PKP/PVP combine chemotherapy in the treatment of multiple myeloma patients with vertebral pathological fractures: minimum 3-year follow-up of 108 cases

Appropriate use criteria for neoplastic compression fractures

BACKGROUND CONTEXT

Clinical outcomes are directly related to patient selection and treatment indications for improved quality of life. With emphasis on quality and value, it is essential that treatment recommendations are optimized.

PURPOSE

The purpose of the North American Spine Society (NASS) Appropriate Use Criteria (AUC) is to determine the appropriate (ie, reasonable) multidisciplinary treatment recommendations for patients with metastatic neoplastic vertebral fractures across a spectrum of more common clinical scenarios.

STUDY DESIGN

A Modified Delphi process.

PATIENT SAMPLE

Systematic Review OUTCOME MEASURES: Final rating for cervical fusion recommendation as either "Appropriate," "Uncertain," or "Rarely Appropriate" based on the median final rating among the raters.

METHODS

The methodology was based on the AUC development process established by the Research AND Development (RAND) Corporation. The topic of neoplastic vertebral fracture was selected by NASS for its Clinical Practice Guideline development (CPG). In conjunction, the AUC work group determined key modifiers and adopted the standard definitions developed by CPG, with minimal modifications. A literature search and evidence analysis performed by the CPG were reviewed by the AUC work group. A separate multidisciplinary rating group was assembled. Based on the literature, provider experience, and group discussion, each scenario was scored on a 9-point scale on 2 separate occasions, once without discussion and then a second time following discussion based on the initial responses. The median rating for each scenario was then used to determine if indications were rarely appropriate (1-3), uncertain / maybe appropriate (4-6), or appropriate (7-9). Consensus was not mandatory.

RESULTS

Medical management was essentially always appropriate. Radiation therapy was appropriate 50% of the time and uncertain otherwise, and directly related to radiosensitivity of the tumor. Ablation was never rated appropriate with agreement, and about 50% of the time was rated as uncertain. For cement augmentation, the scenarios without stenosis or neurological changes, stable fractures with less than 80% height loss and intact posterior wall, and higher VAS pain scores accounted for 88% probability of an appropriate rating. Otherwise, cement augmentation was uncertain 68% of the time. Surgery was rated as appropriate with agreement in 35%, and uncertain or appropriate with disagreement in 59% of scenarios. The most important variables determining final rating for surgery (in order) were stability, spinal stenosis, and prognosis.

CONCLUSIONS

Multidisciplinary appropriate treatment criteria were generated based on the RAND methodology. Recommendations were made for medical treatment, ablation, radiation, cement augmentation, and surgery based on 432 practical clinical scenarios. This document provides comprehensive evidence-based recommendations for evaluation and treatment of metastatic neoplastic vertebral fractures. The document in its entirety will be found on the NASS website (https://www.spine.org/Research-Clinical-Care/Quality-Improvement/Appropriate-Use-Criteria).

Risk factors for the outcome and prognosis of multiple myeloma patients with pathological fractures undergoing percutaneous vertebroplasty

This study focuses on the clinical features affecting the outcome and prognosis of multiple myeloma (MM) associated with spinal fractures. We retrospectively analyzed the clinical data of 194 MM patients with pathologic thoracic or lumbar spine fractures admitted to Dongying People's Hospital from April 2005 to February 2021. Patients were categorized into effective and ineffective groups based on post-treatment pain scores and mobility to analyze the influencing factors on the efficacy. Univariate analysis showed that age ≥60 years, number of vertebral fractures ≥2, and conservative treatment were associated with the outcomes. The number of vertebral fractures ≥2 (OR=2.198, P=0.034) and conservative treatment (OR=1.685, P=0.012) were identified as independent risk factors. In addition, survival curves were depicted using the Kaplan-Meier method, and independent risk factors affecting 2-year survival included efficacy (HR=17.924, P<0.001), age (HR=3.544, P=0.003) and International Staging System staging (HR=10.770, P=0.001). Finally, we constructed a high-accuracy prognostic model for predicting 2-year survival of MM patients with pathologic fractures (AUC=0.756). In conclusion, this study identified independent risk factors affecting the outcome and survival of MM patients with morbid fractures by systematically analyzing clinical characteristics and constructing a survival prediction model, thus providing effective guideline for clinical treatment.

New Research Progress of Modified Bone Cement Applied to Vertebroplasty

Percutaneous vertebroplasty and percutaneous kyphoplasty are effective methods to treat acute osteoporotic vertebral compression fractures that can quickly provide patients with pain relief, prevent further height loss of the vertebral body, and help correct kyphosis. Many clinical studies have investigated the characteristics of bone cement. Bone cement is a biomaterial injected into the vertebral body that must have good biocompatibility and biosafety. The optimization of the characteristics of bone cement has become of great interest. Bone cement can be mainly divided into 3 types: polymethyl methacrylate, calcium phosphate cement, and calcium sulfate cement. Each type of cement has its own advantages and disadvantages. In the past 10 years, the performance of bone cement has been greatly improved via different methods. The aim of our review is to provide an overview of the current progress in the types of modified bone cement and summarize the key clinical findings.

Risk-benefit ratio of percutaneous kyphoplasty and percutaneous vertebroplasty in patients with newly diagnosed multiple myeloma with vertebral fracture: a single-center retrospective study

The indications for percutaneous kyphoplasty (PKP) and percutaneous vertebroplasty (PVP) are painful vertebral compression fractures. Our study is to assess the risk-benefit ratio of PKP/PVP surgery in the patients with newly diagnosed multiple myeloma (NDMM) without receiving antimyeloma therapy. The clinical data of 426 consecutive patients with NDMM admitted to our center from February 2012 to April 2022 were retrospectively analyzed. The baseline data, postoperative pain relief, the proportion of recurrent vertebral fractures, and survival time were compared between the PKP/PVP surgical group and the nonsurgical group in the NDMM patients. Of the 426 patients with NDMM, 206 patients had vertebral fractures (206/426, 48.4%). Of these, 32 (32/206, 15.5%) underwent PKP/PVP surgery for misdiagnosis of simple osteoporosis prior to diagnosis of MM (surgical group), and the other 174 (174/206, 84.5%) did not undergo surgical treatment prior to definitive diagnosis of MM (non-surgical group). The median age of patients in the surgical and nonsurgical groups was 66 and 62 years, respectively (p = 0.01). The proportion of patients with advanced ISS and RISS stages was higher in the surgical group (ISS stage II + III 96.9% vs. 71.8%, p = 0.03; RISS stage III 96.9% vs. 71%, p = 0.01). Postoperatively, 10 patients (31.3%) never experienced pain relief and 20 patients (62.5%) experienced short-term pain relief with a median duration of relief of 2.6 months (0.2-24.1 months). Postoperative fractures of vertebrae other than the surgical site occurred in 24 patients (75%) in the surgical group, with a median time of 4.4 months postoperatively (0.4-86.8 months). Vertebral fractures other than the fracture site at the first visit occurred in 5 patients (2.9%) in the nonoperative group at the time of diagnosis of MM, with a median time of 11.9 months after the first visit (3.5-12.6 months). The incidence of secondary fractures was significantly higher in the surgical group than in the nonsurgical group (75% vs. 2.9%, p = 0.001). The time interval between the first visit and definitive diagnosis of MM was longer in the surgical group than in the nonsurgical group (6.1 months vs. 1.6 months, p = 0.01). At a median follow-up of 32 months (0.3-123 months), median overall survival (OS) was significantly shorter in the surgical group than in the nonsurgical group (48.2 months vs. 66 months, p = 0.04). Application of PKP/PVP surgery for pain relief in NDMM patients without antimyeloma therapy has a limited effect and a high risk of new vertebral fractures after surgery. Therefore, patients with NDMM may need to have their disease controlled with antimyeloma therapy prior to any consideration for PKP/PVP surgery.

Significance of preoperative peripheral blood neutrophil-lymphocyte ratio in predicting postoperative survival in patients with multiple myeloma bone disease

BACKGROUND

The neutrophil-lymphocyte ratio (NLR) is often used to predict a poor prognosis in patients with tumors. This study investigated the preoperative peripheral blood NLR in predicting postoperative survival (POS) in patients with multiple myeloma bone disease (MMBD).

AIM

To evaluate whether NLR can be used to predict the prognosis of MMBD patients after surgery.

METHODS

The clinical data of 82 MMBD patients who underwent surgical treatments in Beijing Chao-yang Hospital were collected. The NLR was obtained from the absolute number of neutrophils and lymphocytes, calculated by the number of neutrophils and divided by the number of lymphocytes. The peripheral blood lymphocyte percentage was used as the major marker to analyze the change in characteristics of the immune statuses of multiple myeloma patients.

RESULTS

The NLR cut-off values of NLR ≥ 3 patients and NLR ≥ 4 patients were significantly correlated with POS. The 3- and 5-year cumulative survival rates of the high NLR group (NLR ≥ 3 patients) were 19.1% and 0.0%, respectively, which were lower than those of the low NLR group (NLR < 3 patients) (67.2% and 48.3%) (P = 0.000). In the high NLR group, POS (14.86 ± 14.28) was significantly shorter than that in the low NLR group (32.68 ± 21.76). Univariate analysis showed that the lymphocyte percentage 1 wk after the operation (19.33 ± 9.08) was significantly lower than that before the operation (25.72 ± 11.02). Survival analysis showed that postoperative chemotherapy, preoperative performance status and preoperative peripheral blood NLR ≥ 3 were independent risk factors for POS.

CONCLUSION

The preoperative peripheral blood NLR can predict POS in MMBD patients. MMBD patients with a high preoperative NLR (NLR ≥ 3) showed poor prognosis.

Simultaneous C-arm Computed Tomography-Guided Microwave Ablation and Cementoplasty in Patients with Painful Osteolytic Bone Metastases: A Single-center Experience

PURPOSE

To evaluate the clinical benefit of simultaneous percutaneous microwave ablation (PMA) and percutaneous cementoplasty (PC) for patients with painful osteolytic bone metastases under flat-detector C-arm computed tomography (CACT).

METHODS AND MATERIALS

Thirty patients (17 men and 13 women) with 42 osteolytic metastatic tumors were prospectively treated with PMA and PC simultaneously under CACT guidance. Technical success, major complications, local tumor control status, and daily morphine consumption were recorded. Visual analog scale, Oswestry disability index, and the short-form 36 questionnaire (SF-36, 8 domains) were used to evaluate pain, functional status, and quality of life (QoL), respectively.

RESULTS

The technical success rate was 100% without major complications, and local tumor control rates were 100% and 75% for lesion diameter ≤3 cm and >3 cm, respectively. Daily morphine consumption, visual analog scale, and Oswestry disability index improved significantly from the respective pretreatment values of 75 mg, 7.4, and 59.2 to 17.3 mg, 1.7, and 22.9 at 1 week; 8.5 mg, 1.4, and 6.7 at 4 weeks; and 5.3 mg, 1.3, and 9.2 at 12 weeks, respectively (p< 0.01). The QoL assessments at 4 weeks showed significant improvements in physical function, role physical, bodily pain, general health and vitality (p < 0.05).

CONCLUSION

Simultaneous PMA and PC under CACT guidance is effective to control pain and improve QoL in selective patients with painful osteolytic bone metastases.

Clinical efficacy and safety of bone cement combined with radiofrequency ablation in the treatment of spinal metastases

Background

To investigate the clinical efficacy and safety of bone cement combined with radiofrequency ablation (RFA) in the treatment of spinal metastases.

Methods

The medical records of patients with spinal metastatic tumor admitted to our hospital from January 2016 to December 2018 were retrospectively analyzed. Based on different surgical methods, the patients were divided into groups A (treated with RFA combined with bone cement) and B (treated with bone cement only). Group A included 35 patients with 47 segments of diseased vertebral bodies. Group B consisted of 52 patients with 78 vertebral segments. Pain, quality of life score, vertebra height, bone cement leakage, postoperative tumor recurrence, and complications were assessed 3 days and 1 and 6 months after surgery.

Results

All the patients had smooth operation without paraplegia, spinal cord injury, and perioperative death. Visual analogue scales (VAS) and Oswestry Disability Index (ODI) scores of the two groups significantly improved 3 days and 1 month after surgery compared with those before surgery (P < 0.05), but no significant difference was observed between the two groups (P > 0.05). Six months after surgery, the VAS and ODI scores of patients in group A were lower than those in group B, with statistically significant differences (P < 0.05). The postoperative vertebral body height of the two groups significantly increased compared with that before surgery, and the difference was statistically significant (P < 0.05). Meanwhile, no significant difference was observed between the two groups (P > 0.05). Postoperative bone cement permeability in group A was 6.4%, and postoperative tumor recurrence rate was 11.4%. The permeability of bone cement in group B was 20.5%, and the tumor recurrence rate was 30.8%. The bone cement permeability and tumor recurrence rate in group A were lower than those in group B, with statistically significant differences (P < 0.05).

Conclusions

Bone cement combined with RFA for the treatment of spinal metastases can achieve good efficacy, desirable analgesic effect, low incidence of complications, small surgical trauma, and high safety. The proposed method has the value of clinical popularization and application.

Percutaneous balloon kyphoplasty for the vertebral compression osteoporotic and pathological fracture: one-year retrospective study of 112 patients

AIM

The aim of the study was to look for the effectiveness of percutaneous balloon kyphoplasty in the management of vertebral compression osteoporotic and pathological fracture.

METHODS

A retrospective analysis of 112 patients with 198 symptomatic wedge vertebral compression fractures who were treated by percutaneous balloon kyphoplasty was done. Visual Analogue pain (VAP) scale, Oswestry Disability index (ODI) and Short Form (SF-36) were used to look for the outcome.

RESULTS

Pre-operative median VAS score was (8.0, IQR 2.0) which decreased to (4.0, IQR 3.0) at 12 months. Pre-operative median ODI score was (66, IQR 22) which at 12 months follow up decreased to (28, IQR 31). Short-form 36 showed improvement in all quality of life sub-domains. The physical component summary (PCS) improved from 33.0 ± 5.0 to 37.4 ± 6.1. The Mental component summary (MCS) improved from 17.1 ± 8.6 to 23.5 ± 18.9. The results were statistically significant (p < 0.001).

CONCLUSION

Percutaneous balloon kyphoplasty alleviates pain and improves function, disability, and quality of life in osteoporotic and pathological fracture.