jamar F, Gheysens O, Vande Berg BC. Imaging of treatment response and minimal residual disease in multiple myeloma: state of the art WB-MRI and PET/CT. Skeletal Radiol 2022; 51:59-80. [PMID: 34363522 PMCID: PMC8626399 DOI: 10.1007/s00256-021-03841-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/28/2021] [Accepted: 06/06/2021] [Indexed: 02/02/2023]
Abstract
Bone imaging has been intimately associated with the diagnosis and staging of multiple myeloma (MM) for more than 5 decades, as the presence of bone lesions indicates advanced disease and dictates treatment initiation. The methods used have been evolving, and the historical radiographic skeletal survey has been replaced by whole body CT, whole body MRI (WB-MRI) and [18F]FDG-PET/CT for the detection of bone marrow lesions and less frequent extramedullary plasmacytomas.Beyond diagnosis, imaging methods are expected to provide the clinician with evaluation of the response to treatment. Imaging techniques are consistently challenged as treatments become more and more efficient, inducing profound response, with more subtle residual disease. WB-MRI and FDG-PET/CT are the methods of choice to address these challenges, being able to assess disease progression or response and to detect "minimal" residual disease, providing key prognostic information and guiding necessary change of treatment.This paper provides an up-to-date overview of the WB-MRI and PET/CT techniques, their observations in responsive and progressive disease and their role and limitations in capturing minimal residual disease. It reviews trials assessing these techniques for response evaluation, points out the limited comparisons between both methods and highlights their complementarity with most recent molecular methods (next-generation flow cytometry, next-generation sequencing) to detect minimal residual disease. It underlines the important role of PET/MRI technology as a research tool to compare the effectiveness and complementarity of both methods to address the key clinical questions.
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Affiliation(s)
- Frederic E. Lecouvet
- Radiology Department, Institut de Recherche Expérimentale et Clinique (IREC), Cliniques Universitaires Saint-Luc, UCLouvain, Hippocrate Avenue 10, 1200 Brussels, Belgium
| | - Marie-Christiane Vekemans
- Haematology Unit, Cliniques Universitaires Saint-Luc, Institut de Recherche Expérimentale et Clinique (IREC), 1200 Brussels, Belgium
| | - Thomas Van Den Berghe
- Radiology Department, Universiteit Ghent, Sint-Pietersnieuwstraat 33, 9000 Gent, Belgium
| | - Koenraad Verstraete
- Radiology Department, Universiteit Ghent, Sint-Pietersnieuwstraat 33, 9000 Gent, Belgium
| | - Thomas Kirchgesner
- Radiology Department, Institut de Recherche Expérimentale et Clinique (IREC), Cliniques Universitaires Saint-Luc, UCLouvain, Hippocrate Avenue 10, 1200 Brussels, Belgium
| | - Souad Acid
- Radiology Department, Institut de Recherche Expérimentale et Clinique (IREC), Cliniques Universitaires Saint-Luc, UCLouvain, Hippocrate Avenue 10, 1200 Brussels, Belgium
| | - Jacques Malghem
- Radiology Department, Institut de Recherche Expérimentale et Clinique (IREC), Cliniques Universitaires Saint-Luc, UCLouvain, Hippocrate Avenue 10, 1200 Brussels, Belgium
| | - Joris Wuts
- Department of Electronics and Informatics (ETRO), Vrije Universiteit Brussel, Avenue du Laerbeek 101, 1090 Jette, Belgium
| | - Jens Hillengass
- Departement of Medicine, Myeloma Unit, Park Comprehensive Cancer Center, Buffalo, NY USA
| | - Vincent Vandecaveye
- Radiology Department, Katholieke Univesiteit Leuven, Oude Markt, 13, 3000 Leuven, Belgium
| | - François Jamar
- Nuclear Medicine Department, Institut de Recherche Expérimentale et Clinique (IREC), Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | - Olivier Gheysens
- Nuclear Medicine Department, Institut de Recherche Expérimentale et Clinique (IREC), Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium
| | - Bruno C. Vande Berg
- Radiology Department, Institut de Recherche Expérimentale et Clinique (IREC), Cliniques Universitaires Saint-Luc, UCLouvain, Hippocrate Avenue 10, 1200 Brussels, Belgium
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Schenone D, Dominietto A, Campi C, Frassoni F, Cea M, Aquino S, Angelucci E, Rossi F, Torri L, Bignotti B, Tagliafico AS, Piana M. Radiomics and Artificial Intelligence for Outcome Prediction in Multiple Myeloma Patients Undergoing Autologous Transplantation: A Feasibility Study with CT Data. Diagnostics (Basel) 2021; 11:diagnostics11101759. [PMID: 34679456 PMCID: PMC8535117 DOI: 10.3390/diagnostics11101759] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 09/08/2021] [Accepted: 09/20/2021] [Indexed: 11/16/2022] Open
Abstract
Multiple myeloma is a plasma cell dyscrasia characterized by focal and non-focal bone lesions. Radiomic techniques extract morphological information from computerized tomography images and exploit them for stratification and risk prediction purposes. However, few papers so far have applied radiomics to multiple myeloma. A retrospective study approved by the institutional review board: n = 51 transplanted patients and n = 33 (64%) with focal lesion analyzed via an open-source toolbox that extracted 109 radiomics features. We also applied a dedicated tool for computing 24 features describing the whole skeleton asset. The redundancy reduction was realized via correlation and principal component analysis. Fuzzy clustering (FC) and Hough transform filtering (HTF) allowed for patient stratification, with effectiveness assessed by four skill scores. The highest sensitivity and critical success index (CSI) were obtained representing each patient, with 17 focal features selected via correlation with the 24 features describing the overall skeletal asset. These scores were higher than the ones associated with a standard cytogenetic classification. The Mann–Whitney U-test showed that three among the 17 imaging descriptors passed the null hypothesis. This AI-based interpretation of radiomics features stratified relapsed and non-relapsed MM patients, showing some potentiality for the determination of the prognostic image-based biomarkers in disease follow-up.
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Affiliation(s)
- Daniela Schenone
- LISCOMP, Dipartimento di Matematica, Università di Genova, Via Dodecaneso 35, 16146 Genova, Italy; (D.S.); (C.C.); (F.F.)
| | - Alida Dominietto
- Ospedale Policlinico San Martino-IRCCS, Largo Rossana Benzi 10, 16132 Genova, Italy; (A.D.); (M.C.); (S.A.); (E.A.); (L.T.); (B.B.)
| | - Cristina Campi
- LISCOMP, Dipartimento di Matematica, Università di Genova, Via Dodecaneso 35, 16146 Genova, Italy; (D.S.); (C.C.); (F.F.)
| | - Francesco Frassoni
- LISCOMP, Dipartimento di Matematica, Università di Genova, Via Dodecaneso 35, 16146 Genova, Italy; (D.S.); (C.C.); (F.F.)
| | - Michele Cea
- Ospedale Policlinico San Martino-IRCCS, Largo Rossana Benzi 10, 16132 Genova, Italy; (A.D.); (M.C.); (S.A.); (E.A.); (L.T.); (B.B.)
- Dipartimento di Medicina Interna, Università di Genova, Viale Benedetto XV, 16132 Genova, Italy
| | - Sara Aquino
- Ospedale Policlinico San Martino-IRCCS, Largo Rossana Benzi 10, 16132 Genova, Italy; (A.D.); (M.C.); (S.A.); (E.A.); (L.T.); (B.B.)
| | - Emanuele Angelucci
- Ospedale Policlinico San Martino-IRCCS, Largo Rossana Benzi 10, 16132 Genova, Italy; (A.D.); (M.C.); (S.A.); (E.A.); (L.T.); (B.B.)
| | - Federica Rossi
- Dipartimento di Medicina Sperimentale, Università di Genova, Via L. B. Alberti 1, 16132 Genova, Italy;
| | - Lorenzo Torri
- Ospedale Policlinico San Martino-IRCCS, Largo Rossana Benzi 10, 16132 Genova, Italy; (A.D.); (M.C.); (S.A.); (E.A.); (L.T.); (B.B.)
| | - Bianca Bignotti
- Ospedale Policlinico San Martino-IRCCS, Largo Rossana Benzi 10, 16132 Genova, Italy; (A.D.); (M.C.); (S.A.); (E.A.); (L.T.); (B.B.)
- Dipartimento di Medicina Sperimentale, Università di Genova, Via L. B. Alberti 1, 16132 Genova, Italy;
| | - Alberto Stefano Tagliafico
- Ospedale Policlinico San Martino-IRCCS, Largo Rossana Benzi 10, 16132 Genova, Italy; (A.D.); (M.C.); (S.A.); (E.A.); (L.T.); (B.B.)
- Dipartimento di Scienze della Salute, Università di Genova, Via Pastore 1, 16132 Genova, Italy
- Correspondence: (A.S.T.); (M.P.)
| | - Michele Piana
- Ospedale Policlinico San Martino-IRCCS, Largo Rossana Benzi 10, 16132 Genova, Italy; (A.D.); (M.C.); (S.A.); (E.A.); (L.T.); (B.B.)
- CNR-SPIN Genova, Via Dodecaneso 33, 16146 Genova, Italy
- Correspondence: (A.S.T.); (M.P.)
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Andriessen AS, Donnelly CR, Ji RR. Reciprocal interactions between osteoclasts and nociceptive sensory neurons in bone cancer pain. Pain Rep 2021; 6:e867. [PMID: 33981921 PMCID: PMC8108580 DOI: 10.1097/pr9.0000000000000867] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 09/10/2020] [Accepted: 09/22/2020] [Indexed: 02/07/2023] Open
Abstract
Many common cancers such as breast, prostate, and lung cancer metastasize to bones at advanced stages, producing severe pain and functional impairment. At present, the current pharmacotherapies available for bone cancer pain are insufficient to provide safe and efficacious pain relief. In this narrative review, we discuss the mechanisms used by cancer cells within the bone tumor microenvironment (TME) to drive bone cancer pain. In particular, we highlight the reciprocal interactions between tumor cells, bone-resorbing osteoclasts, and pain-sensing sensory neurons (nociceptors), which drive bone cancer pain. We discuss how tumor cells present within the bone TME accelerate osteoclast differentiation (osteoclastogenesis) and alter osteoclast activity and function. Furthermore, we highlight how this perturbed state of osteoclast overactivation contributes to bone cancer pain through (1) direct mechanisms, through their production of pronociceptive factors that act directly on sensory afferents; and (2) by indirect mechanisms, wherein osteoclasts drive bone resorption that weakens tumor-bearing bones and predisposes them to skeletal-related events, thereby driving bone cancer pain and functional impairment. Finally, we discuss some potential therapeutic agents, such as denosumab, bisphosphonates, and nivolumab, and discuss their respective effects on bone cancer pain, osteoclast overactivation, and tumor growth within the bone TME.
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Affiliation(s)
- Amanda S. Andriessen
- Department of Anesthesiology, Center for Translational Pain Medicine, Duke University Medical Center, Durham, NC, USA
| | - Christopher R. Donnelly
- Department of Anesthesiology, Center for Translational Pain Medicine, Duke University Medical Center, Durham, NC, USA
| | - Ru-Rong Ji
- Department of Anesthesiology, Center for Translational Pain Medicine, Duke University Medical Center, Durham, NC, USA
- Department of Cell Biology, Duke University Medical Center, Durham, NC, USA
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Role of Key Guidelines in an Era of Precision Oncology: A Primer for the Radiologist. AJR Am J Roentgenol 2021; 216:1112-1125. [PMID: 33502227 DOI: 10.2214/ajr.20.23025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE. The purpose of this article is to familiarize radiologists with the evidence-based imaging guidelines of major oncologic societies and organizations and to discuss approaches to effective implementation of the most recent guidelines in daily radiology practice. CONCLUSION. In an era of precision oncology, radiologists in practice and radiologists in training are key stakeholders in multidisciplinary care, and their awareness and understanding of society guidelines is critically important.
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Quantitative Imaging and Radiomics in Multiple Myeloma: A Potential Opportunity? ACTA ACUST UNITED AC 2021; 57:medicina57020094. [PMID: 33494449 PMCID: PMC7912483 DOI: 10.3390/medicina57020094] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 01/19/2021] [Accepted: 01/19/2021] [Indexed: 12/25/2022]
Abstract
Multiple Myeloma (MM) is the second most common type of hematological disease and, although it is rare among patients under 40 years of age, its incidence rises in elderly subjects. MM manifestations are usually identified through hyperCalcemia, Renal failure, Anaemia, and lytic Bone lesions (CRAB). In particular, the extent of the bone disease is negatively related to a decreased quality of life in patients and, in general, bone disease in MM increases both morbidity and mortality. The detection of lytic bone lesions on imaging, especially computerized tomography (CT) and Magnetic Resonance Imaging (MRI), is becoming crucial from the clinical viewpoint to separate asymptomatic from symptomatic MM patients and the detection of focal lytic lesions in these imaging data is becoming relevant even when no clinical symptoms are present. Therefore, radiology is pivotal in the staging and accurate management of patients with MM even in early phases of the disease. In this review, we describe the opportunities offered by quantitative imaging and radiomics in multiple myeloma. At the present time there is still high variability in the choice between various imaging methods to study MM patients and high variability in image interpretation with suboptimal agreement among readers even in tertiary centers. Therefore, the potential of medical imaging for patients affected by MM is still to be completely unveiled. In the coming years, new insights to study MM with medical imaging will derive from artificial intelligence (AI) and radiomics usage in different bone lesions and from the wide implementations of quantitative methods to report CT and MRI. Eventually, medical imaging data can be integrated with the patient’s outcomes with the purpose of finding radiological biomarkers for predicting the prognostic flow and therapeutic response of the disease.
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Herget GW, Kälberer F, Ihorst G, Graziani G, Klein L, Rassner M, Gehler C, Jung J, Schmal H, Wäsch R, Engelhardt M. Interdisciplinary approach to multiple myeloma - time to diagnosis and warning signs. Leuk Lymphoma 2020; 62:891-898. [PMID: 33225781 DOI: 10.1080/10428194.2020.1849681] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Delayed diagnosis is a common challenge in the management of multiple myeloma (MM). This prospective interdisciplinary study evaluated symptoms and time to diagnosis (TTD) in 81/295 screened patients at our tertiary center, who were examined by an orthopedist prior to the MM diagnosis. The most frequent complaint was back pain (81%), mainly localized thoracic and/or lumbar. Pain was independent of movement in 85%, occurred at night in 69%, and at multiple localizations in 30% of patients. Notably, 63% patients with an orthopedic disease noticed substantial symptom change before the MM diagnosis was made. The median TTD was 7 months and did not differ significantly between patients with or without a preexisting skeletal disease. To avoid delayed diagnosis, physicians should consider MM as a differential diagnosis, whenever warning signs such as skeletal pain independent from movement, at night, at various localizations, and change in pain characteristics accompanied by fatigue, are reported.
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Affiliation(s)
- Georg W Herget
- Department of Orthopedics and Trauma Surgery, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany.,Comprehensive Cancer Center Freiburg (CCCF), Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
| | - Felix Kälberer
- Department of Orthopedics and Trauma Surgery, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
| | - Gabriele Ihorst
- Clinical Trials Unit, Medical Clinic, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
| | - Giulia Graziani
- Comprehensive Cancer Center Freiburg (CCCF), Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany.,Department of Medicine, Hematology and Oncology, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
| | - Lukas Klein
- Department of Orthopedics and Trauma Surgery, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
| | - Michael Rassner
- Comprehensive Cancer Center Freiburg (CCCF), Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany.,Department of Medicine, Hematology and Oncology, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
| | - Christian Gehler
- Department of Orthopedics and Trauma Surgery, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
| | - Johannes Jung
- Comprehensive Cancer Center Freiburg (CCCF), Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany.,Department of Medicine, Hematology and Oncology, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
| | - Hagen Schmal
- Department of Orthopedics and Trauma Surgery, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany.,Comprehensive Cancer Center Freiburg (CCCF), Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany.,Department of Orthopaedics and Traumatology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Ralph Wäsch
- Comprehensive Cancer Center Freiburg (CCCF), Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany.,Department of Medicine, Hematology and Oncology, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
| | - Monika Engelhardt
- Comprehensive Cancer Center Freiburg (CCCF), Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany.,Department of Medicine, Hematology and Oncology, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
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Jairam V, Yang DX, Yu JB, Park HS. Emergency Department Visits for Opioid Overdoses Among Patients With Cancer. J Natl Cancer Inst 2020; 112:938-943. [PMID: 31845985 PMCID: PMC7492769 DOI: 10.1093/jnci/djz233] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 12/03/2019] [Accepted: 12/11/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Patients with cancer may be at risk of high opioid use due to physical and psychosocial factors, although little data exist to inform providers and policymakers. Our aim is to examine overdoses from opioids leading to emergency department (ED) visits among patients with cancer in the United States. METHODS The Healthcare Cost and Utilization Project Nationwide Emergency Department Sample was queried for all adult cancer-related patient visits with a primary diagnosis of opioid overdose between 2006 and 2015. Temporal trends and baseline differences between patients with and without opioid-related ED visits were evaluated. Multivariable logistic regression analysis was used to identify risk factors associated with opioid overdose. All statistical tests were two-sided. RESULTS Between 2006 and 2015, there were a weighted total of 35 339 opioid-related ED visits among patients with cancer. During this time frame, the incidence of opioid-related ED visits for overdose increased twofold (P < .001). On multivariable regression (P < .001), comorbid diagnoses of chronic pain (odds ratio [OR] 4.51, 95% confidence interval [CI] = 4.13 to 4.93), substance use disorder (OR = 3.54, 95% CI = 3.28 to 3.82), and mood disorder (OR = 3.40, 95% CI = 3.16 to 3.65) were strongly associated with an opioid-related visit. Patients with head and neck cancer (OR = 2.04, 95% CI = 1.82 to 2.28) and multiple myeloma (OR = 1.73, 95% CI = 1.32 to 2.26) were also at risk for overdose. CONCLUSIONS Over the study period, the incidence of opioid-related ED visits in patients with cancer increased approximately twofold. Comorbid diagnoses and primary disease site may predict risk for opioid overdose.
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Affiliation(s)
- Vikram Jairam
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Daniel X Yang
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - James B Yu
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, CT, USA
| | - Henry S Park
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, CT, USA
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13
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Enhanced vertebra to disk ratio as a new semi-quantitative imaging biomarker for Gaucher disease patients. Eur J Radiol 2020; 129:109091. [DOI: 10.1016/j.ejrad.2020.109091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 04/16/2020] [Accepted: 05/21/2020] [Indexed: 11/18/2022]
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14
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Shah N, Aiello J, Avigan DE, Berdeja JG, Borrello IM, Chari A, Cohen AD, Ganapathi K, Gray L, Green D, Krishnan A, Lin Y, Manasanch E, Munshi NC, Nooka AK, Rapoport AP, Smith EL, Vij R, Dhodapkar M. The Society for Immunotherapy of Cancer consensus statement on immunotherapy for the treatment of multiple myeloma. J Immunother Cancer 2020; 8:e000734. [PMID: 32661116 PMCID: PMC7359060 DOI: 10.1136/jitc-2020-000734] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2020] [Indexed: 12/24/2022] Open
Abstract
Outcomes in multiple myeloma (MM) have improved dramatically in the last two decades with the advent of novel therapies including immunomodulatory agents (IMiDs), proteasome inhibitors and monoclonal antibodies. In recent years, immunotherapy for the treatment of MM has advanced rapidly, with the approval of new targeted agents and monoclonal antibodies directed against myeloma cell-surface antigens, as well as maturing data from late stage trials of chimeric antigen receptor CAR T cells. Therapies that engage the immune system to treat myeloma offer significant clinical benefits with durable responses and manageable toxicity profiles, however, the appropriate use of these immunotherapy agents can present unique challenges for practicing physicians. Therefore, the Society for Immunotherapy of Cancer convened an expert panel, which met to consider the current role of approved and emerging immunotherapy agents in MM and provide guidance to the oncology community by developing consensus recommendations. As immunotherapy evolves as a therapeutic option for the treatment of MM, these guidelines will be updated.
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Affiliation(s)
- Nina Shah
- Division of Hematology-Oncology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Jack Aiello
- Patient Empowerment Network, San Jose, California, USA
| | - David E Avigan
- Division of Hematology and Hematologic Malignancies, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jesus G Berdeja
- Department of Medicine, Sarah Cannon Research Institute, Nashville, Tennessee, USA
| | - Ivan M Borrello
- Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center of Johns Hopkins, Baltimore, Maryland, USA
| | - Ajai Chari
- Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Adam D Cohen
- Department of Medicine, Abramson Cancer Center at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Karthik Ganapathi
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, California, USA
| | - Lissa Gray
- University of California San Francisco, San Francisco, CA, USA
| | - Damian Green
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Amrita Krishnan
- Department of Hematology and Hematopoietic Cell Transplantation, Judy and Bernard Briskin Multiple Myeloma Center for Clinical Research, City of Hope Comprehensive Cancer Center, Duarte, California, USA
| | - Yi Lin
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Division of Experimental Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Elisabet Manasanch
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nikhil C Munshi
- Jerome Lipper Multiple Myeloma Disease Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Ajay K Nooka
- Department of Hematology/Oncology, Emory University, Atlanta, Georgia, USA
| | - Aaron P Rapoport
- University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, Maryland, USA
| | - Eric L Smith
- Myeloma Service and Cellular Therapeutics Center, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ravi Vij
- Division of Medical Oncology, Siteman Cancer Center, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Madhav Dhodapkar
- School of Medicine, Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
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15
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The Role of Imaging and Systemic Treatments in Myeloma: A Primer for Radiologists. AJR Am J Roentgenol 2020; 214:1321-1334. [DOI: 10.2214/ajr.19.21725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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16
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Tagliafico AS, Belgioia L, Bonsignore A, Signori A, Formica M, Rossi F, Piana M, Schenone D, Dominietto A. Development and definition of a simplified scoring system in patients with multiple myeloma undergoing stem cells transplantation on standard computed tomography: myeloma spine and bone damage score (MSBDS). Cancer Imaging 2020; 20:31. [PMID: 32345379 PMCID: PMC7189746 DOI: 10.1186/s40644-020-00306-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 04/13/2020] [Indexed: 12/21/2022] Open
Abstract
Background In clinical practice, there is the need to optimize imaging usage in MM patients. Accordingly, the aim of this paper was to develop a simple computed tomography (CT) scoring method for MM, able to shorten and simplify the interpretation time with good intra- and inter-reader reliability. This method, named MSBDS (Myeloma Spine and Bone Damage Score) was developed with the final aim to use standard total-body CT in the routine practice of MM centres as a complement of standard evaluations in patients undergoing stem cells transplantation. Methods We used a widely accepted consensus formation method and literature research during three structured face-to-face meetings specifically designed to combine opinions from a group of experts with proven experience in multiple myeloma care and/or musculoskeletal CT to facilitate the consensus on the field of study topics and the contents of the MSBDS score. Seven practical requisites for the MSBDS score were agreed. A total of 70 MM patients (mean age, 60 years ±9.2 [standard deviation]; range, 35–70 years) undergoing total-body CT was included to develop MSBDS scores. Patients data were already stored in the Radiological database for other Research studies IRB approved (054/2019). Readers to test the MSDMS were radiologists and clinicians involved in MM care or expert in bone damage scores with different level of experience in musculoskeletal and total body CT. Readers were blinded to the clinical data of the patients. Results The MSBDS scores based on the consensus work described above and literature analysis was finalized. MSBDS is based on an additive scale with assessment of a total body CT with the bone window one time and includes indicators of structural bone damage and instability or fracture risk. The total score is given by the sum of item scores for abnormalities detected. Its values range from 0 (minimum) to values > 10 where 10 is represented by high-risk patients. In high-risk patients immediate surgical or radiation oncologist consultation is suggested. Conclusions The MSBDS descriptive criteria are easy, highly reproducible and can be considered as a strong base for harmonizing total body CT interpretation in multiple myeloma patients undergoing stem cell transplantation.
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Affiliation(s)
- Alberto Stefano Tagliafico
- Department of Health Sciences, University of Genoa, Via A. Pastore 1, 16132, Genoa, Italy. .,Ospedale Policlinico San Martino, Largo R. Benzi 10, 16132, Genoa, Italy.
| | - Liliana Belgioia
- Department of Health Sciences, University of Genoa, Via A. Pastore 1, 16132, Genoa, Italy.,Ospedale Policlinico San Martino, Largo R. Benzi 10, 16132, Genoa, Italy
| | - Alessandro Bonsignore
- Department of Health Sciences, University of Genoa, Via A. Pastore 1, 16132, Genoa, Italy.,Ospedale Policlinico San Martino, Largo R. Benzi 10, 16132, Genoa, Italy
| | - Alessio Signori
- Department of Health Sciences, University of Genoa, Via A. Pastore 1, 16132, Genoa, Italy
| | - Matteo Formica
- Ospedale Policlinico San Martino, Largo R. Benzi 10, 16132, Genoa, Italy.,Dipartimento Di Scienze Chirurgiche e Diagnostiche Integrate - Disc, University of Genoa, Via A. Pastore 1, 16132, Genoa, Italy
| | - Federica Rossi
- Department of Health Sciences, University of Genoa, Via A. Pastore 1, 16132, Genoa, Italy
| | - Michele Piana
- Dipartimento Di Matematica - Dima, University of Genoa, via Dodecaneso 35, 16146, GENOVA Genoa, Italy.,CNR - SPIN, Genoa, Italy
| | - Daniela Schenone
- Dipartimento Di Matematica - Dima, University of Genoa, via Dodecaneso 35, 16146, GENOVA Genoa, Italy
| | - Alida Dominietto
- Ospedale Policlinico San Martino, Largo R. Benzi 10, 16132, Genoa, Italy
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17
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Subspecialty Second-Opinion in Multiple Myeloma CT: Emphasis on Clinically Significant Lytic Lesions. ACTA ACUST UNITED AC 2020; 56:medicina56040195. [PMID: 32340143 PMCID: PMC7230835 DOI: 10.3390/medicina56040195] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/02/2020] [Accepted: 04/19/2020] [Indexed: 12/25/2022]
Abstract
Background and objectives: In order to increase the accuracy of lytic lesion detection in multiple myeloma, a dedicated second-opinion interpretation of medical images performed by subspecialty musculoskeletal radiologists could increase accuracy. Therefore, the purpose of this study is to evaluate the added value (increased accuracy) of subspecialty second-opinion (SSO) consultations for Computed Tomography (CT) examinations in Multiple Myeloma (MM) patients undergoing stem cell transplantation on standard computed tomography with a focus on focal lesion detection. Materials and Methods: Approval from the institutional review board was obtained. This retrospective study included 70 MM consecutive patients (mean age, 62 years ± 11.3 (standard deviation); range, 35–88 years) admitted in the last six years. Pre-transplant total-body CT (reported by general radiologists) was the only inclusion criteria. Each of these CT examinations had a second-opinion interpretation by two experienced subspecialty musculoskeletal (MSK) radiologists (13 years of experience and 6 years of experience, mean: 9.5 years), experts in musculoskeletal radiology and bone image interpretation with a focus on lytic lesions. Results: Per lesion intra- and inter-observer agreement between the two radiologists was calculated with K statistics and the results were good (K = 0.67: Confidence Inteval (CI) 95%: 0.61–0.78). When the initial CT reports were compared with the re-interpretation reports, 46 (65%) of the 70 cases (95% CI: 37–75%) had no discrepancy. There was a discrepancy in detecting a clinically unimportant abnormality in 10/70 (14%) patients (95% CI: 7–25%) unlikely to alter patient care or irrelevant to further clinical management. A discrepancy in interpreting a clinically important abnormality was registered in 14/70 (21%) patients for focal lesions. The mean diameter of focal lesions was: 23 mm (95% CI: 5–57 mm). The mean number of focal lesions per patient was 3.4 (95% CI). Conclusions: subspecialty second-opinion consultations in multiple myeloma CT is more accurate to identify lesions, especially lytic lesions, amenable to influence patients’ care.
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18
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Kuźnik A, Październiok-Holewa A, Jewula P, Kuźnik N. Bisphosphonates-much more than only drugs for bone diseases. Eur J Pharmacol 2019; 866:172773. [PMID: 31705903 DOI: 10.1016/j.ejphar.2019.172773] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 10/23/2019] [Accepted: 11/01/2019] [Indexed: 12/22/2022]
Abstract
α,α-Bisphosphonates (BPs) are well established in the treatment of bone diseases such as osteoporosis and Paget's disease. Their successful application originates from their high affinity to hydroxyapatite. While the initially appreciated features of BPs are already beneficial to many patients, recent developments have further expanded their pleiotropic applications. This review describes the background of the interactions of BPs with bone cells that form the basis of the classical treatment. A better understanding of the mechanism behind their interactions allows for the parallel application of BPs against bone cancer and metastases followed by palliative pain relief. Targeted therapy with bone-seeking BPs coupled with a diagnostic agent in one particle resulted in theranostics which is also described here. For example, in such a system, BP moieties are bound to contrast agents used in magnetic resonance imaging or radionuclides used in positron emission tomography. In addition, another example of the pleiotropic function of BPs which involves targeting the imaging agents to bone tissues accompanied by pain reduction is presented in this work.
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Affiliation(s)
- Anna Kuźnik
- Department of Organic and Bioorganic Chemistry and Biotechnology, Silesian University of Technology, B. Krzywoustego 4, 44-100, Gliwice, Poland; Biotechnology Center of Silesian University of Technology, B. Krzywoustego 8, 44-100, Gliwice, Poland.
| | - Agnieszka Październiok-Holewa
- Department of Organic and Bioorganic Chemistry and Biotechnology, Silesian University of Technology, B. Krzywoustego 4, 44-100, Gliwice, Poland; Biotechnology Center of Silesian University of Technology, B. Krzywoustego 8, 44-100, Gliwice, Poland
| | - Pawel Jewula
- Central European Institute of Technology, Brno University of Technology, Purkyňova 656/123, 612-00, Brno, Czech Republic
| | - Nikodem Kuźnik
- Department of Organic and Bioorganic Chemistry and Biotechnology, Silesian University of Technology, B. Krzywoustego 4, 44-100, Gliwice, Poland
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19
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Manier S, de Charette de la Contrie M, Hieulle J, Daniel A, Facon T. [Multiple myeloma: New criteria for diagnosis and treatment, strong therapeutic hopes]. Presse Med 2019; 48:825-831. [PMID: 31447337 DOI: 10.1016/j.lpm.2019.07.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 07/18/2019] [Indexed: 12/18/2022] Open
Abstract
Diagnosis criteria have been revised in 2014 and allow the treatment of some asymptomatic patients. Since 2015, a new prognostic score includes tumor plasma cells chromosomal abnormalities. It helps in the distinction between "standard risk" and "high risk" myelomas. Scanner, MRI and Pet Scan are the radiological reference exams to evaluate bone involvement. Alkylating agents, immunomodulators, proteasome inhibitors, and monoclonal antibodies became the most important antitumoral treatments. Risk notion will become more and more important for therapeutic choices. These choices will depend on residual disease evaluation. The next decade will be the immunotherapies development decade.
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Affiliation(s)
- Salomon Manier
- CHU de Lille, hôpital Huriez, université de Lille, service d'hématologie, 59000 Lille, France
| | | | - Julia Hieulle
- CHU de Lille, hôpital Huriez, université de Lille, service d'hématologie, 59000 Lille, France
| | - Adrien Daniel
- CHU de Lille, hôpital Huriez, université de Lille, service d'hématologie, 59000 Lille, France
| | - Thierry Facon
- CHU de Lille, hôpital Huriez, université de Lille, service d'hématologie, 59000 Lille, France.
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20
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Facon T, Anderson K. Treatment approach for the older, unfit patient with myeloma from diagnosis to relapse: perspectives of a European hematologist. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:83-87. [PMID: 30504295 PMCID: PMC6245965 DOI: 10.1182/asheducation-2018.1.83] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Mrs. A. is a 73-year-old woman who has developed increasing fatigue and lower back pain over the past year. The pain limits her exercise tolerance such that she can now walk only 1 block. She is a retired schoolteacher who does volunteer efforts in her community but has limited her activities due to fatigue. Karnofsky performance status is 70%. She has a history of chronic hypertension treated with a diuretic, adult-onset diabetes mellitus treated with metformin, and hypothyroidism treated with levothyroxine. Initial evaluation reveals anemia, renal dysfunction, an elevated total protein, and an L2 compression fracture on lumbosacral radiographs. Results of initial and subsequent evaluation are shown below, and she is referred to a hematologist for further evaluation, which revealed the following: calcium 9.0 mg/dL, creatinine 3.2 mg/dL with estimated creatinine clearance using the Modification of Diet in Renal Disease equation of 15 mL/min, hemoglobin 9.6 g/dL, total protein 11 g/dL, albumin 3.2 g/dL, immunoglobulin A (IgA) λ M protein 6.8 g/dL, total IgA 7.2 g/dL, IgG 0.4 g/dL, IgM 0.03 g/dL, free κ <0.01 mg/L, free λ 1000 mg/L, free light chain ratio <0.01, β-2-microglobulin 4.2, viscosity 3.0, lactate dehydrogenase 200 U/L, urine protein electrophoresis: 125 mg/dL with 30% M protein, and urine immuno-electrophoresis: λ light chain. Skeletal bone survey showed lytic lesions in femurs and humeri and diffusely in ribs bilaterally as well as compression fractures at T4, T6, and L2. Bone marrow biopsy revealed λ-restricted plasma cells comprising 50% of the bone marrow core. Fluorescence in situ hybridization testing on marrow showed that del(17p) was present in 80% of the plasma cells. Mrs. A. is informed of the diagnosis of multiple myeloma and the need for therapy. She requests consultation with 2 of the leading world experts. However, she wants to be treated near her home and does not want treatment on a clinical trial.
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Affiliation(s)
- Thierry Facon
- Department of Haematology, Centre Hospitalier Universitaire Lille, Lille, France; and
| | - Kenneth Anderson
- Jerome Lipper Multiple Myeloma Center, LeBow Institute for Myeloma Therapeutics, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
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