Multiple Myeloma with T10 Compression Fracture Post Vertebroplasty with Still Back Pain: the Role and Treatment Consideration of Radiotherapy

Transcription

1 Multiple Myeloma with T10 Compression Fracture Post Vertebroplasty with Still Back Pain: the Role and Treatment Consideration of Radiotherapy Case Number: RT (M) Potential Audiences: Intent Doctor, Oncology Special Nurse, Resident Doctor Purpose: to present a case with multiple myeloma with T10 compression fracture post vertebroplasty with still back pain; to discuss the role and treatment consideration of radiotherapy Scenario: You are radiotherapy (RT) Intent Doctor/Special Nurse/Resident Doctor, and you are assigned to evaluate the following patient before visiting of your RT attending physician. Please review the following description carefully; your RT attending physician will visit this patient later and discuss with you after your review. Case Presentation: This 42 year-old male patient, 黃 OO, was referred to us for radiotherapy assessment of Multiple myeloma with T10, T11, and L5 involvement, with T10 compressive fracture, post vertebroplasty (2008/11), with increasing back pain. S: 1. He suffered from back pain for several years. 2. In 2008/11, T10 compression fracture was found and biopsy was done. Pathology reported multiple myeloma. 3. In 2008/11, vertebral bone cement injection was done. More severe back pain after bone cement injection was found, and only bed rest can be done after operation. 4. On 2008/11/21, you visited this patient in the ward. Histories: NDKA; no major medical disease history. Review of systems: severe back pain with major impairment of daily practice with bed rest only O: 1. General Condition: ECOG: 4; lying on bed; speech: OK 2. Physical Examinations: (1). HEENT & SCF: no LNs; (2). CHE: neg.; (3). ABD: no tenderness; (4). Back & Spine: severe knocking pain on the middle and low back; (5). Extremities: free movement in the four limbs; no decrease in muscle power; no numbness on the lower limbs; (6). Others: neg. 3. ***Pathology in 2008/11, bone biopsy: multiple myeloma with positive lambda light chain 4. Images: (1). Spine Plain film in 2008/11 (post vertebroplasty): bone cement in place; with a small bone fragment retro-protruding on the fractured T10 spine. (2). Spine MRI in 2008/11: T10 bone mets with retro-protruding. (3). Bone scan in 2008/11: T10-T11 and L5 increase uptake (4). ABD sono in 2008/11: neg. 5. Others: IgG in 2008/11: 4393; serum Cr. < 2.

2 Key Image(s): Fig. 1. Fig. 2. Fig. 3.

3 Questions & Discussions: (Please answer the following questions commented from your RT attending physician.) Q1: What are your findings/interpretations for the above key image(s)? Q2: What is your clinical cancer stage, according to the AJCC 2006, for this case? Q3: What is your pathologic cancer stage, according to the AJCC 2006, for this case? Q4: What are your Oncology Diagnosis / Assessments for this case? Q5: What is your Oncology Plan for this case? Q6: What is your Radiotherapy Plan for this case? (Please reply with the following form: Indication/Contraindication, Goal, Target & Volume, Technique, and Dose & Fractionation.)

4 Questions & Discussions: (with potential answers) (Please answer the following questions commented from your RT attending physician.) Q1: What are your findings/interpretations for the above key image(s)? A1: As described in the last attached page. Q2: What is your clinical cancer stage, according to the AJCC 2006, for this case? A2: stage IIIA (2008/11) according to the Durie-Salmon Criteria Q3: What is your pathologic cancer stage, according to the AJCC 2006, for this case? A3: no pathologic stage can be defined in this case. Q4: What are your Oncology Diagnosis / Assessments for this case? A4: 1. Oncology Diagnosis: Multiple myeloma (2008/11), IgG (2008/11, 4393) and Lambda light-chain type, with T10-T11 and L5 bone involvement, with T10 compression fracture, stage IIIA (2008/11) according to the Durie-Salmon Criteria, post vertebroplasty (2008/11, T10), with persisted bone pain Q5: What is your Oncology Plan for this case? A5: Suggest: (1). Total bed rest with back brace use; preventing spinal cord compression (2). Pain control medications with morphine or ultracet; medications for stool soften; steroid use if indicated. (3). Monitor lower limbs weakness and numbness; monitor function of defecations and urinations. (4). Keep chemotherapy and add palliative RT Q6: What is your Radiotherapy Plan for this case? (Please reply with the following form: Indication/Contraindication, Goal, Target & Volume, Technique, and Dose & Fractionation.) A6: RT Plan may be designed as the following one: (1). Indication: Multiple myeloma post T10 vertebroplasty with still back pain (2). Goal: palliative; symptoms alleviation (3). Target & Volume: T10-T11 and L5 with limited margin (4). Technique: 2DRT (5). Dose & Fractionation: 2000 cgy in 10 fractions. Further Readings & References: NCCN 2009 & Perez 2008 & AJCC 2006 Radiation Oncologist Hon-Yi Lin 2009/05/15

5 Key Image(s): (with marked) Fig. 1. Fig. 1. The T10 and L5 showed increase uptake on the bone scan, c/w bone remodeling after bone involvement by multiple myeloma (as the black arrows). Fig. 2. Fig. 2. T10 compression fracture was noted in the spine MRI, c/w involvement by multiple myeloma (as the white arrow). Fig. 3. Fig. 3. The T10 compression fracture before-and-after vertebroplasty (cement injection) (as the short white arrows); after vertebroplasy, a small posterior protruding to the spinal canal was found (as the long white arrow).