Diagnosis and Treatment of Bone Disease in Multiple Myeloma: Spotlight on Spinal Involvement

Abstract

Bone disease is observed in almost 80% of newly diagnosed symptomatic multiple myeloma patients, and spine is the bone site that is more frequently affected by myeloma-induced osteoporosis, osteolyses, or compression fractures. In almost 20% of the cases, spinal cord compression may occur; diagnosis and treatment must be carried out rapidly in order to avoid a permanent sensitive or motor defect. Although whole body skeletal X-ray is considered mandatory for multiple myeloma staging, magnetic resonance imaging is presently considered the most appropriate diagnostic technique for the evaluation of vertebral alterations, as it allows to detect not only the exact morphology of the lesions, but also the pattern of bone marrow infiltration by the disease. Multiple treatment modalities can be used to manage multiple myeloma-related vertebral lesions. Surgery or radiotherapy is mainly employed in case of spinal cord compression, impending fractures, or intractable pain. Percutaneous vertebroplasty or balloon kyphoplasty can reduce local pain in a significant fraction of treated patients, without interfering with subsequent therapeutic programs. Systemic antimyeloma therapy with conventional chemotherapy or, more appropriately, with combinations of conventional chemotherapy and compounds acting on both neoplastic plasma cells and bone marrow microenvironment must be soon initiated in order to reduce bone resorption and, possibly, promote bone formation. Bisphosphonates should also be used in combination with antimyeloma therapy as they reduce bone resorption and prolong patients survival. A multidisciplinary approach is thus needed in order to properly manage spinal involvement in multiple myeloma.

Risk of vertebral compression fractures in multiple myeloma patients

“…Almost 80% of MM patients are diagnosed with osteoporosis; hence BMD currently has a major impact on survival in MM patients. [14,15] It is believed that osteoporosis status could be an indicator of disease progression to MM. [16] Osteoporotic patients (20%) presenting with vertebral fractures have either monoclonal gammopathy undetermined significance or MM.…”

Simultaneous occurrence of Hodgkin's lymphoma and multiple myeloma: A case report and review of the literature

“…In recent years, the OS and progression-free survival of MM has been increasing due to the application of targeted drugs, including bortezomib, thalidomide and lenalidomide (7). The coexistence of HL and MM is rare (8)(9)(10). The current study reports the case of a patient who presented with HL and MM at the same time, for which a good outcome was achieved using chemotherapy.…”

Creation of RANKL mutants with low affinity for decoy receptor OPG and their potential anti‐fibrosis activity

“…Interestingly, many tissue macrophages express RANK, and through RANKL stimulation, proteases are released which can degrade ECM [20]. In bone, osteoclasts are derived from macrophage/monocyte and can produce MMPs and other proteolytic enzymes to degrade bone ECM [21,22]. In fibrotic tissue, the stimulation of the RANKL/RANK axis may also be a possible way to activate antifibrotic macrophages and reverse fibrosis [20].…”