1 / 44

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

ban
Download Presentation

Metastatic Bone Disease and Multiple Myeloma

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  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!

More Related