Original ArticleEvaluation of the Relevance of Surgery in Patients with Multiple Myeloma Harboring Symptomatic Spinal Involvement: A Retrospective Case Series
Introduction
Multiple myeloma is a malignant hematologic disorder, in which plasma cells proliferate in the bone marrow, leading to osteolytic bone lesions, commonly involving the spine. It accounts for approximately 1.8% of cancers, and 13% of hematologic malignancies,1, 2 and is the most frequent primary cancer of the spine.3 With a median age of patients at diagnosis of 69 years, myeloma is considered an age-related disease and, given the aging population trend, the current incidence of 6.6 cases per 100 000 is likely to increase in the future.1 The outcome remains highly heterogeneous with a 5-year survival of approximately 50% (SEER [Surveillance Epidemiology and End Results] data).4, 5
Bone disease is typically characterized by numerous well-circumscribed focal lesions, as well as diffuse demineralization, which is aggravated/worsened by steroids.6, 7, 8, 9, 10, 11, 12, 13, 14, 15 Periosteal infiltration causes severe pain, often requiring morphine.10 Vertebral involvement is frequent and leads to spinal instability, pathologic fractures, and epidural involvement.7, 8, 10, 16, 17, 18, 19, 20 All these factors imply a high risk of neurologic complications,10, 17, 21, 22, 23, 24, 25, 26, 27, 28 and substantially reduce independence and quality of life.29, 30, 31, 32, 33
The treatment of myeloma is complex and requires a truly multidisciplinary approach, especially when considering spine lesions.10, 24, 32, 34 Although chemotherapy in combination with bisphosphonates aims to reduce plasma-cell proliferation and bone destruction,9, 19, 34, 35, 36, 37, 38 there is still no consensus regarding the role of local treatments such as radiotherapy, vertebroplasty/kyphoplasty, or surgery. Unlike spinal metastases, the surgical management of spinal deposits in multiple myeloma is not well documented. Although some indications are commonly accepted, its role remains controversial, especially in the absence of neurologic impairment. Surgery may be associated with increased morbidity, in such frail patients who harbor poor bone quality and have a high risk of infection inherent in their disease.34, 39, 40 It is therefore crucial that the iatrogenic potential of surgery does not outweigh the expected benefits.
In this study, we aimed to evaluate both efficacy and safety of surgery for the management of symptomatic spinal lesions in patients with multiple myeloma.
Section snippets
Inclusion Criteria
Using our local medical coding system, we reviewed the medical records of the 724 patients who underwent surgery for the treatment of a spinal tumor in the Lille University Hospital between January 2007 and December 2015. We excluded patients who underwent surgery for a spine metastasis from solid cancer as well as patients with solitary bone plasmocytoma or other hematologic disease. In total, 55 patients underwent surgery for a myeloma-related spinal lesion during the study period.
Data Collection
We
Population
A total of 55 patients were included in this retrospective study. The number of patients operated on annually increased significantly during the study period (P = 0.009) (Figure 1). The main demographics are summarized in Table 2. There were 36 men and 19 women in our cohort and the median age at surgery was 62 years (interquartile range, 54–68). The KPS was ≥80% in 33 patients and <80% in 20 patients. KPS could be low because of acute neurologic impairment. Thus, the operability was a
Population
Our study is, to the best of our knowledge, the largest surgical series of myeloma spinal lesions. Because our patients had been selected and considered eligible for surgery, they were younger than the general population of patients with myeloma1 and had mostly favorable KPS and ISS scores. Coherently, most of our patients received intensive medical treatment, including autologous stem-cell transplantation. The other demographic characteristics matched the general population with myeloma. All
Conclusions
The management of myeloma spine lesions is complex and requires a truly multidisciplinary effort. Surgery is the only therapeutic option that can rapidly provide both decompression and stabilization of the affected vertebrae. Using a strict and individual evaluation, we reported rewarding functional results, with an acceptable morbidity. Therefore, offering surgery for multiple myeloma–related vertebral lesions seems to be a valuable option, for carefully selected patients.
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2020, International Journal of Spine Surgery
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.