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Metastatic Bone Disease and Multiple Myeloma

Metastatic Bone Disease and Multiple Myeloma. 16000122-01. Southwest Spine Institute. Douglas S. Won, MD Spine Surgery Specialist Director of Southwest Spine Institute Clinical Asst. Professor, UT Southwestern Medical School Baylor Spine & Brain Center at Irving

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Metastatic Bone Disease and Multiple Myeloma

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  1. Metastatic Bone Disease and Multiple Myeloma 16000122-01

  2. Southwest Spine Institute • Douglas S. Won, MD • Spine Surgery Specialist • Director of Southwest Spine Institute • Clinical Asst. Professor, UT Southwestern Medical School • Baylor Spine & Brain Center at Irving • Irving Native, Graduate of MacArthur High

  3. Metastases to Bone Metastatic bone carcinoma • Originates from other cancers, such as breast, prostate, lung, renal cell, etc.. and spreads to bone • Metastatic cancer causes skeletal complications every 3-4 months1 1 Janjan, N. (2001). "Bone Metastases: Approaches to Management." Seminars in Oncology28(4): 28-34.

  4. Metastasis • Cancer typically spreads to1:. • Lymphatic system • Lungs • Liver • Skeleton2 • Vertebrae 75% • Pelvis 40% • Femur 25% 1 Levesque, J et al.. A Clinical Guide to Primary Bone Tumors. Baltimore: Williams & Wilkins; 1988. 2 Kleerekoper, M et al. (eds.) The Bone and Mineral Manual: A Practical Guide. Academic Press; 1999.

  5. Classifications • Osteoblastic lesions • Increase bone density • Do not change bone strength • Decrease bone stiffness • Characterized by increased bone formation • Example: • Metastatic osteoblastic carcinoma

  6. Metastatic Osteoblastic Carcinoma

  7. Classifications • Osteolytic lesions - Decrease both bone strength and stiffness - Characterized by increased bone resorption, causing swiss cheese type lesions on bone • Examples: - Multiple Myeloma - Metastatic osteolytic carcinoma

  8. Metastatic Osteolytic Carcinoma

  9. Metastases to Bone • Cancers that frequently metastasize to the skeleton include1: • Breast cancer • 75% of cases • 65% of the lesions are lytic2 • Lung cancer • 35% of cases • 80% of the lesions are lytic2 • Kidney cancer • 25% of cases • 1 Kleerekoper, M. et al (eds.) The Bone and Mineral Manual: A Practical Guide. Academic Press; 1999. • 2 Mirra, J. Bone Tumors: Clinical, Radiologic, and Pathologic Correlations. Philadelphia: Lea & Febiger; 1989.

  10. Metastases to the Vertebrae • > 70% of patients who die from cancer have vertebral metastases1 • Lytic destruction of the anterior portion of the vertebral body1 • Lytic lesions are associated with higher fracture risk • Metastatic bone disease is painful2 • Up to 2/3 of patients experience severe pain and disability 1 Harrington, K. (1986). Journal of Bone and Joint Surgery68-A(7): 1110-1115. 2 Janjan, N. (2001). Seminars in Oncology28(4): 28-34.

  11. Fracture Risk • Osteolytic lesions = higher fracture rate • Fracture probability increases with the duration of metastatic involvement1 • Certain cancers almost always metastasize with osteolytic lesions2 • Coleman, R. (2001). Cancer Treatment Reviews27: 165-176. • 2 Mirra, J. Bone Tumors: Clinical, Radiologic, and Pathologic Correlations. Philadelphia: Lea & Febiger; 1989.

  12. Biomechanics of Pathologic Spine Fractures • Center of gravity (CG) moves forward • Large bending moment created • Posterior muscles and ligaments must counterbalance increased bending • Anterior spine must resist larger compressive stresses CG White III and Panjabi 1990

  13. Radiation Therapy • May leave bone unstable • Radiation may increase risk of fracture1 • Up to 41% of patients who undergo radiation experience bone fractures • Cannot correct an anatomic abnormality such as a fracture2 • 1 Patel, B. and H. DeGroot III (2001). Orthopedics24(6): 612-7. • 2 Janjan, N. (2001). Seminars in Oncology28(4): 28-34.

  14. Fracture Treatment • Pain is due to spinal instability • radiotherapy or systemic treatment will not relieve the pain1 • Stabilization is required for pain relief1 • Spinal cord involvement and neurologic deficit possible if not stabilized2 • Coleman, R. (2001). Cancer Treatment Reviews27: 165-176. • 2 Harrington, K. (1986). Journal of Bone and Joint Surgery68-A(7): 1110-1115.

  15. Multiple Myeloma Myeloma cells Picture courtesy of the International Myeloma Foundation

  16. Multiple Myeloma • Cancer of the bone marrow • 75,000 – 100,000 patients in the US at any one time • Over 13,500 new cases diagnosed each year in the US • Male to female ratio is 3:2 • Trend towards patients under the age of 55 From “Multiple Myeloma: Cancer of the Bone Marrow.” International Myeloma Foundation, 2001 edition.

  17. Multiple Myeloma • Disruption of bone marrow function • Suppression of immune function • Osteoclasts activated • Osteoblasts inhibited • Hallmark is osteolytic lesions Picture courtesy of the International Myeloma Foundation

  18. Common Sites for Bone Involvement • Skull • Spine • Pelvis • Long bones Picture courtesy of the International Myeloma Foundation

  19. T-10 fracture due to multiple myeloma Photo courtesy of Steve James, M.D.

  20. T2 weighted MRI showing myeloma related fracture at L3 and L4

  21. Vertebral BodyCompressionFractureTreatment Options 16000040-02

  22. ORTHOPEDIC FRACTURE CARE Why have we been content to leave the spine in a physiologically and biomechanically compromised condition?

  23. Fracture Treatment Objectives Four AO principles1 • Fracture reduction and fixation to restore anatomical relationships • Stability by fixation or splintage, as the nature of the fracture and the injury requires • Preservation of blood supply to soft tissues and bone by careful handling and gentle reduction techniques • Early and safe mobilization of the part and the patient *Arbeitsgemeinschaft Osteosynthesefragen (English translation: Association for the Study of Internal Fixation - ASIF) 1 Ruedi & Murphy, AO Principles of Fracture Management, Thieme, Stuttgart, New York, 2000

  24. Vertebral Body Compression Fracture (VCF) Depressed endplate(s) Spine shorter, tilted forward Wedge- shaped Normal Fractured

  25. Aug 31, 2000 Sept 3, 2000 Deformity Progression 16º kyphosis 25º kyphosis Lieberman et al., Spine 2001

  26. VCF Treatment Options Medical Management • Treatment Protocol • Bed rest • Narcotic analgesics • Braces • Shortcomings • May fail to relieve pain • Does not provide long-term functional improvement • May exacerbate bone loss • Does not attempt to restore the anatomy

  27. VCF Treatment Options Open Surgical Treatment • Indication • Only if neurologic deficit (very rare, only 0.05%) • Instrumented fusion, anterior or posterior • Shortcomings • Invasive • Poor outcomes in osteopenic bone

  28. VCF Treatment Options Vertebroplasty • Designed to stabilize painful VCFs • Shortcomings • Risk of filler leaks (27-74% reported1,2,4,5,6,7,8,9,10) • High pressure injection • Uncontrolled fill • High complication rate (1-20% reported3,4,5) • Freezes spinal deformity • Does not reduce fracture or restore anatomy • Not designed to reposition bone • 1 Cortet et al., J Rheum 1999 5 Jensen et al., AJNR 1997 8 Grados et al., Rheumatology 2000 • 2 Alvarez et al., Eurospine 2001 6 Cotten et al. Radiology 1996 9 Peh et al., Radiology 2002 • 3Padovani et al., AJNR 1997 7 Gaughen et al., AJNR 2002 10 Ryu et al., J Neurosurgery 2002 • 4 Weill et al., Radiology 1996

  29. Why Fracture Reduction? • What is orthopedic reduction? • The restoration, by surgical or manipulative procedures, of a part to its normal anatomical relation1 • What is the goal? • To produce optimal outcomes with early diagnosis and treatment2 • To accommodate the frail physical status and co-morbidities of geriatric patients2 1 Stedman’s Concise Medical Dictionary. 1997. Williams and Wilkins. 2 Brakoniecki, Anesthetic Management of the Trauma Patient with Skeletal Injuries, Skeletal Trauma, W.B. Saunders Company, 1998, 1:7:171-172

  30. New VCF Treatment Option Minimally Invasive Fracture Reduction

  31. Minimally Invasive Fracture Reduction • KyphX® Inflatable Bone Tamp (IBT) For use as a conventional bone tamp for the reduction of fractures and/or creation of a void in cancellous bone in the spine, hand, tibia, radius and calcaneus.

  32. KyphX® Introducer Tool Kit Allows precise, minimally invasive access to the vertebral body and provides a working channel

  33. KyphX® IBT Inflation Reduces the fracture, compacts the bone, and may elevate the endplates

  34. KyphX® IBT Removal Leaves a defined cavity within the vertebral body

  35. Minimally Invasive Fracture ReductionClinical Experience • Over 3 years of orthopedic fracture reduction • As of June 30, 2002 • Fractures reduced > 22,000 • Patients > 17,000

  36. Minimally Invasive Fracture Reduction KyphX® Inflatable Bone Tamp has been developed for patients with symptomatic VCFs

  37. Possible causes of VCFs • Primary osteoporosis • Secondary osteoporosis • Drug-induced (corticosteroids, tobacco, barbituates, heparin) • Endocrine (hyperparathyroidism, diabetes) • Miscellaneous (renal failure, COPD, rheumatoid arthritits, hepatic disease or transplant) Merck Manual, 16th ed., 1992

  38. Possible causes of VCFs • Osteolytic lesions • Multiple Myeloma • Bone metastases • Paget’s disease • Trauma • ½ of all trauma cases are misclassified

  39. Summary • The general goal for fracture treatment is restoration of anatomy and early return to function • Conventional therapy not always effective • KyphX® IBT is a new option for VCFs designed to: • reduce the fracture • move cancellous bone (elevate endplates) • create void inside vertebral body • As with hip fracture surgery, early diagnosis and intervention are important for fracture reduction

  40. Case Study Patient: 55 YO MaleDiagnosis: Multiple Myeloma Fracture Reduced: L-1, 3 day old

  41. Case Study Patient: 61 YO Female Diagnosis: Multiple MyelomaFracture Reduced: T11-L2, 1 ½ yrs old

  42. Case Study Patient: 61 YO MaleDiagnosis: Multiple MyelomaFracture Reduced: T-11, 5 weeks o

  43. Southwest Spine Institute • 2120 N. MacArthur Blvd Irving • 2200 Morriss Rd. #100 Flower Mound • 200 Pecan Creek Dr., Southlake • www.SwSpineInst.com 972-438-4636

  44. Thank you!

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