Overview
➤ The skeleton is a frequent site of metastasis in patients with cancer.
➤ Multiple myeloma is a plasma cell malignancy in which 70-80% of
patients present with lytic lesions in the skeleton.
➤ Bone lesions, whether from metastatic carcinoma or multiple myeloma,
can be painful and limit physical activity.
• They may require radiation therapy, surgery or both.
➤ Metastatic carcinoma or myeloma bone lesions that progress to
pathologic fracture diminish functional capacity and quality of life and can
potentially reduce overall survival.
Imaging and Clinical Findings
➤ In the absence of reliable evidence, it is the opinion of the workgroup that
the combination of imaging findings and lesion-related pain is predictive
of risk of pathologic femur fracture. There is no reliable evidence to
suggest that MRI is a strong predictor of femur fracture. (
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Efficacy of Bone Modifying Agents (BMAs)
➤ In the absence of reliable evidence, it is the opinion of the workgroup that
the use of BMAs may assist in reducing incidence of femur fractures in
patients with patients with bone lesions from metastatic carcinoma or
multiple myeloma. (
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Dosage Response of BMAs
➤ Clinicians should consider decreasing the frequency of zoledronic acid
dosing to 12 weeks (compared to the standard 4-week interval), since
this is associated with non-inferior SRE outcomes and similar adverse
event rates in patients with metastatic carcinoma or multiple myeloma.
Clinicians should consider long-term use of BMAs to reduce skeletal
related events in patients with multiple myeloma. (
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ASCO CPGC Addendum: Further discussion on the use of BMAs in multiple myeloma can
be found in the updated American Society of Clinical Oncolog y (ASCO) CPGC on the Role
of Bone-Modifying Agents in Multiple Myeloma [Amadori D et al. Lancet Oncolog y 2013;
7: 663-70]. That guideline recommends therapy of up to 2 years for patients with multiple
myeloma. Also, ASCO CPGC noted that current practice in multiple myeloma remains
every 4 weeks frequency of zoledronic acid. In addition, due to an absence of evidence, no
recommendation was made with respect to denosumab.
Management
