Combined Spinal TB and Multiple Myeloma with Symptomatic Bony Disease: the Role and

Treatment Consideration of Radiotherapy Case Number: RT2009 - 80(M) Potential Audiences: Intent Doctor, Oncology Special Nurse, Resident Doctor Purpose: to present a case of combined spinal TB and multiple myeloma with symptomatic bony disease; 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 patient, 劉 OO, was consulted under the diagnosis of ‘multiple myeloma with spinal compression fraction for RT evaluation’ on 2007/08/28.

S: 1. In 2007/04, TB spine was diagnosed by TB-PCR and anti-TB medications were given. 2. In 2007/08, chest wall pain still with re-biopsy showed multiple myeloma in pathology. 3. On 2007/08/28, you visited the patient and his wife in the ward for RT consultation and

evaluation. Hx: TB spine under TB medication with TB spondylitis progression, NKA Review of systems: bilateral chest wall pain off and on for about 1 year; severe middle

back pain for 1 month with regression after pain control medications now O:

1. ECOG: 3-4, 70 y/o male, lying on bed, no obviously knocking pain on back at visiting (on pain control medication now) 2. Spine MRI in 2007/08: T9 compression fracture with mild posterior impinging the spinal cord; a 1.9 cm nodular lesion over the anterior T8 body; regressed soft tissue mass over the para-spinal region on T8-10 level; multiple small nodular lesion over multiple bone; all c/w TB with bone involvement. 3. Bone scan and SPECT in 2007/08: significant enhanced lesion on T9 with compression lesion, and L4. 4. ***Pathology in 2007/08, T9 vertebral biopsy: multiple myeloma; IHC stain: kappa and lambda light chain 5. Pathology in 2007/03, T spine biopsy: necrotic tissue 6. Anti-body survey in 2007/08: IgA (1399 high) 7. Biochemitry in 2007/08: BUN/Cr (38/2.9) 8. B/R in 2007/08: Hgb (8.2)

Key Image(s): Fig. 1.

Fig. 2.

Fig. 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 for this case? Q3: What are your Oncology Diagnosis / Assessments for this case? Q4: What is your Oncology Plan for this case? Q5: What is your Radiotherapy Plan for this case?

(Please reply with the following form: Indication/Contraindication, Goal, Target & Volume, Technique, and Dose & Fractionation.)

Q6: Please indicate the staging systems used for multiple myeloma.

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 for this case? A2: Durie-Salmon Criteria, Stage IIIB (2007/08, advanced lytic bone disease) Q3: What are your Oncology Diagnosis / Assessments for this case? A3: 1. IgA-type multiple myeloma with associated T9 compression fracture, anemia,

renal insufficiency, International Staging system, Durie-Salmon Criteria, Stage IIIB (2007/08, advanced lytic bone disease, Cr >2)

2. TB spine on anti-TB medications Q4: What is your Oncology Plan for this case? A4: Suggest current Oncology Plan:

(1) Oral chemotherapy if indicated and suitable (2) RT to the significant bone involved region. (3) Keep anti-TB medications

Q5: What is your Radiotherapy Plan for this case?

(Please reply with the following form: Indication/Contraindication, Goal, Target & Volume, Technique, and Dose & Fractionation.)

A5: RT Plan may be designed as the following one: (1). Indication: T9 compression fracture with against the spinal cord with symptoms (2). Goal: palliative; both symptoms alleviation and prevent major co-morbidity (3). Target & Volume: the T9 bone involvement site with adequate margin (4). Technique: CT-based 3DCRT (5). Dose & Fractionation: 20-30 Gy in 10-15 fractions.

Q6: Please indicate the staging systems used for multiple myeloma. A6: As the following figure [NCCN 2009].

Further Readings & References: NCCN 2009 & Perez 2008

Radiation Oncologist Hon-Yi Lin 2009/03/28

Key Image(s): (with marked) Fig. 1.

Fig. 2.

Fig. 3.

Fig. 2. The SPECT/CT shows T9 increasing uptake, c/w bone mets with bony destruction (as the white arrow and the red crossers).

Fig. 3. The following spine MRI shows T9 compression fracture with posterior protruding with against the spinal cord (as the long white arrows); multiple small low-signal lesions over the other spines, c/w spinal TB and multiple myeloma involvement (as the short white arrows).

Fig. 1. The T-spine plain films show that T9 compression fracture (as the white arrows); the T12 was indicated by the black arrow.