Surgical Stabilization for Patients with Mechanical Back Pain Secondary to Metastatic Spinal Disease is Associated with Improved Objective Mobility Metrics: Preliminary Analysis in a Cohort of 26 Patients.

OBJECTIVES: To investigate the effect of surgical stabilization for patients with metastatic spinal disease on objective mobility metrics. METHODS: A retrospective chart review identified patients who had mechanical back pain from metastatic spinal disease and underwent spinal stabilization during 2017. Mobility metrics, the Activity Measure for Post-Acute Care (AM-PAC) inpatient mobility short form (IMSF) and the Johns Hopkins Highest Level of Mobility (JH-HLM), were reviewed. RESULTS: A total of 26 patients were included in the analysis with median hospital stay of 8 days. Preoperative JH-HLM scores were available for 17 patients with a mean score of 5.4, increasing to mean score of 6.6 at last follow-up (P = 0.036). Preoperative AM-PAC IMSF scores were available for 14 patients with a mean score of 19.4, decreasing slightly to a mean score of 18.7 at last follow-up (P = 0.367). Last follow-up with mobility metrics occurred a median of 6.5 days postoperatively (range: 3-66 days). Multivariable analysis showed that American Spinal Injury Association and Karnofsky Performance Status scores were significantly associated with both JH-HLM and AM-PAC mobility scores at last follow-up. A higher JH-HLM or AM-PAC score was significantly associated with direct home discharge and a higher AM-PAC score was associated with shorter hospital stay. CONCLUSIONS: Surgical stabilization for patients with mechanical back pain secondary to metastatic spinal disease might lead to an objective improvement in JH-HLM score. JH-HLM and AM-PAC scores may be correlated with length of hospital stay and discharge disposition. Future studies are encouraged to further characterize the role of these mobility metrics in the management plan of these patients.

Secondary myeloma in patients with chronic lymphoblastic leukemia: A case report and analysis of data from SEER database.

Both chronic lymphocytic leukemia (CLL) and multiple myeloma (MM) are common hematological malignancies originating from mature B cells of different differentiation stage. However, it is quite rare that MM could develop after CLL diagnosed. We reported a 66-year-old female progressed forward myeloma 3 years after she was diagnosed as CLL and conducted an analysis to investigate the epidemiology and clinical features among these patients based on the Surveillance, Epidemiology, and End Results (SEER) database. Our data demonstrated that CLL patients were 19% less likely to develop myeloma than general U.S. population (standardized incidence ratio 0.81; 95% confidence interval 0.62-1.03), although without statistical difference. The median overall survival from CLL diagnosed was 90 (58.1-121.9) months, which was the same as general CLL patients according to historical data. But the outcomes of secondary MM was much poorer than general MM patients. Age and gender were independent factors that impact the survival among these patients.

Non-operative management of spinal metastases: A prognostic model for failure.

OBJECTIVES: To describe patient-specific characteristics associated with non-operative failure leading to surgery. PATIENTS AND METHODS: We conducted a retrospective review of patients treated for spinal metastases from 2005 to 2017. We deemed patients as failures if they were treated non-operatively and then received a surgical intervention within one year of starting a non-operative regimen. We used multivariable Poisson regression to identify factors associated with non-operative failure. We conducted internal validation using bootstrapping with 1000 replications. RESULTS: We identified 1205 patients with spinal metastases, of whom 834 were initially treated non-operatively and constituted the analytic sample. Of these 77 (9%) went on to have surgery within 1-year of presentation and were deemed non-operative treatment failures. We identified vertebral body collapse and/or pathologic fracture (adjusted Risk Ratio [RR] 1.75; 95% Confidence Interval [CI] 1.11, 2.76) and neurologic signs or symptoms at presentation (RR 1.90; 95% CI 1.19, 3.03) as factors independently associated with an increased risk of non-operative failure. Platelet-lymphocyte ratio >155, a marker for inflammatory state, was also associated with an increased risk of failure (RR 2.32; 95% CI 1.15, 4.69). Failure rates among those with 0, 1, 2 or all three of these risk factors were 5%, 7%, 12% and 20%, respectively (p = 0.004). CONCLUSION: We found that 9% of patients with spinal metastases initially treated non-operatively received surgery within 1-year of commencing care. The likelihood of surgery increased with the number of risk factors. These results can be used in counseling and shared decision making at the time of initial presentation.

A Specialized Orthosis for Suppressing Bony Destruction from Multiple Myeloma and to Enhance Healing of a Pathologic Fracture in an Appendicular Lesion.

Appendicular metastasis from multiple myeloma (MM) frequently presents with a pathologic fracture. In this case report, a patient with a long history of MM and an associated pathologic fracture was treated using a specialized brace. This orthosis uses a deforming element to asymmetrically increase the soft tissue pressure around the pathologic fracture. The patient experienced rapid pain relief and bony healing without surgical intervention.

Incidence of skeletal-related events in patients with breast or prostate cancer-induced bone metastasis or multiple myeloma: A 12-year longitudinal nationwide healthcare database study.

BACKGROUND: This study examined the incidence of skeletal-related events (SRE) among patients with breast cancer (BC)- or prostate cancer (PC)-induced bone metastasis or multiple myeloma (MM) based on a population-based, 12-year healthcare database. METHODS: Patients aged ≥18 years with bone metastasis from BC or PC or with MM between 2004 and 2015 were included. SRE was defined as pathologic fracture, spinal cord compression, radiation, or surgery to bone. Patients were followed-up from the initial diagnosis of bone metastasis (for those with BC or PC) or MM until SRE occurrence. To estimate multiple SREs, we applied a 21-day time window to ensure that subsequent SREs occurred independently from the previous event. We calculated the incidence and 95% confidence intervals (CIs), stratified according to the previous SRE history. RESULTS: Our cohort included 53,231 patients, including 23,811 with BC, 19,170 with PC, and 10,250 with MM. The incidence of multiple SREs in the 21-day time window was 1.03 (95% CI = 1.01-1.05) in patients with previous SRE history and 0.19 (95% CI = 0.19-0.20) in those without. The cumulative SRE incidences were 47%, 31.4%, and 38.0% in BC, PC, and MM patients. CONCLUSION: The incidences of multiple SREs in BC- or PC-induced bone metastasis or MM in this 12-year South Korean cohort were slightly higher than those in European countries. Our study provided real-world evidence that patients with BC- or PC-induced bone metastasis or MM are at high risk of SRE.

Utilization Patterns of Single Fraction Radiation Therapy for Multiple Myeloma.

BACKGROUND: Patients with multiple myeloma (MM) are living longer than ever before thanks to new therapies. As a consequence, radiation therapy (RT) is increasingly important in the management of bone lesions from MM. Current American Society for Radiation Oncology guidelines recommend greater usage of 8 Gy in 1 fraction for treatment of these lesions. The objective of this study is to analyze utilization of 8 Gy in 1 fraction for treatment of MM bone lesions in the United States utilizing the National Cancer Data Base (NCDB). MATERIALS AND METHODS: The NCDB was used to identify patients with MM treated with palliative RT for painful bony lesions in the period between 2004 and 2014. Utilization rate of RT in this patient population as well as single-fraction (SFRT) versus multiple-fraction RT (MFRT) was compared according to demographic, socioeconomic, and logistic details. RESULTS: A total of 95,190 patients met our inclusion criteria. Of these, 10,261 (10.8%) patients received RT, and a total of 243 (2.4%) of these patients received SFRT over the 10-year period. There was an 11.73% annual increase (P = .0001) in SFRT utilization from 2004 to 2014. Older age, black race, longer distance from the treatment facility, lower degree of education, treatment at an academic or integrated healthcare network, worse comorbidities, and more recent diagnoses were all associated with increased usage of SFRT. CONCLUSION: SFRT for the management of MM painful bony metastases remains underutilized. Trends show that radiation oncologists do not appear to be changing their approach to treating this disease.

Risk of secondary primary malignancies in multiple myeloma patients with or without autologous stem cell transplantation.

Outcomes for patients with multiple myeloma (MM) have improved through use of novel treatments, especially lenalidomide combined with autologous stem cell transplantation. However, because of their increased life expectancy, an increased risk of secondary primary malignancies (SPMs) has been observed in MM patients, particularly after lenalidomide maintenance in both transplant-eligible (TE) and transplant-ineligible (TI) patients. To evaluate the incidence and risk factors of developing SPMs, we identified 17 TE-MM and 12 TI-MM patients with SPMs among 211 TE-MM and 280 TI-MM patients, including seven TE-MM and four TI-MM patients with hematological malignancies and ten TE-MM and eight TI-MM patients with non-hematological cancers, respectively. The median follow-up time from diagnosis was > 4 years. Multivariate analysis identified a history of high-dose cyclophosphamide use for peripheral blood stem cell harvest in TE-MM patients and > 65 years of age at diagnosis, or a history of adriamycin, lenalidomide, or thalidomide use in TI-MM patients as independent risk factors for SPMs (P < 0.001). Patients with a history of lenalidomide use had a lower risk of death among both TE-MM (P = 0.0326) and TI-MM (P < 0.001) patients. The survival benefit of receiving lenalidomide outweighed the increased risk of SPMs in both TE-and TI-MM patients.

Beyond Mirels: Factors Influencing Surgical Outcome of Metastasis to the Extremities in the Modern Era.

Mirels scoring system for determining prophylactic stabilization need of skeletal metastases includes a limited number of variables and does not differentiate between procedure types. This study sought to identify additional variables associated with surgical failure, radiographic disease progression, and patient survival. A retrospective review was performed of patients from January 2004 to 2014 who underwent surgical treatment of skeletal metastases of the extremities, were >18 years of age, and had adequate radiographic surveillance. Eighty-nine metastatic bone lesions in 77 patients were included. Mirels score >8 (p = .015) and tumor origin (p = .008) were associated with surgical failure, which was 16.8%. Male gender (p < .001) and use of bone cement (p = .019) were associated with radiographic progression, 43.8% overall. Antiresorptive medications usage (p = .02) was associated with survival. The study concluded that tumor origin may be highly important when considering surgical treatment for metastatic bone disease and antiresorptive medications should be used postoperatively, given an association with survival. (Journal of Surgical Orthopaedic Advances 27(3):178-186, 2018).

Ultrasound-guided biopsy of osteolytic metastasis - could be less than three cores enough?

AIMS: The purpose of this study was to analyze the diagnostic yield and accuracy of the ultrasound (US) guided core biopsy in a population of patients with osteolytic metastasis. MATERIALS AND METHODS: We performed a retrospective analysis of 16 consecutive cases of US-guided core biopsies of osteolytic lesions performed in our Ultrasound Unit, from January 2006 to May 2017. We used 18G or 16G Tru-cut needles coupled with automated biopsy guns. We procured a maximum number of two tissue specimens per patient. RESULTS: We obtained a diagnostic yield and accuracy of 93.75% (15 of 16 patients) for US-guided core biopsy of osteolytic metastasis. Most of our cases were metastasis of adenocarcinomas (8 patients), squamous cell carcinomas (3 patients) followed by multiple myelomas (2 patients). Other pathologic lesions recorded were undifferentiated carcinoma (1 patient) and mesenchimal undifferentiated tumor (1 patient). The pathologic result was inconclusive in one patient. CONCLUSIONS: Our study supports the important diagnostic role of US-guided core biopsy for osteolytic bone metastasis. Two US-guided passages may be sufficient to procure a diagnostic tissue samples from osteolytic bone metastasis, if theirlength is at least 10 mm.

Case Report: Metastatic Infratemporal Soft Tissue Myeloma Presenting as a Numb Lower Lip.

This is a case of a patient presenting to his general dental practitioner (GDP) with altered sensation in his lower lip with no obvious cause. Due to a prompt referral, the patient was investigated and diagnosed with an extramedullary presentation of multiple myeloma. A numb lip can present in general dental practice, although this is not common. There are several causes, for example, dental infection or fractured mandible. Clinical relevance: It is very important for the dental practitioner to recognize when there could be a potential sinister underlying cause and prompt referral, under the two week rule referral system, is indicated

Volume-Outcome Relationship in Surgical Interventions for Spinal Metastases.

BACKGROUND: Surgery for spinal metastases is challenging and carries a high risk of perioperative morbidity and mortality. Procedures with such characteristics often exhibit a volume-outcome relationship. This has not been previously characterized for spinal metastasis surgery to our knowledge. METHODS: The Florida State Inpatient Database (2011 through 2014) was queried to identify patients who had undergone surgery for spinal metastases. Surgeon and hospital surgical volumes were compared with 90-day complication and readmission rates to develop procedural cut-points used to define high and low-volume providers. These were included in a multivariable logistic regression analysis that was adjusted for confounders. A separate analysis was performed to evaluate the effect of race/ethnicity and insurance status on the likelihood of receiving care from a high-volume surgeon or hospital. RESULTS: This study included 3,135 patients treated by 1,488 surgeons at 162 hospitals. Patients treated at low-volume hospitals had significantly higher odds of having postoperative complications (odds ratio [OR] = 1.47; 95% confidence interval [CI] = 1.13, 1.91) and readmissions (OR = 1.36; 95% CI = 1.06, 1.75). Those treated by low-volume surgeons also demonstrated a higher likelihood of complications (OR = 1.40; 95% CI = 1.16, 1.69) and readmissions (OR = 1.38; 95% CI = 1.17, 1.62). The likelihood of receiving intervention from a high-volume surgeon was significantly lower for African Americans (OR = 0.55; 95% CI = 0.41, 0.75) and Hispanics (OR = 0.60; 95% CI = 0.44, 0.83). The odds of being treated at a high-volume hospital were also significantly lower for African Americans (OR = 0.58; 95% CI = 0.40, 0.84) and Hispanics (OR = 0.28; 95% CI = 0.20, 0.38). CONCLUSIONS: There is a clear relationship between the volume and outcomes of surgical treatment of spinal metastases, with high-volume providers demonstrating reduced complication and readmission rates. Racial and ethnic minorities appear to experience health-care segregation when it comes to surgical care for spinal metastases. Regionalization of care for these conditions may help improve access to high-volume providers and mitigate disparities in care. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Overall Survival in Spine Myeloma Metastases: Difficulties in Predicting With Prognostic Scores.

STUDY DESIGN: Fifty-one patients with spinal multiple myeloma (MM) metastases were operated and followed between January 2004 and July 2014. OBJECTIVE: The aim of this study was to consider the efficiency of surgical prognosis scores in the management of spinal metastases myelomas. SUMMARY OF BACKGROUND DATA: The spine is the most common site of bone metastases in MM. Surgery in spine metastases MM is a matter of debate and its impact on the increase of a patient's survival time is not clear. Several surgical survival scores have been developed to determine the best treatment in these patients. METHODS: We studied 51 patients operated for spinal MM metastases between January 2004 and July 2014. We determined the Tokuhashi and Tomita survival scores and compared them with documented patient survivals. The two scores were also compared with the International Staging System (ISS). RESULTS: Median survival (MS) was 108 months [standard deviation (SD) 62] for ISS I, 132.2 (SD 40) for ISS II, and 45.5 months (SD 16.3) for ISS III (P = 0.09). According to Tokuhashi survival score, 21 patients (41.2%) will survive <6 months, 6 (11.8%) 6 to 12 months, and 24 (47%) >12 months. According to Tomita et al., 50 patients (98%) will survive >49.9 months and 1 patient (2%) <15 months. Regardless of the ISS grade prognosis, Tokuhashi survival score, and to a lesser extent Tomita score, underestimated the actual survival very significantly [P < 0.0001, Log Rank (Mantel-Cox)]. CONCLUSION: We suggest that spine surgical prognosis scores are not accurate and are not able to predict the survival of patients with spine myeloma metastases. Spine surgeons have to be guided not by the initial ISS stage but rather by spinal instability and neurological status. LEVEL OF EVIDENCE: N/A.

Radial Shaft Reconstruction With an Intercalary Endoprosthesis Following Resection of Metastatic Tumor.

Improvements in imaging and treatment of musculoskeletal tumors have increased the variety of options for reconstruction following joint-sparing diaphyseal resection. The purpose of this case series was to show that reconstruction of malignant tumors of the radial shaft with an intercalary prosthesis may be an option for patients with segmental bone loss. Three consecutive patients underwent wide resection of the radial diaphysis followed by reconstruction with a custom intercalary prosthesis. A custom intercalary prosthesis with lap joint design was used in all 3 cases. Mean follow-up was 18 months (range, 9-25 months). All patients were weight bearing as tolerated 1 week postoperatively. At the most recent follow-up, patients' mean elbow flexion and extension arc was 137° (range, 130°-140°). At the forearm, mean supination was 60° (range, 30°-90°) and mean pronation was 70° (range, 60°-90°). At the wrist, mean palmar flexion was 80° (range, 70°-90°) and mean dorsiflexion was 80° (range, 70°-90°). All patients reported minimal to no pain and no significant functional limitations. Mean Musculoskeletal Tumor Society score was 26/30 (87%). Reconstruction with an intercalary prosthesis is a viable option for patients with metastatic disease of the radial shaft. All patients had satisfactory results and early return to function; none required return to the operating room. Possible advantages of reconstruction with an intercalary prosthesis compared with reconstruction with a bone graft or polymethylmethacrylate osteosynthesis include early return to function and minimal weight-bearing restrictions postoperatively. [Orthopedics. 2017; 40(2):e242-e247.].

A phase II trial of small-dose bortezomib, lenalidomide and dexamethasone (sVRD) as consolidation/maintenance therapy in patients with multiple myeloma.

PURPOSE: Consolidation/maintenance therapy induces deep remission in patients with multiple myeloma (MM); however, the most suitable regimen has been under investigation. The combination therapy with bortezomib, lenalidomide and dexamethasone (VRD) is a powerful regimen for relapsed/refractory as well as newly diagnosed MM as an induction therapy. However, severe adverse events (AEs) may become a problem when VRD is introduced without dose reduction as a consolidation/maintenance therapy. METHODS: In this single-arm phase II study, we evaluated the efficacy of small-dose VRD regimen (sVRD) in the consolidation/maintenance setting. Sixteen patients who had partial response (PR) or better after any induction therapy were enrolled. Patients received at least six 28-day cycles of subcutaneous bortezomib (1.3 mg/m2 on days 1 and 15), lenalidomide (10 mg on days 1-21) and dexamethasone (40 mg on days 1, 8, 15 and 22). RESULTS: The overall response rate and the complete response (CR) rate were 100 and 43.8 %, respectively. In particular, one patient with CR and two patients with very good PR at enrollment achieved stringent CR during 6 courses of sVRD. With a median follow-up time of 29.4 months, the median progression-free survival (PFS) and overall survival (OS) were not reached, while the PFS and OS rates at 2.5 years were 66.6 and 77.3 %, respectively. Univariate analysis demonstrated that disease progression as a reason for discontinuation of sVRD had a negative impact on OS. There were no grade 3 or 4 hematologic or nonhematologic AEs. CONCLUSION: Our sVRD regimen as a consolidation/maintenance therapy was highly effective and well tolerable.

[Hematologic neoplasms with testicular involvement]. / Neoplasias hematológicas con implicación testicular.

OBJECTIVE: We report two cases of patients with a previous diagnosis of hematologic tumor who present with testicular recurrence, and we carry out a review of the literature regarding the infrequency of this pathology. METHODS: We present a retrospective review of the medical records of two patients diagnosed with hematologic malignancies (acute myelogenous leukemia and multiple myeloma) with occurrence of relapse in the testicle. We reviewed the management and outcome after treatment with bilateral orchiectomy. RESULTS: Case 1: The patient was diagnosed with acute myeloid leukemia and treated with an allogeneic transplant. Two years later, the patient reported an increase in testicular size. The complementary studies lead us to suspect a testicular recurrence that was confirmed after orchiectomy. Currently, the patient awaits the start of a chemotherapy treatment prior to a new allogeneic transplant. Case 2: Patient with the diagnosis of multiple myeloma who started a polychemotherapy treatment without response and underwent allogeneic transplant. After five months with complete remission, there were signs of systemic recurrence, and a study for a new transplant was carried out. During the study, potential testicular recurrence was observed. After a batch of complementary tests, bilateral orchiectomy was performed and the diagnosis was confirmed. Currently, the patient is undergoing an allogeneic transplant protocol after radiotherapy and chemotherapy treatment. CONCLUSIONS: Currently the mortality rate in cases of relapse of hematologic malignancy in the testicle has declined despite the sharp rise in its incidence. This is because of, as in our case, early diagnosis and the combined use of chemotherapy, radiotherapy and surgery. This has been achieved through an interdisciplinary collaboration of urologists, hematologists, oncologists and radiotherapists.