The Management of Spinal Cord Compression in Multiple Myeloma

Review Article

Ann Hematol Oncol. 2016; 3(5): 1090.

The Management of Spinal Cord Compression in Multiple Myeloma

Sen E¹ and Yavas G²*

¹Department of Medical Oncology, Selcuk University, Turkey

²Department of Radiation Oncology, Selcuk University, Turkey

*Corresponding author: Güler Yavas, Department of Radiation Oncology, Selcuk University, Faculty of Medicine, Konya, Turkey

Received: May 13, 2016; Accepted: July 09, 2016; Published: July 12, 2016

Abstract

Multiple myeloma (MM) is a hematopoietic disorder which is characterized by accumulation of monoclonal plasma cells with the most common localization being the spine. Spinal cord compression (SCC) occurs approximately 5% of patients with the diagnosis of MM. Signs and symptoms of SCC include pain, motor defects, sensory deficits; and bowel and bladder dysfunction. Magnetic resonance imaging or computed tomographic myelography of the entire spine must be performed immediately if this complication is suspected. Prompt diagnosis and immediate treatment are critically important in the preservation of neurological function in patients with SCC. The goals of treatment for patients with SCC are pain control, avoidance of complications from local disease progression, and the preservation or improvement of neurologic functioning. The choice of definitive treatment must be appropriate to the patient’s burden of disease, life expectancy, and values. For patients with SCC and either neurologic symptoms or substantial the cal sac compression by imaging, corticosteroids should be an integral component of the initial management. The choice of modality for definitive treatment depends on many factors, including the presence of absence of spinal instability, the degree of spinal cord compression, and the relative radio sensitivity of the tumor. Surgery and radiotherapy are the primary approaches to treat tumor compressing the spinal cord. Systemic therapy such as chemotherapy agents with steroids and either proteasome inhibitors or immunomodulatory drugs, with or without high-dose chemotherapy and stem cell transplantation work rapidly and can be used instead of radiation in selected patients if there is minimal neurologic deficit.

Keywords: Multiple myeloma; Radiation therapy; Spinal cord compression; Surgery

Abbreviations

BKP: Balloon kyphoplasty; CT: Computed Tomography; EBRT: External Beam Radiotherapy; MM: Multiple Myeloma; MBD: Myeloma Bone Disease; MRI: Magnetic Resonance Imaging; PV: Percutaneous Vertebroplasty; RT: Radiation Therapy; SCC: Spinal Cord Compression; SMD: Spinal Myeloma Disease; SINS: Spine Instability Neoplastic Score; SBRT: Stereotactic Body Radiotherapy

Introduction

Multiple myeloma (MM) is a hematological malignancy characterized by accumulation of monoclonal plasma cells. It accounts for approximately 1 % of all cancers and represents about 10 % of all hematological malignancies [1]. The annual incidence is 4.3 per 100,000 [2]. The American Cancer Society estimates that 26,850 new cases of MM will be diagnosed in the US in 2015 [3]. MM is slightly more common in males than females [4]. The median age at diagnosis is 66 years. Only 2% of patients are younger than 40 years of age [5]. MM is an almost incurable disease. Current advances have led to increased survival [6], although this is still much shorter than for other mature B-cell malignancies, such as follicular lymphoma and chronic lymphocytic leukemia [7].This discrepancy may be due to the development of myeloma bone disease (MBD), which affects approximately 60% of patients rising to 80-90% at some stage of their disease [8]. Typically, the disease involves the bone marrow and breaks through the cortex, invading the surrounding tissue. MBDassociated morbidities include pain, pathological fractures, spinal cord compression and hypercalcemia [7-9].

The spine is the most affected skeletal organ, and single or multiple spinal lesions are due to bone destruction caused by MM. Spinal myeloma disease (SMD) is present in up to 60% of patients at diagnosis which may or may not be symptomatic [5]. SMD is most commonly indicated by the presence of lytic lesions or generalized osteopenia. Most lesions occur in the vertebral bodies but they can also be found in other parts of the vertebral columna including the facets, pedicles and transverse/spinous processes [10]. Affected vertebral bodies may become weakened with progressive bone destruction and eventually collapse, resulting in a vertebral compression fracture. Vertebral compression fractures are causing spinal injury. Spinal cord compression can also result from direct extension of tumor into the epidural space.

The spinal cord compression (SCC), which is an oncologic emergency that can cause pain and potential paralysis, occurring in approximately %5 of all patients with myeloma often leads to disability and a profound impact on prognosis, even if myeloma is otherwise contained [5, 11]. MM with spinal involvement may represent with spinal cord or cauda equine compression, with or without neurological impairment. Signs and symptoms of SCC include pain (83–95%), motor defects (60–85%), sensory deficits (40–90%); and bowel and bladder dysfunction. Back pain is typically the first symptom. Weakness is the most apparent and problematic manifestation of SCC. Sensory deficits are less common. Bowel and bladder dysfunction tend to occur late and typically match the degree of weakness [12]. Magnetic resonance imaging (MRI) or computed tomographic (CT) myelography of the entire spine must be performed immediately if this complication is suspected. This review aims to summarize recent development in the treatment of SCC in patients with MM.

Management of spinal cord compression in multiple myeloma

Prompt diagnosis and immediate treatment are critically important in the preservation of neurological function in patients with SCC. Treatment and management of spinal myeloma disease requires a multidisciplinary approach. The goal of the treatment of the SCC is adequate control of pain; relief of spinal cord or cauda equina compression and maintenance of spinal stability; preserving or improving neurologic functions. Management of patients with SCC includes the immediate administration of glucocorticoids in nearly all patients, followed by surgery, external beam radiation therapy (EBRT), or stereotactic body radiotherapy (SBRT). Systemic therapy may be beneficial in patients with chemosensitive tumors. In patients with neurologic symptoms directly due to cord compression, radiation therapy (RT) is given along with dexamethasone, and up to half of patients may have improvement of motor function with RT with longer fractionation schedules providing better relief [13]. Systemic therapy with regimens such as bortezomib, cyclophosphamide, dexamethasone or bortezomib, thalidomide, dexamethasone work rapidly and can be used instead of radiation in selected patients if there is minimal neurologic deficit. Surgical decompression is necessary only if the neurologic deficit does not improve or if the compression is due to retropulsed bone.

Symptomatic treatment

Symptomatic treatment of SCC often begins prior to definitive therapy and consists of the pain management, bed-rest and anticoagulation [14]: Patients with SCC have frequently a severe pain, often limiting the ability to perform a thorough neurologic examination. Corticosteroids usually improve the pain within several hours, but most patients require opiate analgesics to tolerate the physical examination and necessary diagnostic studies. There is generally no need to confine the patient to bed. Patients are generally quite adept at avoiding maneuvers that trigger their pain and there is no risk that movement will worsen the neurologic status. Many patients with cancer are in a hypercoagulable state. Although the value of prophylaxis against venous thromboembolism has not been studied specifically in patients with SCC, anticoagulation (i.e., unfractionated heparin, low molecular weight heparin, fondaparinux) should be considered if the patient is immobilized due to the SCC and there is no active bleeding or other contraindications to the use of anticoagulants [14]. If surgery is planned in the immediate future, anticoagulation should be withheld. If there are contraindications to the use of anticoagulants, such patients should be treated with mechanical prophylaxis, such as pneumatic venous compression devices or graduated compression stockings.

Corticosteroids

The beneficial actions of glucocorticoids in restoring neurologic function in patients with SCC were first reported in the late 1960s. After this, several preclinical and clinical studies investigated the effect of steroids in SCC. Sorensen and colleagues studied the effect of corticosteroids in patients with SCC [15]. The authors randomly assigned 57 patients with carcinoma (two-thirds with a primary in the breast) to receive either dexamethasone (96 mg intravenously followed by 24 mg four times daily for three days and then tapered over 10 days) or no dexamethasone. Their results suggested that a significantly higher percentage of patients in the dexamethasone group remained ambulatory both at the conclusion of therapy (81% versus 63%) and at six months (59% versus 33 %). Significant side effects were seen in three patients (11 percent in the steroid group. In meta-analyses it was concluded that there is insufficient evidence as to the role of corticosteroids and the appropriate initial dose [16].

Corticosteroids relieve pain management, reduce vasogenic cord edema and may prevent additional damage to the spinal cord from decreased perfusion. Therefore high-dose corticosteroid therapy (Initial bolus of 100 mg followed by 96 mg divided into four doses for 3 days) is generally considered to be part of the standard regimen for SCC, despite limited documented evidence of benefit and a significant risk of serious side effects [17]. Several studies have suggested that lower doses can be effective but they have not been assessed in randomized trials. Long-term use is not recommended because of the potential to cause further osteopenia and other steroidrelated adverse effects.

Pain management

Pain is the most common symptom of spinal involvement with myeloma and treatment is aimed at alleviating it as much as possible to preserve quality of life. Patients with SCC are frequently in severe pain, often limiting the ability to perform a thorough neurologic examination. Glucocorticoids usually improve the pain within several hours, but most patients require opiate analgesics to tolerate the physical examination and necessary diagnostic studies. Opioids are the most commonly used analgesics but they may cause significant adverse effects that can reduce quality of life, especially in older patients [18]. Patients with persistent severe pain requiring highdose opioid pain relief should be referred to the palliative pain care specialist [19].

Bisphosphonates

The aim of bisphosphonate treatment is to slow down or prevent the progression of bone destruction and, in the process, can help alleviate bone pain and reduce the risk of skeletal fractures. Zoledronic acid or pamidronate are used for myeloma bone disease. Currently, there is no consensus regarding the optimal duration of bisphosphonate treatment [10]. The monoclonal antireceptor activator of nuclear factor kapa-B ligand (RANKL) antibody denosumab was found to be no inferior to zoledronic acid in preventing or delaying first on study SRE in patients with metastatic to bone or myeloma [20].

Systemic chemotherapy

Patients with a chemosensitive malignancy, chemotherapy are an attractive option because it can also treat tumor deposits elsewhere in the body. Targeting the myeloma cells, anti-myeloma treatments can disrupt the interaction with the bone microenvironment, thus inhibiting the osteoclastogenic effect. Treatment for myeloma is based around various anti-myeloma regimens combining chemotherapy agents with steroids and either proteasome inhibitors or immunomodulatory drugs, with or without high-dose chemotherapy and stem cell transplantation [10, 21]. Systemic therapy with regimens such as bortezomib, cyclophosphamide, dexamethasone (VCD) or bortezomib, thalidomide, dexamethasone (VTD) work rapidly and can be used instead of radiation in selected patients if there is minimal neurologic deficit [14]. Conventional treatment of the myeloma is effective in reducing spinal pain and the risk of further damage. It is not effective in treating spinal fracture pain.

Spinal treatment

The choice of modality for definitive treatment depends on many factors, including the presence of absence of spinal instability, the degree of spinal cord compression, and the relative radio sensitivity of the tumor. An algorithmic approach to treatment based upon these factors is available (Figure 1). An important component of the decision making process when considering definitive therapy is assessment of spinal stability. Treatment of a SCC differs in those patients whose spine is unstable compared to those with a stable spine. Pain from an unstable spine will not be relieved with RT, and there is a lack of evidence on whether spinal bracing is an effective technique for reducing pain [22]. Thus, an unstable spine must be stabilized either by surgery with fixation [23] or by percutaneous vertebral repair [24].