Multiple Myeloma (Part 2) - Update on The Approach to Bone Disease

Guedes, Alex; Becker, Ricardo Gehrke; Teixeira, Luiz Eduardo Moreira

doi:10.1055/s-0043-1770150

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Update Article • Rev Bras Ortop 58 (3) • May-Jun 2023 • https://doi.org/10.1055/s-0043-1770150 copy

Multiple Myeloma (Part 2) - Update on The Approach to Bone Disease

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

The increase in life expectancy of the world population has led to a concomitant increase in the prevalence of multiple myeloma (MM), a disease that usually affects the elderly population. Bone lesions are frequent in patients with this condition, demanding an early approach, from drug treatment, through radiotherapy to orthopedic surgery (prophylactic or therapeutic) with the objective of preventing or delaying the occurrence of fracture, or, when this event has already occurred, treat it through stabilization or replacement (lesions located in the appendicular skeleton) and/or promote stabilization and spinal cord decompression (lesions located in the axial skeleton), providing rapid pain relief, return to ambulation and resocialization, returning quality of life to patients. The aim of this review isto update the reader on the findings of pathophysiology, clinical, laboratory and imaging, differential diagnosis and therapeutic approach of multiple myeloma multiple myeloma bone disease (MMBD).

Diphosphonates; Fractures Spontaneous; Multiple myeloma; Prophylactic Surgical procedures; Orthopedic procedures; Radiotherapy

Imaging Examination	Advantages	Disadvantages
Whole-body radiographs	Cost; readily available; detects skull and limb injuries -findings consist of punch injuries, osteoporosis, or fractures in 75% of patients.	Low sensitivity and positivity; detects lesions only after apparent bone destruction (30 to 50% bone loss); discomfort due to positioning and repetitive exams; the image collection process is slow.
Whole-body low-dose CT	High sensitivity and positivity; allows aspiration biopsy and surgery guided by 3D images; defines radiotherapy planning; demonstrates the measurement of extrame-dullary lesions, detects bone marrow invasion and osteolysis; allows to evaluate the tumor load; data collection is fast; lower cost than MRI or PET-CT; little discomfort for the patient.	Cost; may miss skull and costal arch injuries; difficult determination of the number of injuries; when lytic bone lesions are not identified, the negative predictive value is low (59%), not excluding the diagnosis, requiring follow-up and complementation with MRI, WBMRI and/or PET-CT.
MRI	There is no exposure to radiation; allows locating and measuring infiltrative lesions in the bone marrow and focal lesions; it allows accurately diagnosing eventual spinal cord compression; the number of lesions may indicate prognosis; displays extramedullary lesions; 3D reconstruction imaging can help with biopsy and planning surgery and radiotherapy.	Cost; lengthy process for data collection; unsuitable for patients with claustrophobia or metal implant wearers; the drug used as a contrast agent is contraindicated in patients with severe renal impairment; bone marrow infiltration may be misdiagnosed as an osteolytic lesion; presence of electric field limitations and motion artifacts.
WBMRI	No ionizing radiation or need for contrast; faster image acquisition than PET/CT; well tolerated; superior spatial resolution; High accuracy in the study of bone marrow, especially when there is no detectable bone destruction on radiographs or CT; more sensitive than PET-CT in detecting bone involvement; better differentiation between therapeutic response and disease progression; provides information with prognostic value (number and extent of lesions, prediction of fracture risk).	Cost; accessibility and availability; time for image acquisition may require sedation; as it is a very sensitive methodology, it may lead to unnecessary tests and biopsies; same contraindications as MRI.
PET-CT	Reflects the activity of the lesions; it allows evaluating the activity of the lesions in the pre and postoperative period; extramedullary lesions can be imaged; it facilitates the evaluation of the prognosis in the pre and postoperative period; the use of new radionuclides makes it possible to identify different diseases.	Cost; accessibilityand availability; lowresolution in lesions smaller than 0.5 mm; MM insensitive with low fluorodexyglucose activity; limited diagnostic value (false-positive results due to inflammation, infection, fractures, bone remodeling, post-surgical or post-biopsy changes, recent chemotherapy and radiotherapy).

		Score
Component	7	2	3
Site	Upper limb	Lower limb	Pertrochanteric
Pain	Mild	Moderate	Severe
Lesion	Blastic	Mixed	Lytic
Size	< 1/3 of cortex	1/3-2/3 of cortex	> 2/3 of cortex

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E-mail: rbo@sbot.org.br

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[1] Address for correspondence Alex Guedes, MD, MSc, PhD, Rua Marechal Floriano 212/401, Canela, 40.110-010, Salvador-BA, Brasil (e-mail: alexguedes2003@yahoo.com.br).