1. Reduced Pain and Improved Mobility Gained When Part of Treatment Plan for Vertebral Compression Fractures in Those With Multiple Myeloma Reduced Pain and Improved Mobility Gained When Part of Treatment Plan for Vertebral Compression Fractures in Those With Multiple Myeloma Eren Erdem, MD Interventional Neuroradiologist Division Director and Associate Professor University of Arkansas for Medical Sciences Vertebroplasty: Integral to Treating Back Pain in Blood Marrow Cancer Patients

2. The minimally invasive, image-guided treatment of vertebroplasty is an integral component to the complicated treatment of multiple myeloma, an incurable (yet treatable) cancer of the bone marrow that causes destructive lesions in bones and makes them more susceptible to fracture.

3. Vertebral compression fractures are very common in patients with multiple myeloma (up to 70 %) and cause severe pain and debilitation. Patients can experience compression of abdominal contents, decrease in lung capacity, depression, anorexia and reduced ability to perform normal daily functions

4. By reducing pain and improving mobility, vertebroplasty helps patients become better equipped to continue with their rigorous treatment for multiple myeloma

5. Founded 1989, Bart Barlogie, MD, PhDFounded 1989, Bart Barlogie, MD, PhD

8. Epidemiology 10% hematologic malignancies, 1% all10% hematologic malignancies, 1% all Incidence 3-4/10 5, 20,000/year USIncidence 3-4/10 5, 20,000/year US 100,000 US patients in treatment100,000 US patients in treatment 3:2 Male to female ratio3:2 Male to female ratio African-Americans increased riskAfrican-Americans increased risk

9. Multiple Myeloma Uncontrolled overgrowth of plasma cells Bone marrow failureBone marrow failure Anemia Anemia Immune dysfunction Immune dysfunction Monoclonal Protein SecretionMonoclonal Protein Secretion Renal Failure Renal Failure Increased osteoclast, decreased osteoblast activityIncreased osteoclast, decreased osteoblast activity Bone destruction Bone destruction

10. Osteoclast & Osteblast “Un-coupling” Bone Destruction SEM courtesy of Dr. Arnett, UCL

12. Secondary osteoporosis

13. Study Objective Distribution and Extent Vertebral FracturesDistribution and Extent Vertebral Fractures Efficacy of Vertebral AugmentationEfficacy of Vertebral Augmentation –Pain –Analgesic Usage –Disability

14. Material & Methods 792 consecutive MM patients792 consecutive MM patients January 2001 through May 2007January 2001 through May 2007 Prospective, IRB-approved studyProspective, IRB-approved study

15. Results n=792 n=440 mean age 61.6 yrs, SD 10.9 p<0.001 n=352 65.6 yrs, SD 13.0

16. Results

17. Results

18. Results

19. Results

20. Results Pain AssessmentPain Assessment p < 0.001 n=520

21. Results

22. Results

23. Vertebroplasty Procedure Under local and intravenous medication No surgical incision Needles are placed into the vertebral bone precisely, under advanced live x-ray The cement is then injected very carefully to stabilize the fracture and alleviate pain

24. Most procedures are done outpatient and rarely requires limited time in the hospital There’s no incision, so there’s less pain and less recovery time, only a bandaid Less expensive than surgery

25. Multiple Myeloma can be very debilitating

27. one month later

28. Pre/Post treatment –Jan 2005 Improved kyphosis

29. When there is no pressure on the spinal cord even the worst fractures can be treated with vertebroplasty

30. Retropulsion

31. Why not open surgery? Open surgery is the last resort for multiple myeloma and other cancer patients with metastasis to the vertebra Usually, the bones don’t have enough structure to anchor instruments such as screws and plates Also, being sick with cancer, these are very aggressive surgeries to handle for the patients

32. Failed back sugery

35. When there is aggressive tumor, interventional radiologists would ablate the tumor at the time of vertebroplasty, to achieve local disease control as well

36. T 11 expansile lesion

37. RFA and Cement injection

38. 5 days post RFA

39. When the patient has many fractures and decompensated, aggressive but safe long procedures can be performed

40. 14 levels treated only two procedures

41. Conclusion Although there is multiple large series of the procedure’s success in osteoporotic patients, this is the first large series on a cancer population of multiple myeloma With increasing experience, interventional radiologists can effectively treat the most complex and difficult cases of compression fractures throughout the spinal column with vertebroplasty