Multiple myeloma surgery
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Haytham Allaham, M.D. [2] Shyam Patel [3]
Overview
Surgery places a role for specific conditions that occur in patients with multiple myeloma. Surgical removal of plasmacytoma is frequently done in an attempt to achieve cure. Surgery can be done for bone stabilization in patients who have osseous breakdown. Benefits of surgical intervention include pain relief, restoration of functional disability, and alleviation of neurologic deficits. Risks of surgery include neurologic compromise (for vertebral spine surgeries), bleeding, infection, and inherent surgical risk.
Surgery
Surgical Removal of Plasmacytoma
Solitary plasmacytoma represents a localized form of multiple myeloma that manifests as a solid tumor. This can be treated by surgical removal and radiation. The combination of surgery and radiation therapy for plasmacytoma results in a higher 5-year survival rates compared with single-modality therapy.[1] However, at the current time, the role for surgery in plasmacytoma is still under debate, as radiation is the primary modality of therapy. The location of the plasmacytoma can guide decisions about surgical management.
Surgery for Osseous Involvement
In many patients with multiple myeloma, bone involvement can lead to significant pain and limitation of mobility. Lytic lesions in the axial or appendicular skeleton may require surgical intervention for stabilization. The most common anatomic site that requires surgical stabilization is the vertebral spine, as pathologic fractures can result in spinal cord compromise and subsequent neurological deficits.[2] Decompression, fixation, or other surgical techniques may be required to prevent impending spinal cord damage.[2] The risks and benefits of surgery must be weighed in all patients underlying surgery for lytic lesions.
Benefits of surgical intervention
- Pain relief: Surgical stabilization of lytic lesions can improve pain symptoms.
- Restoration of functional disability: Stabilization of lytic lesions provides mechanical and structural support for the axial and appendicular skeleton.
- Alleviation of neurologic deficits: Stabilization of the spine can help alleviate neurologic defects that were caused by compressive neurologic damage. The most common neurological symptoms include lower extremity numbness, lower extremity weakness, decreased deep tendon reflexes, and impaired gait. These neurologic functions are supplied by the nerve roots located near the thoracic and lumbar spine, which are the most common sites of lytic lesions in patients with multiple myeloma.[2]
Risks of surgical intervention
- Neurologic compromise: In rare cases, surgery on the vertebral spine can result is worsening neurologic function, given the proximity of the spinal cord to the vertebrae.
- Bleeding: Excess bleeding can occur in patients with multiple myeloma undergoing surgery because these patients typically have thrombocytopenia from underlying myelophthisis (crowding out of normal bone marrow cells). In patients with a high bone marrow plasma cell count, thrombocytopenia can be quite prominent. The risk for bleeding in these patients is typically higher than for patients undergoing the same surgery but without multiple myeloma.
- Infection: Infectious complications at the surgical site can occur in patients with multiple myeloma undergoing surgery because these patients may have leukopenia or neutropenia from underlying myelophthisis (crowding out of normal bone marrow cells). In patients with a high bone marrow plasma cell count, leukopenia or neutropenia can be quite prominent. The risk for infections in these patients is typically higher than for patients undergoing the same surgery but without multiple myeloma.
- Inherent surgical risk: Concurrent cardiopulmonary comorbidities can place patients at risk for surgical complications, including adverse effects from anesthesia and mechanical ventilation.
References
- ↑ Thumallapally N, Meshref A, Mousa M, Terjanian T (2017). "Solitary plasmacytoma: population-based analysis of survival trends and effect of various treatment modalities in the USA". BMC Cancer. 17 (1): 13. doi:10.1186/s12885-016-3015-5. PMC 5216567. PMID 28056880.
- ↑ 2.0 2.1 2.2 Quidet M, Zairi F, Boyle E, Facon T, Vieillard MH, Machuron F; et al. (2018). "Evaluation of the Relevance of Surgery in Patients with Multiple Myeloma Harboring Symptomatic Spinal Involvement: A Retrospective Case Series". World Neurosurg. 114: e356–e365. doi:10.1016/j.wneu.2018.02.184. PMID 29530691.