Hypercalcemia caused by humoral effects and bone damage indicate poor outcomes in newly diagnosed multiple myeloma patients.

BACKGROUND: Hypercalcemia of malignancy (HCM) is a serious metabolic complication, and the highest rates are in multiple myeloma (MM). The cause of hypercalcemia in newly diagnosed multiple myeloma (NDMM) remains unknown. We sought to evaluate the prognostic impact and mechanism of hypercalcemia in patients with symptomatic NDMM. METHODS: We studied all consecutive MM patients who were initially diagnosed and followed up at Beijing Jishuitan Hospital between February 2013 and December 2019; 357 patients were included in the retrospective analysis. RESULTS: A total of 16.8% of MM patients presented with hypercalcemia at the time of MM diagnosis. The presence of hypercalcemia was associated with higher serum levels of ß2 microglobulin, creatinine, phosphorus, uric acid, procollagen I N-terminal peptide, ß-carboxy-terminal cross-linking telopeptide of type I collagen and osteocalcin, lower serum levels of hemoglobin, parathyroid hormone (PTH), and advanced ISS and R-ISS stages. Multivariate analysis showed that serum PTH, hemoglobin, creatinine, and uric acid levels were the main factors affecting hypercalcemia. The presence of hypercalcemia was associated with significantly inferior survival (40 months vs 57 months, p < 0.05) based on univariate analysis, and it remained an independent poor prognostic factor (HR: 1.854, 95% CI: 1.006-3.415, adjusted p = 0.048) in a multivariate model that included age and R-ISS stage. CONCLUSION: This study shows that hypercalcemia is associated with poor survival and is caused by manifold factors with humoral effects and local bone destruction.

Stability and survival analysis of elderly patients with osteolytic spinal bone metastases after palliative radiotherapy : Results from a large multicenter cohort.

PURPOSE: This retrospective study aimed to evaluate the stability and fracture rates of osteolytic spinal bone metastases (SBM) in elderly patients following palliative radiotherapy (RT) and to derive prognostic factors for stability and survival. METHODS: A total of 322 patients aged at least 70 years received palliative RT at two major German academic medical centers or at the German Cancer Research Center. Stability assessment was based on the validated Taneichi score prior to RT and at 3 and 6 months after RT. The survival time following RT was assessed, and prognostic factors for stability and survival were analyzed. RESULTS: Prior to RT, 183 patients (57%) exhibited unstable SBM and 68 patients (21%) pathological fractures. At 3 and 6 months after RT, significant recalcification and stabilization were evident in 19% (23/118) and 40% (31/78) of surviving patients, respectively. Only 17 patients (5%) experienced new pathological fractures following RT. Tumor histology was found to significantly influence stabilization rates with only breast cancer patients exhibiting increased stabilization compared to patients with other histologies. The median survival time and 6­month survival rates following RT were 5.4 months (95% confidence interval 4.4-7.2 months) and 48%, respectively. The patients' performance status was found to be the strongest predictor for survival after RT in this patient cohort; further factors demonstrating a significant association with survival were the application of systemic treatment, the number of SBM and the primary tumor histology. To analyze the influence of age on survival after RT, study patients were stratified into 3 age groups (i.e., 70-74 years, 75-79 years, and ≥80 years). The subgroup of patients aged at least 80 years showed a strong trend towards a worse survival time following RT compared to younger patients (i.e., 6­month survival rate 39% vs. 51%; p = 0.06, log-rank test). CONCLUSIONS: Prognostic factors influencing overall survival such as performance status and histology should guide the choice for palliative RT for SBM. Strongly hypofractionated RT regimes may be advisable for most elderly patients considering the overall poor prognosis in order to reduce hospitalization times.

Whole-body computed tomography versus conventional skeletal survey in patients with multiple myeloma: a study of the International Myeloma Working Group.

For decades, conventional skeletal survey (CSS) has been the standard imaging technique for multiple myeloma (MM). However, recently whole-body computed tomography (WBCT) has been implemented into the diagnostic criteria of MM. This analysis compares sensitivity and prognostic significance of WBCT and CSS in patients with smoldering MM (SMM) and MM. Fifty-four of 212 patients (25.5%) had a negative CSS and a positive WBCT for osteolytic lesions (P<0.0001). Of 66 patients with SMM based on CSS, 12 (22.2%) had osteolytic lesions on WBCT. In comparison, WBCT failed to detect some bone destructions in the appendicular skeleton possibly due to limitations of the field of view. Presence of lytic bone lesions in WBCT was of borderline prognostic significance (P=0.051) for SMM patients, with a median time to progression of 38 versus 82 months for those without bone destructions. In conclusion, WBCT identifies significantly more sites of bone destruction than CSS. More than 20% of patients with SMM according to CSS have in fact active MM detectable with WBCT. On the basis of this and other studies, WBCT (either computed tomography (CT) alone or as part of a positron emission tomography-CT protocol) should be considered the current standard for the detection of osteolytic lesions in MM.

Effects of Radiotherapy in the treatment of multiple myeloma: a retrospective analysis of a Single Institution.

BACKGROUND: Palliative irradiation of osteolytic lesions is a considerable component in the treatment for patients with multiple myeloma. In this study, we analyzed the efficacy of irradiation in these patients. PATIENTS AND METHODS: We retrospectively analyzed 153 patients with multiple myeloma who were admitted to our department between 1989 and 2013. According to the staging system of Durie & Salmon 116 patients were classified as stage III. 107/153 patients were treated with radiotherapy of at least one and up to 6 bony lesions at different times. In order to evaluate the effect of local radiotherapy on pain relief and bone recalcification a uni- and multivariate analysis was performed using a binary logistic regression model to correct for multiple measurements. Complete information on dose, fractionation and volume of radiotherapy was available from 81 patients treated in 136 target volumes for pain relief, and from 69 patients treated in 108 target volumes for recalcification. Total radiation doses varied between 8 Gy to 50 Gy (median dose 25 Gy in 2.5 Gy fractions, 5 times a week). RESULTS: Radiotherapy resulted in complete local pain relief in 31% and partial local pain relief in 54% of the patients. In the univariate analysis, higher total radiation doses (p = 0.023) and higher age (p = 0.014) at the time of radiotherapy were significantly associated with a higher likelihood of pain relief, whereas no significant association was detected for concurrent systemic treatment, type and stage of myeloma and location of bone lesions. The same variables were independent predictors for pain relief in the multivariate analysis. Recalcification was observed in 48% of irradiated bone lesions. In the uni- and multivariate analysis higher radiation doses were significantly associated (p = 0.048) with an increased likelihood of recalcification. Side effects of radiotherapy were generally mild. CONCLUSIONS: Higher total biological radiation doses were associated with better pain relief and recalcification in this retrospective evaluation of multiple myeloma patients. In addition, in the elderly the therapeutic measures appear to develop a better analgesic effect.

Does the presence of tumor-induced cortical bone destruction at CT have any prognostic value in newly diagnosed diffuse large B-cell lymphoma?

PURPOSE: To determine the prognostic value of tumor-induced cortical bone destruction at computed tomography (CT) in newly diagnosed diffuse large B-cell lymphoma (DLBCL). MATERIALS AND METHODS: This retrospective study included 105 patients with newly diagnosed DLBCL who had undergone CT and bone marrow biopsy (BMB) before R-CHOP (rituximab, cyclophosphamide, hydroxydaunorubicin, Oncovin, and prednisolone) chemo-immunotherapy. Cox regression analyses were used to determine the associations of cortical bone status at CT (absence vs. presence of tumor-induced cortical bone destruction), BMB findings (negative vs. positive for lymphomatous involvement), and dichotomized National Comprehensive Cancer Network International Prognostic Index (NCCN-IPI) strata (low risk vs. high risk) with progression-free survival (PFS) and overall survival (OS). RESULTS: Univariate Cox regression analysis indicated that cortical bone status at CT was no significant predictor of either PFS or OS (p = 0.358 and p = 0.560, respectively), whereas BMB findings (p = 0.002 and p = 0.013, respectively) and dichotomized NCCN-IPI risk strata (p = 0.002 and p = 0.003, respectively) were significant predictors of both PFS and OS. In the multivariate Cox proportional hazards model, only the dichotomized NCCN-IPI score was an independent predictive factor of PFS and OS (p = 0.004 and p = 0.003, respectively). CONCLUSIONS: The presence of tumor-induced cortical bone destruction at CT was not found to have any prognostic implications in newly diagnosed DLBCL.

Acetabular reconstruction with the Burch-Schneider antiprotrusio cage and bulk allografts: minimum 10-year follow-up results.

Reconstruction of severe pelvic bone loss is a challenging problem in hip revision surgery. Between January 1992 and December 2000, 97 hips with periprosthetic osteolysis underwent acetabular revision using bulk allografts and the Burch-Schneider antiprotrusio cage (APC). Twenty-nine patients (32 implants) died for unrelated causes without additional surgery. Sixty-five hips were available for clinical and radiographic assessment at an average follow-up of 14.6 years (range, 10.0 to 18.9 years). There were 16 male and 49 female patients, aged from 29 to 83 (median, 60 years), with Paprosky IIIA (27 cases) and IIIB (38 cases) acetabular bone defects. Nine cages required rerevision because of infection (3), aseptic loosening (5), and flange breakage (1). The average Harris hip score improved from 33.1 points preoperatively to 75.6 points at follow-up (P < 0.001). Radiographically, graft incorporation and cage stability were detected in 48 and 52 hips, respectively. The cumulative survival rates at 18.9 years with removal for any reason or X-ray migration of the cage and aseptic or radiographic loosening as the end points were 80.0% and 84.6%, respectively. The use of the Burch-Schneider APC and massive allografts is an effective technique for the reconstructive treatment of extensive acetabular bone loss with long-lasting survival.

10-year results of the uncemented Allofit press-fit cup in young patients.

BACKGROUND AND PURPOSE: Uncemented acetabular components in primary total hip arthroplasty (THA) are commonly used today, but few studies have evaluated their survival into the second decade in young and active patients. We report on a minimum 10-year follow-up of an uncemented press-fit acetabular component that is still in clinical use. METHODS: We examined the clinical and radiographic results of our first 121 consecutive cementless THAs using a cementless, grit-blasted, non-porous, titanium alloy press-fit cup (Allofit; Zimmer Inc., Warsaw, IN) without additional screw fixation in 116 patients. Mean age at surgery was 51 (21-60) years. Mean time of follow-up evaluation was 11 (10-12) years. RESULTS: At final follow-up, 8 patients had died (8 hips), and 1 patient (1 hip) was lost to follow-up. 3 hips in 3 patients had undergone acetabular revision, 2 for deep infection and 1 for aseptic acetabular loosening. There were no impending revisions at the most recent follow-up. We did not detect periacetabular osteolysis or loosening on plain radiographs in those hips that were evaluated radiographically (n = 90; 83% of the hips available at a minimum of 10 years). Kaplan-Meier survival analysis using revision of the acetabular component for any reason (including isolated inlay revisions) as endpoint estimated the 11-year survival rate at 98% (95% CI: 92-99). INTERPRETATION: Uncemented acetabular fixation using the Allofit press-fit cup without additional screws was excellent into early in the second decade in this young and active patient cohort. The rate of complications related to the liner and to osteolysis was low.

Stability of spinal bone metastases in breast cancer after radiotherapy: a retrospective analysis of 157 cases.

PURPOSE: This retrospective analysis was performed to evaluate osteolytic bone lesions of breast cancer in the thoracic and lumbar spine after radiotherapy (RT) in terms of stability using a validated scoring system. METHODS: The stability of 157 osteolytic metastases, treated from January 2000 to January 2012, in 115 patients with breast cancer was evaluated retrospectively using the Taneichi score. Predictive factors for stability were analyzed and survival rates were calculated. RESULTS: Eighty-five (54%) lesions were classified as unstable prior to RT. After 3 and 6 months, 109 (70%) and 124 (79%) lesions, respectively, were classified as stable. Thirty fractures were detected prior to RT, and after RT seven cases (4.5%) with pathologic fractures were found within 6 months. None of the examined predictive factors showed significant correlation with stability 6 months after RT. After a median follow-up of 16.7 months, Kaplan-Meier estimates revealed an overall survival of 83% after 5 years. CONCLUSION: The majority of patients showed an improved or unchanged stability of the involved vertebral bodies after 6 months. The patients showed only minor cancer-related morbidity during follow-up and reached comparably high survival rates.

Mortalidad en pacientes con osteólisis de origen linfático. Revisión de 54 casos / Mortality in patients with osteolysis of lymphatic origin: a review of the experience with 54 patients and the literature

Introducción: La osteólisis de origen linfático es una enfermedad poco frecuente cuya alta mortalidad es difícil atribuir al propio cuadro o a la iatrogenia que genera su tratamiento. El objetivo del trabajo es revisar las causas de la mortalidad en nuestros pacientes y en la literatura médica en la osteólisis de origen linfático. Pacientes y métodos: Hemos revisado a todos los pacientes con osteólisis de origen linfático tratados en nuestro departamento y que han fallecido en los últimos 15 años, así como todos los casos publicados de defunción con esta enfermedad desde los años cincuenta. Resultados: De los 57 pacientes con osteólisis de origen linfático tratados en nuestro hospital, 3 han fallecido, 2 por infección y uno por distrés respiratorio agudo. Todos presentaban desnutrición y 2 de ellos quilotórax bilateral. Entre las 51 muertes revisadas de la literatura entre los años 1954 y 2010, 19 tenían quilotórax bilateral, 15 derecho, y sólo 2 tenían afectación exclusivamente izquierda. Once tuvieron complicaciones respiratorias en forma de neumonía y distrés, 10 presentaron fracturas patológicas y otros 10 quilopericardio y/o ascitis quilosa. La causa más común de defunción fue el fallo respiratorio en 25 pacientes, seguida de la neumonía y la sepsis. Las publicaciones no especifican la causa última de la insuficiencia respiratoria. Conclusiones: El paciente con osteólisis de origen linfático grave suele presentarse con 3 cuadros que se solapan: la malformación linfática de partes blandas, la reabsorción ósea y el quilotórax. Mientras que la mortalidad de los 2 primeros es excepcional, la del quilotórax es frecuente, sobre todo cuando es bilateral y no responde al tratamiento. El fallo respiratorio y la infección están agravados por la inmunosupresión, la desnutrición y el emplazamiento prolongado de catéteres centrales. A diferencia del fallo respiratorio, difícil de controlar tras el fracaso del tratamiento médico-quirúrgico, la morbimortalidad causada por las infecciones puede disminuirse mediante un adecuado soporte nutricional, una correcta profilaxis antibiótica y la reducción al mínimo indispensable de los accesos venosos y de la nutrición parenteral total (AU)

Introduction: Osteolysis of lymphatic origin is a rare disease with a high mortality which is difficult to attribute whether it is due to the disease itself or the therapeutic morbidity. The aim of this study is to review the causes of mortality in our group of patients with osteolysis of lymphatic origin, compared with the group of patients previously reported in the medical literature. Patients and methods: We reviewed all patients with osteolysis of lymphatic origin and treated in our department who had died in the last 15 years, and we reviewed all published cases of death with this disease since the 1950's.ResultsA total of 57 patients with osteolysis of lymphatic origin had been studied at our institution, of whom three died, two from sepsis, and one from acute respiratory distress syndrome. All of them suffered severe malnutrition from massive lymphatic loss and 2 had bilateral chylothorax. Among the 51 cases reviewed in the literature between 1954 - 2010, 19 had bilateral chylothorax, 15 had right side involvement and only 2 had an exclusive left chylothorax. Eleven patients had complications, such as respiratory distress and pneumonia. Ten of them suffered from pathological fractures, and 10 from chylopericardium and/or chylous ascites. The most common cause of death was respiratory failure in 25 patients, followed by pneumonia and sepsis. The publications do not specify the ultimate cause of respiratory failure. Conclusions: Patients with severe osteolysis of lymphatic origin suffer three main disorders with overlapping comorbidity: the lymphatic malformation of soft tissue, the bone resorption and the chylothorax. While mortality in the first two is exceptional, the mortality of the chylothorax is common, especially when it is bilateral and does not respond to different therapies. Respiratory failure and infection are aggravated by immunosuppression, malnutrition and the non-restrictive use of central catheters. Unlike respiratory failure, which is difficult to control after the failure of medical and surgical treatment, morbidity from infections can be reduced through careful nutritional support, rational antibiotic prophylaxis and a reduction to a minimum in the use of central catheters and total parenteral nutrition (AU)

[Mortality in patients with osteolysis of lymphatic origin: a review of the experience with 54 patients and the literature]. / Mortalidad en pacientes con osteólisis de origen linfático. Revisión de 54 casos.

INTRODUCTION: Osteolysis of lymphatic origin is a rare disease with a high mortality which is difficult to attribute whether it is due to the disease itself or the therapeutic morbidity. The aim of this study is to review the causes of mortality in our group of patients with osteolysis of lymphatic origin, compared with the group of patients previously reported in the medical literature. PATIENTS AND METHODS: We reviewed all patients with osteolysis of lymphatic origin and treated in our department who had died in the last 15 years, and we reviewed all published cases of death with this disease since the 1950's. RESULTS: A total of 57 patients with osteolysis of lymphatic origin had been studied at our institution, of whom three died, two from sepsis, and one from acute respiratory distress syndrome. All of them suffered severe malnutrition from massive lymphatic loss and 2 had bilateral chylothorax. Among the 51 cases reviewed in the literature between 1954 - 2010, 19 had bilateral chylothorax, 15 had right side involvement and only 2 had an exclusive left chylothorax. Eleven patients had complications, such as respiratory distress and pneumonia. Ten of them suffered from pathological fractures, and 10 from chylopericardium and/or chylous ascites. The most common cause of death was respiratory failure in 25 patients, followed by pneumonia and sepsis. The publications do not specify the ultimate cause of respiratory failure. CONCLUSIONS: Patients with severe osteolysis of lymphatic origin suffer three main disorders with overlapping comorbidity: the lymphatic malformation of soft tissue, the bone resorption and the chylothorax. While mortality in the first two is exceptional, the mortality of the chylothorax is common, especially when it is bilateral and does not respond to different therapies. Respiratory failure and infection are aggravated by immunosuppression, malnutrition and the non-restrictive use of central catheters. Unlike respiratory failure, which is difficult to control after the failure of medical and surgical treatment, morbidity from infections can be reduced through careful nutritional support, rational antibiotic prophylaxis and a reduction to a minimum in the use of central catheters and total parenteral nutrition.

The Medical Research Council Myeloma IX trial: the impact on treatment paradigms.

Osteolytic bone disease is a hallmark of symptomatic multiple myeloma. Bisphosphonates have been the mainstay of treatment to preserve skeletal integrity and prevent skeletal-related events in patients with myeloma-related bone disease. Recently, the MRC Myeloma IX trial demonstrated for the first time improved survival and delayed disease progression with the use of an intravenous amino-bisphosphonate, zoledronic acid, vs. an oral agent, clodronate, with intensive and non-intensive anti-myeloma treatment regimens in patients with newly diagnosed multiple myeloma. These results validate a large body of preclinical, translational and other clinical data suggesting anti-myeloma effects of amino-bisphosphonates. In addition, this trial also provided the first head-to-head evidence for superiority of one bisphosphonate over another (zoledronic acid vs. clodronate) for reducing skeletal morbidity in patients with multiple myeloma, as well as a prospective comparison of toxicities. Despite the use of non-bortezomib containing anti-myeloma treatment regimens in the MRC Myeloma IX trial, these results are encouraging and provide an impetus to continue to evaluate current treatment guidelines for myeloma-associated bone disease.

A prospective study of hip revision surgery using the Exeter long-stem prosthesis: function, subsidence, and complications for 57 patients.

BACKGROUND: The long-stem Exeter femoral component is commonly used in revision hip surgery. Subsidence of the femoral stem in primary hip arthroplasty has been studied extensively, but much less is known about its significance in revision surgery. This prospective study examined the relationship between radiological subsidence, Western Ontario and McMaster (WOMAC) osteoarthritis index pain score, patient satisfaction and complication rates for the long-stem Exeter hip prosthesis. MATERIALS AND METHODS: Data was prospectively collected for a single-surgeon series of 96 patients undergoing revision surgery with a mean follow-up period of 36 months. Pre- and post-operative clinical evaluation was carried out using the validated WOMAC osteoarthritis index. Radiographic evaluation was carried out on magnification-adjusted digital radiographic images. RESULTS: Data from 57 patients were analysed. The mean rate of subsidence recorded was 0.43 mm/year, with a mean total subsidence of 0.79 mm [95% confidence interval (CI) 0.57-1.01] at 36.3 months. There was no correlation between subsidence and post-operative WOMAC score, complication rate or patient satisfaction. There was a statistically significant reduction between pre-operative and post-operative WOMAC scores, with means of 33.5 and 10.7, respectively (P < 0.001), and high patient satisfaction. CONCLUSION: Our subsidence rates for long-stem revision femoral components are lower than the published data but demonstrate the same plateau. Radiographic subsidence does not appear to relate to functional outcome or complication rates in our data.

Management of complications in multiple myeloma.

Multiple myeloma (MM) is characterized by the presence of osteolytic bone disease, renal impairment, anemia, and immune dysfunction. Adequate supportive care is considered an essential part of anti-myeloma therapy. The administration of bisphosphonates has been shown to reduce skeletal related events and hypercalcemia. Bisphosphonates are well tolerated, but preventive steps should be taken to avoid renal impairment and osteonecrosis of the jaw (ONJ). Adequate pain control is of crucial importance for the quality of life of MM patients. Local radiotherapy may rapidly ameliorate symptoms of painful MM bone lesions, and vertebroplasty and kyphoplasty are able to control symptoms and restore the original height of vertebral fractures. Symptomatic chemotherapy-induced anemia should preferentially be treated with erythropoietic growth factors, but further studies are required to confirm the long-term safety of this approach. Light-chain-induced renal impairment should be treated without delay with a highly effective anti-myeloma regimen consisting of novel drugs. Prophylaxis of infections should be considered particularly in patients with poorly controlled disease and documented infections should be treated aggressively as they contribute significantly to morbidity and mortality. The concerted action of these supportive therapies can significantly improve the quality of life of MM patients during the different phases of their disease.

Combination therapy with thalidomide, incadronate, and dexamethasone for relapsed or refractory multiple myeloma.

The feasibility and efficacy of a combination of thalidomide, incadronate, and dexamethasone (TID) were studied in 12 patients with relapsed or refractory multiple myeloma. The protocol, consisting of 300 mg/day of thalidomide administered orally, intravenous incadronate (10 mg/day) administered weekly, and 12 mg/day dexamethasone for 4 days, was repeated every 3 weeks. Evaluations of efficacy and toxicity were carried out every 3 weeks and were continued for 3 cycles. Three patients were excluded during the study because of apnea, severe somnolence, and pancytopenia. Of 9 evaluated patients, the partial responses achieved in 3 patients and the minor responses achieved in 4 patients corresponded to a response rate of 78% according to the criteria of the European Group for Blood and Marrow Transplantation. In addition, painful osteolytic symptoms improved rapidly after 1 cycle of TID therapy in the 10 patients evaluated. These data suggest that TID is a feasible and promising therapeutic approach for refractory and relapsed multiple myeloma.

[Long-term survival and prognostic factors in stage II-III multiple myeloma treated with conventional chemotherapy]. / Survie à long terme et facteurs pronostiques du myélome multiple stade II-III traité par chimiothérapie conventionnelle.

In this retrospective study, survival and prognostic factors were analysed in 65 patients with stage II-III multiple myeloma with osteolytic lesions. Multiple myeloma was diagnosed from 1976 to 1984, and patients were treated with conventional chemotherapy. The response rate to initial chemotherapy was 46%. The median survival time was 31 months. The 10-year survival rate was 10%. Four variables were individually prognostic: response to initial chemotherapy, bone marrow plasma cell percentage, the Durie and Salmon staging system, a biological staging system derived from Durie and Salmon's biological criteria regardless of bone lesions. In the multivariate analysis, only two prognostic variables were retained, namely the response to chemotherapy and the biological staging system. No prognostic value was observed for the extent of osteolytic lesions. This study suggests that, in conventionally treated multiple myeloma, long-term survival has improved compared with the previous decade. It also indicates that the extent of osteolytic lesions has little value for the definition of high-risk myeloma.

Effect of daily etidronate on the osteolysis of multiple myeloma.

Progressive bone disease in multiple myeloma frequently leads to osteolysis, bone resorption, pathologic fractures, vertebral compression, and hypercalcemia. We conducted a double-blind study in 173 newly diagnosed multiple myeloma patients of etidronate disodium (EHDP), a diphosphonate compound that reduces bone resorption by inhibiting osteoclastic activity. The patients were randomly assigned to receive oral EHDP 5 mg/kg/d or placebo until death or discontinuation due to intolerance or refusal. The extent of vertebral deformity was measured by a vertebral index as well as height. The frequency of pathologic fractures, hypercalcemia, and bone pain was regularly assessed, as well as size and number of osteolytic lesions. All patients received melphalan and prednisone daily for 4 days every 4 weeks as the primary chemotherapy for their disease. Although the repeated measures analysis showed a significant height loss, there was no difference between treatment arms (P = .98). There was no significant difference in bone pain, episodes of hypercalcemia, or development of pathologic fractures. Patients on EHDP showed less deterioration in their vertebral index, but this difference only approached statistical significance (P = .07). We conclude that EHDP therapy used in this dosage schedule does not have a clinically significant impact in multiple myeloma.

[Pathological fractures and prefracture osteolytic lesions due to metastases located in the femoral diaphysis: a clinico-radiographic study, a case history review and considerations of treatment evolution]. / Le fratture patologiche e le lesioni osteolitiche pre-fratturative da metastasi localizzate alla diafisi femorale: studio clinico-radiografico, revisione della casistica e considerazioni sull'evoluzione del trattamento.

The authors reviewed the clinical and radiographic documentation of 44 cases of metastatic lesion in the femoral diaphysis, all treated during a 15-year period at the Centro Traumatologico e Ortopedico of Florence. The results obtained with both initial nonoperative treatment (casts) as well as subsequent intramedullary fixation are evaluated with great care. The evaluation of the results in terms of survival was not possible for several reasons, not least of which the recent progress made in radiation-chemo-hormonal therapy for tumors. Despite the precarious general condition of most of the patients surgical treatment did not cause intraoperative or immediate postoperative mortality. Overall, the postoperative complications were not serious and were compensated for by good progress in systemic therapy, good nursing, and in some cases recovery of autonomy.