Optimizing the management of patients with spinal myeloma disease.

Myeloma is one of the most common malignancies that results in osteolytic lesions of the spine. Complications, including pathological fractures of the vertebrae and spinal cord compression, may cause severe pain, deformity and neurological sequelae. They may also have significant consequences for quality of life and prognosis for patients. For patients with known or newly diagnosed myeloma presenting with persistent back or radicular pain/weakness, early diagnosis of spinal myeloma disease is therefore essential to treat and prevent further deterioration. Magnetic resonance imaging is the initial imaging modality of choice for the evaluation of spinal disease. Treatment of the underlying malignancy with systemic chemotherapy together with supportive bisphosphonate treatment reduces further vertebral damage. Additional interventions such as cement augmentation, radiotherapy, or surgery are often necessary to prevent, treat and control spinal complications. However, optimal management is dependent on the individual nature of the spinal involvement and requires careful assessment and appropriate intervention throughout. This article reviews the treatment and management options for spinal myeloma disease and highlights the value of defined pathways to enable the proper management of patients affected by it.

Seeking international consensus on approaches to primary tumour treatment in Ewing sarcoma.

BACKGROUND: The local treatment of Ewing sarcoma of bone involves surgery, radiotherapy or both. The selection of treatment depends on the anatomical extent of the tumour, the effectiveness of the proposed treatment, its morbidity, and the expectation of cure. However, not only are there variations in the approach to local treatment between individual patients, but also between treatment centres and countries. Our aim was to explore variation in practice and develop consensus statements about local treatment. METHODS: A three stage modified Delphi technique was used with international collaborators. This involved an expert panel to identify areas of controversy, an online survey of international collaborators and a consensus meeting in London, UK in June 2017. In the consensus meeting, teams of clinicians discussed the local management of selected cases and their responses were collected with electronic voting. RESULTS: Areas of greater or less consensus were identified. The lack of evidence underpinning different approaches was noted and areas for collaborative research became apparent. CONCLUSION: This has demonstrated that there is an international consensus around many aspects of the local treatment of Ewing sarcoma of bone, including the use of specialist MultiDisciplinary Team (MDT) meetings with access to all appropriate treatments. However, considerable variation remains including the use of different staging investigations, decision making, definitions of response, and radiotherapy doses and timing. Further collaborative work should be undertaken to determine the impact of these variations in order to define best practice.

Continued lumbar spinal erosion after repair of chronic contained rupture of a mycotic abdominal aortic aneurysm.

INTRODUCTION: Mycotic aneurysm of the aorta is a rare, dangerous condition. We report a case of an abdominal aortic aneurysm (AAA) caused by Candida albicans. METHODS: Case report and review of pertinent English-language literature. CASE REPORT: A 48 year-old man presented with an acute exacerbation of long-standing back pain. Examination revealed a pulsatile epigastric mass, and radiologic examinations confirmed a 9 cm chronic contained rupture of an inflammatory infrarenal AAA. At operation, no posterior aneurysm sac was found, and lumbar vertebral erosion was noted. Lower limb vascularity was secured with left axillo-bifemoral bypass. The patient presented 12 months later with severe non-mechanical back pain. Imaging confirmed continuing vertebral erosion. At laparotomy, an autologous fibula strut was used for spinal stabilization. CONCLUSION: Aggressive multimodality therapy of infected AAA and associated vertebral osteomyelitis is necessary for a successful outcome.