Challenges in the Treatment of Spinal Lesions in Patients with Multiple Myeloma

Due to improved systemic therapies, the life expectancy of patients suffering from multiple myeloma (MM) has increased significantly over the past few years. Patients who suffer from the disease for a longer period of time have an increased chance of developing skeletal-related events (SREs), i.e. a pathologic fracture, epidural spinal cord compression (ESCC), radiation (for pain or impending fracture) or surgery to the bone. No definitive guidelines exist on how to treat patients with spinal myeloma disease. Most patients with minimal neurologic deficits can be treated with systemic therapy. Unfortunately, some patients need an intervention like radiotherapy or surgery to relieve their symptoms (i.e. pain or neurologic deficits). However, both radiation and surgery are not without risks in the MM population. The emergence of innovative and highly effective systemic treatment options requires an evaluation of the benefits and adverse effects of radiation and surgery to create a better framework for optimal patient selection for these treatments. A comprehensive understanding of when certain treatment options should or should not be used is essential to achieve the best possible functional outcomes for these patients. As such, this thesis aims to provide insights into the magnitude of the problem of spinal instability and vertebral fractures (part I), and the effect and outcomes of radiation therapy (part II) and surgery (part III).