Published: 2016-12-16

Transplant ineligible multiple myeloma patients presenting as paraplegia/paraparesis a prospective single institution study

Aravindh Sivanandan Anand, Vipin George Kuriakose, Resmi K. P., Sabarinath P. S.


Background: Multiple myeloma a plasma cell neoplasm characterized by heterogeneous myriad of presentation with paraparesis or paraplegia in 20% cases due to spinal cord compression by vertebral collapse, compression or fracture.

Methods: This is a prospective observational study of thirty transplant ineligible multiple myeloma patients with paraplegia/paraparesis. Pretreatment evaluation done as per standard protocol including MRI whole spine. Involved spine XRT 8Gy single fraction followed by BLD (Bortezomib 1.3mg/m2 weekly once, Lenalidomide 10mg/m2 for 21 days, oral dexamethasone 40 mg weekly once). Neurological parameters, time to neurological and tumor response at 6 months assessed. Patients in very good partial response or complete response were maintained on Lenalidomide and bisphosphonate therapy for a period of two years. The duration of symptoms and time to response were analyzed with Mann Whitney Cox test.

Results: 15 patients were grade 0 power and others grade 1 or 2. Median time to any neurological response was 2.97 weeks. 63.3% of patients achieved power of grade 5, 30% grade 4 and 6.7% grade 3 powers. 23.3% patients received complete response while 63.3% patient’s very good partial response.

Conclusions: Bedridden myeloma patients had an excellent improvement in quality of life and tumor control with this treatment schedule.



Bortezomib, Multiple myeloma, Paraplegia, Radiation

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Jemal A, Siegel R, Xu J, Ward E. Cancer statistics, 2010, CA Cancer J Clin. 2010;60(5):277-300.

Lecouvet FE, Vande Berg BC, Maldague BE, Michaux L, Laterre E, Michaux JL, et al. Vertebral compression fractures in multiple myeloma. Part I. Distribution and appearance at MR imaging, Radiology. 1997;204(1):195-9.

Tosi P. Diagnosis and Treatment of Bone Disease in Multiple Myeloma: Spotlight on Spinal Involvement, Hindawi Scientifica. 2013(2013).

Gerszten PC, Welch WC. Current surgical management of metastatic spinal disease. Oncology. 2000;14(7):1013-24.

Bach F, Larsen BH, Rohde K, Børgesen SE, Gjerris F, Bøge-Rasmussen T, et al. Metastatic spinal cord compression, ActaNeurochirurgica. 1990;107(1-2):37-43.

Helweg-Larsen S, Sorensen PS. Symptoms and signs in metastatic spinal cord compression: a study of progression from first symptom until diagnosis in 153 patients. Eur J Cancer A. 1994;30(3):396-8.

Levack P, Graham J, Collie D, Grant R, Kidd J, Kunkler I et al. Don't wait for a sensory level-Listen to the symptoms: a prospective audit of the delays in diagnosis of malignant cord compression, Clinical Oncology. 2002;14(6):472-80.

Jung HS, Jee WH, McCauley TR, Ha KY, Choi KH. Discrimination of metastatic from acute osteoporotic compression spinal fractures with MR imaging, Radiographics. 2003;23(1):179-87.

Flouzat-Lachaniette CH, Allain J, Roudot-Thoraval F, Poignard A, Treatment of spinal epidural compression due to hematological malignancies: a single institution's retrospective experience. Eur Spine J. 2013;22:548-55.

Byrne TN. Spinal cord compression from epidural metastases. N Engl J Med. 1992;327:614-9.

Quinn JA, DeAngelis LM. Neurologic emergencies in the cancer patient. SeminOncol. 2000;27:311-21.

Nelson KA, Walsh D, Abdullah O, McDonnell F, Homsi J, Komurcu S et al. Common complications of advanced cancer. SeminOncol. 2000;27:34-44.

Maranzano E, Latini P, Checcaglini F, Ricci S, Panizza BM, Aristei C et al., Radiation therapy in metastatic spinal cord compression: A prospective analysis of 105 consecutive patients. Cancer. 1991;67:1311-7.

Gilbert RW, Kim JH, Posner JB. Epidural spinal cord compression from metastatic tumor: diagnosis and treatment. Ann Neurol. 1978;3:40-51.

Patchell RA, Tibbs PA, Regine WF, Payne R, Saris S, Kryscio RJ et al. A randomized trial of direct decompressive surgical resection in the treatment of spinal cord compression caused by matastatic cancer. Lancet. 2005;366:643-8.

Kyle RA, Rajkumar SV. Criteria for diagnosis, staging, risk stratification and response assessment of multiple myeloma. Leukemia. 2008;23:3-9

Durie B, Hoering A, Rajkumar SV, Abidi H, Epstein J, Kahanic SP et al. BLD versus LD in patients with previously untreated multiple myeloma without anintent for immediate autologous stem cell transplant. Results of the randomized phase III trial SWOG 0777. Blood 2015;126.

Hideshima T, Anderson KC. Molecular mechanisms of novel therapeutic approaches for multiple myeloma. Nat Rev Cancer 2002;2:927.

Mitsiades CS, Mitsiades N, Poulaki V, Schlossman R, Akiyama M, Chauhan D, et al. Activation of NF-kappaB and upregulation of intracellular anti-apoptotic proteins via the IGF-1/Akt signaling in human multiple myeloma cells: therapeutic implications. Oncogene 2002;21:5673.

Richardson PG, Weller E, Lonial S Jakubowiak AJ, Jagannath S, Raje NS, et al. BLD combination therapy in patients with newly diagnosed multiple myeloma. Blood. 2010;116(5);679-86.