|Palliative radiotherapy in plasma
Adamietz IA, Radiother Oncol 1991 Feb;20(2):111-6 Department of Radiotherapy,
Medical School, Hannover, F.R.G.
Pain symptoms caused by bone lesions of multiple myeloma can be relieved by a local
irradiation treatment. To estimate the influence of systemic treatment on the palliative
effect of local radiotherapy the records of 70 myeloma patients treated with chemotherapy
combined with or followed by local irradiation were reviewed. The local response rate,
defined as complete pain relief at the irradiated site, was 80%
in patients receiving irradiation during chemotherapy (melphalan and prednisone) and this
palliative effect endured 31.8 +/- 3.6 months. If irradiation was started in the period
without systemic treatment the local response rate was 39.6% and lasted 24.8 +/- 17.9
months. In sites treated with more than one radiotherapy course 94% response rate after
the first treatment, 56% after the second treatment and no response after the third course
was achieved. It is concluded that irradiation during concomitant chemotherapy is
superior to radiotherapy performed in a period without systemic treatment. Local long-term
palliation can only be achieved by a sufficient high radiation dose.
Radiation therapy for the palliation of multiple myeloma.
Leigh BR, Int J Radiat Oncol Biol Phys 1993 Apr 2;25(5):801-4 Department of
Radiation Oncology, University of Arizona College of Medicine and Cancer Center, Tucson
PURPOSE: This reviews the experience at the University of Arizona in an effort to define
the minimum effective radiation dose for durable pain relief in the majority of patients
with symptomatic multiple myeloma. METHODS AND MATERIALS: The records of 101 patients with
multiple myeloma irradiated for palliation at the University of Arizona between 1975 and
1990 were reviewed. Three hundred sixteen sites were treated. Ten sites were asymptomatic,
including six hemibody fields with advanced disease unresponsive to chemotherapy and four
local fields with impending pathological fractures. Three hundred six evaluable
symptomatic sites remained. The most common symptom was bone pain. Other symptoms included
neurological impairment and a palpable mass. RESULTS: Total tumor dose ranged from 3.0 to
60 Gy, with a mean of 25 Gy. Symptom relief was obtained in 297 of
306 evaluable symptomatic sites (97%). Complete relief of symptoms was obtained in 26% and
partial relief in 71%. Symptom relief was obtained in 92% of sites receiving a
total dose less than 10 Gy (n = 13) and 98% of sites receiving 10 Gy or more (n = 293). No
dose-response could be demonstrated. The likelihood of symptom relief was not influenced
by the location of the lesion or the use of concurrent chemotherapy. Of the 297 responding
sites, 6% (n = 19) relapsed after a median symptom-free interval of 16 months. Neither the
probability of relapse nor the time to relapse was related to the radiation dose.
Retreatment of relapsing sites provided effective palliation in all cases. CONCLUSION:
Radiation therapy is effective in palliating local symptoms in multiple myeloma. A total
dose of 10 Gy should provide durable symptom relief in the majority of patients.
Palliative radiation therapy for multiple myeloma
Minowa Y, Nippon Igaku Hoshasen Gakkai Zasshi 1996 Dec;56(14):1056-60
Department of Radiology, Faculty of Medicine, Kyoto University.
PURPOSE: Radiation therapy is a useful palliative modality for refractory lesions of
multiple myeloma. It has been reported that total doses of 10 to 20 Gy are usually
adequate to obtain some degree of pain relief. However, there are many patients who need
additional doses to obtain sufficient pain relief. In this study, we retrospectively
analyzed the records of patients with multiple myeloma irradiated at our department, in an
attempt to develop an effective treatment policy for this disease. MATERIALS AND METHODS:
Twenty-nine patients with 53 lesions were treated between 1968 and 1993. Total irradiation
doses were 4 to 60 Gy(median 40 Gy) with daily fractions of 2 Gy or less, and 16 to 51
Gy(median 30 Gy) with daily fractions greater than 2 Gy. Evaluated were 59 symptoms,
including pain (68%), neurological abnormalities (15%), and masses (28%). RESULTS: Symptomatic remission was obtained in 33 of 36 (92%) lesions with pain, 6
of 8(75%) with neurological abnormalities, and 13 of 15(87%) mass lesions. Pain was
partially relieved at a median TDF of 34, and completely at a median TDF of 66(equivalent
to 40-42 Gy with daily fractions of 2 Gy). CONCLUSIONS: Radiation therapy is an effective
and palliative treatment method for symptomatic multiple myeloma. However, the treatment
seems to require higher radiation doses than those reported to obtain adequate relief of
Radiotherapy in the treatment of multiple
Bosch A, Int J Radiat Oncol Biol Phys 1988 Dec;15(6):1363-9
Department of Radiation Oncology, Oncologic Hospital, Puerto Rico Medical Center, Hato
Fifty-nine patients with multiple myeloma referred for treatment of painful bony lesions
received irradiation to 95 local areas, and 16 of the 59 were irradiated using hemibody
techniques. Pain relief was obtained in practically all of the irradiated regions. Most
local areas were treated to doses of 3000 cGy in 10 to 15 fractions. Patients with
generalized pain due to multiple site involvement were treated with single dose hemibody
irradiation, to doses of 600 cGy to the upper hemibody, and of 800 cGy to the lower
hemibody. This treatment was well tolerated and side effects minimal. Median survival from diagnosis was 30 months and the survival at 1,
3, and 5 years was 80%, 42%, and 12% respectively.
Multiple myeloma of an extremity: must the
entire bone be treated?
Catell D, Int J Radiat Oncol Biol Phys 1998 Jan 1;40(1):117-9
Division of Radiation Oncology, NYU Medical Center, New York 10016, USA.
PURPOSE/OBJECTIVE: Radiation of the entire shaft of a long bone affected by multiple
myeloma (MM) is often advocated to prevent recurrent disease in the bone remote from the
symptomatic site. Our standard of care has been to irradiate only the symptomatic area. We
investigated the pattern of recurrence in patients treated in this manner. METHODS AND
MATERIALS: 163 patient with MM were treated between 1971 and 1994. Twenty-seven patients
received treatment to a long bone with 41 sites irradiated (17 humeri, 22 femurs, 1
radius, 1 ulna). The most common long bone treated was the femur. All patients were
treated with megavoltage therapy. The symptomatic lesion, plus a margin of 1-2 cm was
treated with no attempt to treat the entire shaft. Mean radiation dose was 27.82 Gy (range
6.00-44.80 Gy). The length of the field was measured in centimeters and expressed as both
an absolute (AL) and relative (RL) length (i.e., percentage of total length of bone).
RESULTS: The mean total AL and RL for femur fields was 18 cm and 42%, respectively. For
the humerus, the AL and RL were 20 cm and 68%, respectively. Only four patients developed
progressive disease in the same bone but outside the previously irradiated field. In three
of the four patients the RL was between 20 and 30%. The dose of radiation given to these
patients was 12.50, 21.00, 30.00, and 35.00 Gy. In all of these four cases, treatment of
progressive disease in adjacent sites provided effective palliation of symptoms.
CONCLUSION: Radiation therapy to the symptomatic portion of a long
bone affected by MM is effective for palliation. Symptomatic recurrence out of the
irradiated field is uncommon and can be effectively treated. Potential benefits of this
approach include irradiation of less normal marrow and elimination of use of pairs of
fields or extended distance treatment to cover the entire femur.
Clinical course of solitary extramedullary
Liebross RH, Radiother Oncol 1999 Sep;52(3):245-9
Department of Radiation Oncology, The University of Texas, M.D. Anderson Cancer Centre,
Houston 77030, USA.
BACKGROUND AND PURPOSE: Solitary extramedullary plasmacytoma (EMP) represents a rare
category of malignant disease on which there are limited data in regard to diagnosis,
staging and natural history. This study attempted to clarify the clinical course of
solitary extramedullary plasmacytoma after radiation or surgical therapy given with
curative intent. MATERIALS AND METHODS: The diagnosis was based on a mass of clonal plasma
cells separate from bone or bone marrow without evidence of occult disease elsewhere.
Between 1963 and 1996, 22 previously untreated patients with an EMP were diagnosed. Disease presented in the head or neck in 86%, usually in the nasal cavity
(NC) or maxillary sinus (MS), and in these areas local bone destruction was found
in 10 of 11 patients. Among all patients, serum myeloma protein was present in three
patients (14%) and Bence Jones protein alone was found in two patients (9%). Radiation
therapy was the sole treatment for 18 of 22 patients, and the median
radiotherapy dose was 50 Gy (range, 40-60 Gy); five of seven patients with an EMP
of oral cavity (OC), oropharynx (OP), nasopharynx (NP), parotid or larynx also received
elective neck irradiation. Two patients underwent surgery plus postoperative irradiation
of a plasmacytoma of the sigmoid colon or pleura, and two patients had resection alone of
a plasmacytoma of the colon or cervical lymph node. RESULTS: Local
control was achieved in 21 of 22 patients (95%), and disease never recurred in
regional nodes. Disappearance of myeloma protein occurred in three of five patients with
an evaluable abnormality. Multiple myeloma developed in seven
patients (32%), all within 5 years. The 5-year rate of freedom from progression to
multiple myeloma was 56% and the median survival was 9.5 years. CONCLUSION: Radiation
therapy achieved excellent locoregional control of EMP with an approximate cure fraction
The role of radiation therapy in the treatment
of solitary plasmacytomas.
Mayr NA, Radiother Oncol 1990 Apr;17(4):293-303
Department of Radiology, University of Iowa College of Medicine, Iowa City 52242-1059.
Between 1960 and 1985, 30 patients with solitary plasmacytomas were treated with
radiotherapy at the University of Iowa: 13 patients with extramedullary plasmacytomas
(EMP) and 17 with solitary plasmacytomas of bone (SPB). The local
control rates were 92% for patients with EMP and 88% for those with SPB. Two of
nine patients (22%) with EMP treated to the primary tumor only developed regional lymph
node metastasis, indicating the need for elective irradiation of this area. The most
common pattern of failure in both groups was progression to multiple myeloma. This
occurred in 23% of the patients with EMP and 53% of those with SPB. The time course of
progression to multiple myeloma differed for the two groups. All of those who progressed
to multiple myeloma in the EMP group did so within 2 years, whereas a significant number
of those in the SPB group progressed more than 5 years after initial therapy. None of five
patients who received adjuvant chemotherapy in the SPB group progressed to multiple
myeloma, compared to 75% (9/12) of the patients who did not receive chemotherapy.
Plasmacytomas of the head and neck.
Miller FR, Otolaryngol Head Neck Surg 1998 Dec;119(6):614-8
Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee,
Plasmacytomas are rare tumors that often appear in the head and neck region and are
characterized by a monoclonal proliferation of plasma cells. On both clinical presentation
and pathologic examination these tumors may be confused with more common tumors of the
head and neck. The purpose of this article is to review our experience with these rare
neoplasms, with emphasis on clinical, pathologic, and therapeutic features. On
retrospective chart review, we identified 20 patients with the diagnosis of plasmacytoma
of the head and neck region at the Cleveland Clinic Foundation between 1976 and 1993.
Records were reviewed with regard to initial symptoms, location of the neoplasm,
diagnostic evaluation, treatment modalities, and survival. Of the 20 cases we identified,
the tumor arose in the sinonasal/nasopharyngeal region in 11 (55%). Two cases (10%)
represented medullary plasmacytomas, arising in the clavicle and presenting as
supraclavicular masses. The mean follow-up was 60.2 months (range 6 to 131 months). In 15
of the 20 cases, immunohistochemistry staining for immunoglobulin light chain production
was conducted. One of the two cases (50%) classified as medullary plasmacytoma
demonstrated conversion to multiple myeloma, whereas only 2 of 18 cases of extramedullary
plasmacytoma (11%) converted to multiple myeloma. The primary modality of treatment was
radiation therapy with typical doses of 4500 to 6000 cGy.
Kaplan-Meier survival estimates demonstrated 95% survival at 1 year, 82% survival at 5
years, and 10-year estimated survival of 72%. Plasmacytomas of the head and neck region
are rare and on initial evaluation must be distinguished from multiple myeloma. The
diagnostic evaluation includes appropriate radiologic and pathologic studies including
immunohistochemistry. Despite the typical presentation as a locally destructive tumor, plasmacytomas are highly radiosensitive, and 70% to 80% survival may be
obtained with the use of radiotherapy. Patients with plasmacytomas require
long-term follow-up to detect conversion to multiple myeloma.
Solitary plasmacytoma of bone and soft tissue.
Bolek TW, Int J Radiat Oncol Biol Phys 1996 Sep 1;36(2):329-33
Department of Radiation Oncology, University of Florida, College of Medicine, Gainesville,
PURPOSE: This retrospective review evaluates the results of radiotherapy used for curative
intent in the management of solitary plasmacytoma. METHODS AND MATERIALS: Between August
1963 and January 1993, 37 patients with a solitary plasmacytoma were treated with curative
intent at the University of Florida. Criteria for inclusion in the study were (a) a
biopsy-proven plasmacytoma, (b) no tumor in the bone marrow on biopsy, and (c) no evidence
of disseminated disease on skeletal survey. The primary site was osseous in 27 patients
and extramedullary in 10 patients; 9 of the 10 extramedullary lesions were located in the
upper respiratory passages. Treatment consisted of primary radiotherapy in all but one
patient, who received surgical resection alone. Two patients also received adjuvant
chemotherapy. The median radiation dose was 43.2 Gy in 1.8-Gy
fractions. Absolute survival, progression to myeloma, and local control rates were
calculated using the Kaplan-Meier method. A multivariate analysis was performed for
prognostic factors predictive of absolute survival. RESULTS: Multivariate analysis
revealed tumor type (osseous vs. extramedullary) to be predictive of absolute survival (p
= 0.12). Factors not predictive of survival were age, sex, use of chemotherapy,
immunoglobulin level, and type of immunoglobulin elevated. Patients
with osseous tumors had a lower survival rate than those with extramedullary tumors (55%
vs. 80% at 10 years, p = 0.06). Multiple myeloma was more likely to develop in patients
with osseous tumors (54% vs. 11% at 10 years, 100% vs. 33% at 15 years, p = 0.03).
Of patients in whom multiple myeloma developed, those with osseous tumors had a poorer
survival rate after development of myeloma (32% vs. 100% at 5 years, p = 0.11). Local
relapse developed in 1 patient with an osseous tumor 10 months after treatment with 28.3
Gy in 14 fractions; this was controlled with an additional 28.3 Gy in 10 fractions. Local
failure did not develop in any patient with an extramedullary tumor. CONCLUSIONS:
Radiotherapy is an effective local treatment for solitary plasmacytoma. Osseous tumors
were found to have a poor prognosis compared with extramedullary tumors.
Solitary plasmacytoma of bone: treatment,
progression, and survival.
Chak LY, J Clin Oncol 1987 Nov;5(11):1811-5
Department of Therapeutic Radiology, Stanford University, Medical Center, CA.
Twenty patients with solitary plasmacytoma of bone were treated by radiation therapy.
Local control was achieved in 19 and most patients developed systemic myeloma. To evaluate
disease progression, 65 patients, including 45 from published series, were analyzed.
Younger patients seemed less likely to progress (P = .06), but other clinical
characteristics including site of involvement and paraprotein status did not influence
progression. After dissemination, patients had a clinical course
similar to patients with stage I myeloma, with a median survival of 47 months. Overall,
patients with solitary plasmacytoma of bone had an indolent course of disease, with a
median survival of 10.7 years and a 5-, 10-, and 20-year survival of 75%, 52%, and 37%,
Solitary plasmacytoma of bone: Mayo Clinic
Frassica DA, Int J Radiat Oncol Biol Phys 1989 Jan;16(1):43-8
Mayo Clinic, Rochester, MN 55905.
A review of 46 cases of solitary plasmacytoma of bone was undertaken in an attempt to
better define the clinical features and prognostic indicators associated with this
disease. Criteria for inclusion in the study included the following: (a) solitary lytic
bone lesion on skeletal survey; (b) histologic confirmation of the lesion; and (c) bone
marrow plasmacytosis of less than 10 percent. Patients with extramedullary plasmacytomas
and osteosclerotic lesions were excluded. All patients were evaluated with serum and urine
protein studies at the time of diagnosis. The median follow-up was 90 months with a
minimum of 30 months. Fifty-four percent of the lesions involved the vertebral column. The
thoracic spine was the single most commonly involved site (13/46 patients). The initial
lesion was treated with radiotherapy in all but three patients in whom complete surgical
resection was achieved. Total doses ranged from less than 20 Gy to 70 Gy with a median of 39.75 Gy. Overall, 54% developed
multiple myeloma, 2% failed with new bone lesions without multiple myeloma, and 11%
developed local recurrences. No patient receiving 45 Gy or more to
the solitary lesion had a local failure. While the median time to progression was
18 months, 23% of the failures occurred after 60 months. The five local failures occurred
at 7, 12, 18, 40, and 114 months. The overall survival was 74% at 5 years and 45% at 10
years. The 5- and 10-year disease-free survivals, however, were 43 and 25%, respectively.
Evidence of abnormal serum and/or urine protein was found in 25 of 46 patients. Neither
survival nor disease-free survival was significantly influenced by the presence of
abnormal proteins even if they persisted after irradiation.