Multiple Myeloma with Pathologic Fracture: the Role and Treatment Consideration of RT

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Doris Roberts
8 years ago
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1 Multiple Myeloma with Pathologic Fracture: the Role and Treatment Consideration of RT Case Number: RT (M) Potential Audiences: Intent Doctor, Oncology Special Nurse, Resident Doctor Purpose: to present a case of multiple myeloma with pathology fracture post ORIF; to discuss the role and treatment consideration of RT. 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 58 year-old male patient, 蕭 OO, was referred to us for radiotherapy assessment of multiple myeloma with pathology fracture post ORIF. S: 1. He suffered from right lower limb sciatica and numbness for months. 2. In 2009/02, he suffered from the left humerus fracture. 3. On 2009/02/20, ORIF was done and pathology reported multiple myeloma. 4. On 2009/02/27, you visit this patient in the ward. Histories: NDKA; no major disease history; no prior RT Review of systems: right lower limb sciatica and numbness for several months; numbness sensation also noted, foot more than left more than the thigh; lower back pain also noted. O: 1. General Condition: ECOG, 1-2; ambulatory status; speech: OK 2. Physical Examinations: (1). HEENT & SCF: neg. (2). CHE: neg. (3). ABD: no tenderness (4). Back & Spine: mild knocking pain over the lower back (5). Extremities: the left upper humersus post ORIF with good healing; numbness over the right lower limb; muscle power 4-5 in the other three limbs (except the left upper limb). (6). Others: neg. 3. ***Pathology in 2009/02, humerus, tumor excision: multiple myeloma with pathology fracture; kappa (+), lambda (-), and EMA (-). 4. Images: (1). Bone scan in 2009/02: pathologic fracture to the left humerus; vertebral destruction to the L1 and L2, especially to the L2. (2). ABD CT in 2009/02: Multiple osteolytic lesions of left proximal humerus, multiple levels of the thoracolumbar spine, sacrum, and bilateral pelvis bones; A soft tissue nodule at right T6 paraspinal region (1.9*1.0 cm in size). (3). Plain X-film of the left shoulder in 2009/02: fracture in the left upper humerus shaft 5. Others: IgG, 8665 in 2009/02; BUN/Cr: 28/1.1 in 2009/02

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.

2 Key Image(s): Fig. 1. Pelvic CT Fig. 2. Chest CT Fig. 3. Chest CT

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 Q3: What is your pathologic cancer stage, according to the AJCC 2006, for this Q4: What are your Oncology Diagnosis and/or other Assessments for this Q5: What is your Oncology Plan for this Q6: What is your Radiotherapy Plan for this (Please reply with the following form: Indication/Contraindication, Goal, Target & Volume, Technique, and Dose & Fractionation.)

Q2: What is your clinical cancer stage, according to the AJCC 2006, for this Q3: What is your pathologic cancer stage, according to the AJCC 2006, for

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 A2: International Staging system, Durie-Salmon Criteria, Stage III (2009/02, advanced lytic bone disease & IgG >7g/dl) Q3: What is your pathologic cancer stage, according to the AJCC 2006, for this A3: no pathology stage can be defined in this case. Q4: What are your Oncology Diagnosis and/or other Assessments for this A4: 1. Oncology Diagnosis: Multiple meoloma, IgG type (2009/02, 8665), International Staging system, Durie-Salmon Criteria, Stage III (2009/02, advanced lytic bone disease & IgG >7g/dl), complicated with left upper humerus pathological fracture, post ORIF (2009/02/20) 2. RT is indicated for this patient with the following indicators: (1). Multiple myeloma with pathological fracture post ORIF Q5: What is your Oncology Plan for this A5: Suggest: (1). Chemotherapy (2). Palliative RT to the bone disease. Q6: What is your Radiotherapy Plan for this (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 with symptomatic bone disease (2). Goal: palliative (3). Target & Volume: left humerus surgical bed plus spine/pelvic bone lesions (4). Technique: 2DRT to the left humerus and 3DCRT for the spine/pelvic bone disease (5). Dose & Fractionation: Gy in 5-15 fractions. Further Readings & References: NCCN 2009 & Perez 2008 & AJCC 2006 Radiation Oncologist Hon-Yi Lin 2009/03/02

Q2: What is your clinical cancer stage, according to the AJCC 2006, for this A2: International Staging system, Durie-Salmon Criteria, Stage III (2009/02, advanced lytic bone disease & IgG >7g/dl) Q3:

5 Key Image(s): (with marked) Fig. 1. Pelvic CT Fig. 1. Sacral bone involvement (as the black arrows) with associated soft tissue mass formation over the right sacral region (as the white arrow). Fig. 2. Chest CT Fig. 2. Left upper humeral bone pathologic fracture was noted (as the white arrow). Fig. 3. Chest CT Fig. 3. A pleural-based soft-tissue mass over the right para-spinal region (as the white arrow).

Case Number: RT2009-124(M) Potential Audiences: Intent Doctor, Oncology Special Nurse, Resident Doctor

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