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Treatment of myeloma and plasmacytoma

X-rays of neck showing a myeloma deposit affecting a mid-cervical vertebra (left panel). After surgical stabilisation and radiotherapy (metal surgical stabilisation device and radiotherapy portal shown in right panel) a good result ensued.
X-rays of neck showing a myeloma deposit affecting a mid-cervical vertebra (left panel). After surgical stabilisation and radiotherapy (metal surgical stabilisation device and radiotherapy portal shown in right panel) a good result ensued.

Some patients with early or smouldering myeloma can be watched carefully without therapy and their long term survival will not be jeopardised if the careful watch policy is assiduously carried out such that disease progression is picked up early and treatment instituted at the appropriate time. The reason for this is that the usual types of chemotherapy for this disease are not curative and the life prolonging properties of chemotherapy are as useful at a time when the patient is symptomatic as early in the course of the disease (see below).

 

The choice of drug therapy in myeloma is based on the patient's age, performance status and renal function - all of which influence the decision as to whether the patient is suitable for autologous stem cell therapy; a procedure that follows very high dose chemotherapy, itself used as apart of curative chemotherapy in appropriate patients. Where such high dose chemotherapy will never be utilised (e.g. due to old age and frailty) then simple chemotherapy with alkylating agents such as melphalan, coupled with steroids or thalidomide is often used first but in patients who will later be harvested of their blood/marrow stem cells for the high dose procedure, the doctor will try to avoid alkylating agent chemotherapy. Thalidomide (or one of its derivative drugs e.g. lenalidomide), coupled with steroids or other agents is commonly utilised. Particular care is needed when the patient has presented in renal failure, first reversing the factors that are conspiring to worsen the renal condition (e.g. high uric acid, calcium,dehydration, infection etc).

 

Chemotherapy is usually continued until the patient has achieved a 'plateau' phase (this is when the immunoglobulin marker has achieved a partial remission and remained at this level for 3 months). Following this maximal response to therapy the patient either proceeds to high dose chemotherapy plus the autograft (nowadays with peripheral blood stem cells) or a careful watch policy. The former is the more aggressive approach and reserved for those who are fit enough to withstand the procedure (the potential advantage of which is the hope of eradication of the disease).  In patients who have disappearance of their serum immunoglobulin marker following this procedure, there is a real hope of long disease-free life. In other patients, there follows a period of watchful waiting, until the marker rises or some other event (e.g. bone fracture due to local progression) prompts further therapy. At this time, the patient is treated again, perhaps with the same therapy if first remission was lengthy, or alternative drugs (combinations of active cytotoxic drugs or immuno-modulatory drugs such as thalidomide or bortezomib) will be brought into the therapy. Steroids are also useful.

 

In this context, the use of bisphosphonate therapy should be discussed. The bisphosphonates are an interesting group of compounds, which attach to bone and make it less likely to be broken down by any disease process, particularly here the bony absorption by myeloma. It is now standard practice to give bisphosphonate therapy (either intravenous pamidronate or oral clodronate) in the maintenance period, so long as the renal function is good.

 

 

Lastly it should be stated that local radiotherapy has a very important role in the therapy of multiple myeloma in controlling bony pain. The patient, who comes with low back pain or limb pain because of destructive plasmacytoma in the particular bone, will be most quickly out of pain if he receives local radiotherapy to that bone. Radiotherapy has an important and potentially curative role in the therapy of isolated plasmacytoma.

 

In the photo, the left panel shows a side view of the neck of a patient with myeloma. The bones are so thin that it is hardly possible to make out the cervical vertebrae and one of them has crush fractured. In the right panel we see the same side view of the cervical spine after therapy. Firstly, the bones are now stronger (more radio-opaque and hence more visible on the x-ray), this is due to drug therapy and local radiotherapy to the neck/cervical spine and secondly a spinal stabilisation operation has been performed and we can see the metal stabiliser in situ.


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