Analysis of Compression Fractures in Patients with Newly Diagnosed Multiple Myeloma on Comprehensive Therapy
Edgardo Angtuaco, M.D., Brian Owens, M.D., Margaret Justus, A.P.N., Rajesh Sethi, M.D., Eren Erdem, M.D., Rudy Van Hemert, M.D., Warren Stringer, M.D., Bart Barlogie, M.D.

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Introduction
Multiple myeloma (MM) is a malignant tumor of terminally differentiated B-lymphocytes that results in a clonal proliferation of abnormal plasma cells. MM principally resides within the bone marrow of the axial skeleton. These abnormal plasma cells have increased osteoclastic activity that leads to progressive bony destruction. In the spine, a 50-70% incidence of compression fractures has been reported. The purpose of our study is to review the incidence of compression fractures in newly diagnosed patients with MM, characterize the compression fractures, and detect new and progressive fractures that occur during therapy.

• Materials & Methods
• Results
  • Initial MR study
  • Single Fractures
  • Multiple Fractures
  • Overall MR study
• Conclusions
  1. In our study of 264 patients with newly diagnosed MM, 117 patients (44.3%) of patients had a spinal compression fracture on the initial MR examination (Chart 1).
  2. A majority of the compression fractures were located in the thoracolumbar spine between T7 and L2 (66% with single fractures and 68.8% with multiple fractures) (Charts 6 and 13).
  3. The overall marrow appearance and the presence of multiple focal lesions in the spine did not predict the incidence of compression fractures (Charts 2–4 and 9–11).
  4. In the group of patients with single fracture, MR showed an abnormal marrow appearance, “malignant” fracture, in 80% of cases (associated focal lesion or diffuse marrow involvement) (Chart 7).
  5. In patients with multiple fractures, as the number of fractures increase, the incidence of “malignant” fractures decrease. (61% in patients with 2-3 fractures and 37-42% in patients with 4 or more fractures) (Chart 14).
  6. Follow up MR studies following treatment reveal a low incidence of increasing or new fractures (27 out of 237 patients who had follow up examinations) (Chart 18).
  7. The decision to perform vertebroplasty at time of diagnosis should not be made for the purpose of preventing further compression fractures (80-90% stable fractures or no fractures on followup studies) (Charts 8, 15, 17 and 18).
  8. Vertebroplasty should be performed as a result of patient symptomatology and correlative physical findings. In patients with MM, review of vertebroplasty site on MR is important due to high incidence of associated abnormality within the fractured vertebral body (51% in all fractures in MM, 61% of patients with 2-3 fractures and 80% patients with single fracture) (Charts 7 and 14).
  9. Review of our patient population show that a normal “benign” MR appearance of the bone marrow of the spine, pelvis and calvaria are found in patients with Stage III disease (Durie-Salmon). These findings reflect the fact that low levels of actively secreting plasma cells are present in the bone marrow without being evident on MR imaging protocols to reflect these abnormal cells. Hence “benign” appearing fractures may not be truly benign but rather a reflection of the limitation of MR imaging.

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