Leukemia (2008), 16
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KEYNOTE ADDRESS
The role of vertebral augmentation in multiple myeloma: International Myeloma
Working Group Consensus Statement
MA Hussein1, FD Vrionis2, R Allison3, J Berenson4, S Berven5, E Erdem6, S Giralt7, S Jagannath8, RA Kyle9, S LeGrand10,
R Pflugmacher11, N Raje12, SV Rajkumar9, L Randall13, D Roodman14, D Siegel15, R Vescio16, J Zonder17 and BGM Durie16
on behalf of the International Myeloma Working Group18
1Department of Hematologic Malignancies, H Lee Moffitt Cancer Center, Tampa, FL, USA; 2Department of Neuro-Oncology, H Lee
Moffitt Cancer Center, Tampa, FL, USA; 3Department of Radiation Oncology, Brody School of Medicine at ECU, Greenville, NC,
USA; 4Department of Hematology/Medical Oncology, Institute for Myeloma & Bone Cancer Research, Los Angeles, CA, USA;
5Department of Orthopaedic Surgery, University of California, San Francisco, CA, USA; 6Division of Radiology, Section of
Interventional Neuroradiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA; ; 7Stem Cell Transplantation &
Cellular Therapy Department, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; 8Department of Medical
Oncology/Internal Medicine, St Vincent's Comprehensive Cancer Center, New York, NY, USA; 9Department of Laboratory Medicine
and Pathology, Mayo Clinic, MN, USA; 10Department of Medical Oncology/Internal Medicine, Cleveland Clinic Foundation,
Cleveland, OH, USA; 11Department of Musculature, Charite´ der Humboldt Universita`t, Berlin, Germany; 12Department of Medical
Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; 13Department of Orthopaedics, Huntsman
Cancer Institute, Salt Lake City, UT, USA; ; 14Department of Hematology/Oncology, University of Pittsburgh School of Medicine,
Pittsburgh, PA, USA; 15Department of Medical Oncology, Hackensack Cancer Center, Hackensack, NJ, USA; 16Department of
Hematology/Oncology, Cedars-Sinai Outpatient Cancer Center, Los Angeles, CA, USA and 17Department of Medicine, Division of
Hematology-Oncology, Karmanos Cancer Center, Wayne State University School of Medicine, Detroit, MI, USA
Leukemia advance online publication, 29 May 2008;
can restore vertebral height and reduce kyphotic deformity in
doi:10.1038/leu.2008.127
addition to stabilizing the fractured vertebral body.
The first prospective trial evaluating the role of balloon
kyphoplasty in multiple myeloma showed that over 80% of
Introduction
the treated patients experienced significant pain control.5
In addition, there was an overall 30% height restoration with
There are approximately 20 000 new patients diagnosed with
improvement of 6070% of height restoration when the
myeloma in the United States each year.1 With the availability
procedure was performed for fractures less than 6 months
of better treatments and resultant improved survival, there are
old.5 The procedure was also noted to be effective and safe in
currently close to 100 000 patients living with myeloma in the
other malignancies.6 In another study of 20 multiple myeloma
United States. Similar incidence and prevalence rates exist
patients (48 levels) treated with balloon kyphoplasty, significant
throughout Europe.2 Of these patients, the spine is affected by
pain improvement as judged by visual analogue scale occurred
osteolytic and/or osteopenic bone disease in 70%.3 Myeloma is
within the first year of follow-up.7 About 80% of patients with
the commonest primary cancer affecting the spine. Painful
initial kyphotic deformity had post-operative kyphosis correc-
vertebral compression fractures (VCFs) affect approximately
tion of approximately 61, with only minimal loss of height after
30% of myeloma patients. As myeloma patients live longer, it is
1 year (B1.81). The overall data related to both vertebroplasty
especially relevant to provide the best available treatment for
and balloon kyphoplasty are addressed in a number of
pain and reduce disabilities that can result from VCFs.4
publications.5,820
The focus of this summary is to assess the role of minimally
In considering the potential benefit of PMMA injection, it is
invasive percutaneous injection of polymethyl methacrylate
necessary to be aware of the biomechanics of pathologic spine
(PMMA), first developed as `vertebroplasty' in France in the late
fractures (Figure 1). With the occurrence of a VCF, the center of
1980s. Considerable experience accrued, especially in Europe,
gravity moves forward. Because of the large bending moment
with the use of vertebroplasty as treatment for painful VCFs. The
created, the anterior spine, especially in the regions adjacent to
fractured bone fragments are stabilized and strengthened by
the VCF, must resist larger compressive stresses. The posterior
PMMA and pain is substantially improved. A more recent
muscles and ligaments are additionally stressed, which can be
modification of vertebroplasty is percutaneous balloon kypho-
an obvious source of pain. Early intervention is a way to reduce
plasty whereby inflation of a balloon prior to PMMA injection
the risk of a `domino effect' with increased forward movement
of the center of gravity, additional compressive stresses and
possible further VCFs. The consequences of progressively
Correspondence: Dr BGM Durie, Aptium Oncology Inc., Cedars-Sinai
altered vertebral mechanics and the kyphosis-related VCFs in
Outpatient Cancer Center, 8201 Beverly Boulevard, Los Angeles, CA
90048, USA.
myeloma patients can be substantial as summarized in Table 1.
E-mail: bdurie@aptiumoncology.com or
Obviously, the safety of vertebral augmentation is an
Dr MA Hussein, H Lee Moffitt Cancer & Research Institute 12902
important consideration. The potential complications of vertebral
Magnolia Drive, SRB4, Tampa, FL 33612, USA.
augmentation are summarized in Table 2. A literature review
Email: mohamad.hussein@moffitt.org
18
meta-analysis of procedure-related complications for balloon
See Appendix for members of the International Myeloma Working
kyphoplasty and vertebroplasty indicates that complications
Group
Received 18 February 2008; revised 2 April 2008; accepted 28 April
such as extravasation of PMMA are less with balloon kypho-
2008
plasty.21 It should be noted that asymptomatic extravasation of
The role of vertebral augmentation in multiple myeloma
MA Hussein et al
2
gives a realistic expectation as to outcomes in a center
specializing in myeloma care (Table 3). The presence of any
plasmacytoma tissue between the PMMA and the fractured
cortical bone can lead to suboptimal improvement in stabiliza-
tion and any subsequent pain relief from any form of vertebral
augmentation.9 Active awareness of potential complications and
careful patient selection are obviously crucial.
The role of vertebral augmentation in the treatment of
myeloma of the spine is still evolving. The impact of VCFs
upon quality of life and survival is illustrated by results of a large
study in women aged X65 years. In this study of a total of 9575
women aged 65 years or older, 1915 of the women (20.0%)
were diagnosed as having VCF secondary to osteoporosis. The
fractures were not only associated with increased morbidity, but
also with increased mortality.23 The increased mortality was
particularly from pulmonary complications.23 Moreover, patient
mortality increased with greater numbers of vertebral fractures,
from 19 per 1000 woman-years in women with no fractures to
44 per 1000 woman-years in those with five or more fractures
(Po0.001).
Figure 1 Movement of center of gravity (CG) forward with vertebral
These data accentuate the need for management guidelines
compression fracture.
for VCFs. Formal guidelines on the use of vertebral augmenta-
tion for myeloma in the spine are missing. The purpose of this
Table 1
Consequences of VCF-related kyphosis
paper is to review the evidence regarding the role of vertebral
augmentation in the spine and to provide a consensus statement
Compression of abdominal contents
on the role of vertebral augmentation for the management of
K
Anorexia, weight loss
myeloma affecting the spine. Those aspects of therapy were
reviewed, discussed and considered by the International
Decreased lung capacity
Myeloma Working Group and a special advisory board
K
Limited exercise tolerance/physical activity
convened at the time of the XI International Myeloma Workshop
KOS Greece on 29 June 2007.
Anterior loading of spine (Figure 1)
K
Subsequent fractures
K
Increasing kyphosis and deformity
The following is the consensus statement from the International
Myeloma Working Group:
Abbreviation: VCF, vertebral compression fracture.
1. Indications for vertebral augmentation: The indications are
Table 2
Potential complications of vertebral augmentation
summarized in Table 4. These indications apply, provided
contraindications are not present as summarized in Table 5.
If severe pain is present, the advisory board reached a
K
Extravasation of PMMA cementa
J
consensus that it is very reasonable to proceed with
Local effects
J
Systemic effects including pulmonary
immediate vertebral augmentation. A major advantage is
K
Cord compression (spinal cord)
the rapid pain relief especially compared with alternative
K
Radiculopathy (foramina)
analgesic strategies summarized in Table 6. Early augmenta-
K
Pneumothorax
tion also proactively reduces the risk of the vicious cycle of
K
further VCFs as described above as well as providing the
Retroperitoneal hematoma
maximum chance of restoring height and correcting angular
K
Infection: local/systemic
deformity. Early augmentation also does not preclude
Abbreviation: PMMA, polymethyl methacrylate.
a
additional or subsequent use of any of the alternative strategies
See text for discussion.
such as those summarized in Table 6. In the absence of severe
pain, augmentation is a proactive measure to preserve
Table 3
Outcomes with balloon kyphoplasty at H Lee Moffitt
structural integrity. When there is severe bone destruction
Cancer Centera
and in anticipation of potential long patient survival, this
secondary indication is very much a viable option to
K
41 patients; 62 kyphoplasties
maximize quality of life by preventing potential VCFs.
K
13% PMMA extravasation
2. Identification of patients suitable for vertebral augmentation:
K
The four major components of the recommended baseline
1 case of pneumothorax; resolved
evaluation are summarized in Table 7. Obviously, one must
K
95% partial or substantial pain relief
be certain that the pain is emanating from the collapsed or
K
All patients discharged within 23 h (i.e. o 1 day)
damaged vertebra(e). In addition to X-ray, which most
Abbreviation: PMMA, polymethyl methacrylate.
patients will have undergone to diagnose the problem, more
aData published under Vrionis et al.21
detailed evaluation with magnetic resonance imaging
(including STIR (Short T1 Inversion Recovery) images) is
PMMA occurs in about 7% balloon kyphoplasty versus 19.7%
essential particularly to determine the presence or absence of
vertebroplasty but rarely leads to clinical complications.22 As an
spinal cord compression and/or edema. Also, the potential
example, the single center experience at Moffitt Cancer Center
for retropulsion and/or direct leakage of PMMA can be
Leukemia
The role of vertebral augmentation in multiple myeloma
MA Hussein et al
3
Table 7
Identification of patients suitable for vertebral augmentation
Table 4
Indications for vertebral augmentationa
1 Careful pain assessment to determine source/severity of pain.
Primary: severe pain present (pain 47/10 on VAS)
2 MRI is essential to document the anatomy and assess spinal cord
K
Collapse of one or more vertebra (VCF)
edema/compression
K
Bone destruction (osteolytic/osteopenic) with high risk of
3 Assessment of myeloma disease status and potential anti-myeloma
collapse of one or more vertebra
treatment needs
4 Assessment of other pain therapy options (Table 6)
Secondary: severe pain absent (pain p7/10 on VAS)
K
Significant loss of height and/or structural integrity or stability
Abbreviation: MRI, magnetic resonance imaging.
Abbreviations: VAS, visual analogue scale; VCF, vertebral compression
fractures.
a
3. Timing for the vertebral augmentation: Early intervention is
Provided no contraindications (Table 5).
currently being investigated in the CAFE (Cancer Fracture
Evaluation) trial in which immediate and delayed vertebral
augmentation are being contrasted and compared. The group
Table 5
Contraindications to vertebral augmentation
reviewed available data and clinical experience available
now and agreed to the following:
Absolute
Relative
Immediate vertebral augmentation is a treatment option
K
Contraindications to general
K
Lesions above T3
for acute VCF with severe pain or VCF at high risk for
or local anesthesia
K
Pregnancy
K
Osteoblastic metastases
progressive deformity. Excellent short- and long-term
K
Bleeding disorder
K
Patient o40 years of age
results have been achieved in this setting;
K
Infection at the site
K
Technically not feasible
For patients with lesser pain and/or vertebral damage,a
(vertebra plana)
trial of analgesic therapy with supportive measures
K
Pain unrelated to vertebral
K
Fractures with obstructing
including bisphosphonates and/or systemic therapy is
collapse
plasmacytoma(ta)
generally recommended. The appropriate duration of this
K
Cord compression
K
Retropulsed bone
K
Presence of overt instability
type of therapeutic trial relates to the severity of the pain
K
Severe cardiopulmonary
and potential reversibility with systemic measures. In
insufficiency
general, augmentation can be considered as soon as
K
Allergy to procedure-related
feasible especially if pain worsens and/or persists and/or
drugs/contrast
to prevent further vertebral collapse. Early intervention is
especially important if stabilizing the spinal structure and/
or restoring the height are critical. Excellent results have
been achieved in these settings. Results of the ongoing
Table 6
Alternatives for pain therapy
randomized CAFE´ trial evaluating pain relief and quality of
life with immediate versus delayed balloon kyphoplasty
Options
Discussion
are eagerly awaited;
If pain persists at the site of VCF, there is no upper time
PMMA vertebral
K
Rapid pain relief
limit beyond which augmentation cannot be considered.
augmentation
K
Simple procedure
However, earlier intervention is preferred to achieve
Radiation therapy
K
Pain relief has slower onset and less
maximal stabilization and/or correction of deformities.
complete
K
Reduces tumor mass swelling and may
4. Number of levels to be considered for treatment:
eliminate plasmacytoma(ta) locally
Multiple augmentation procedures may be necessary and
K
Destroys bone marrow stem cells locally
Systemic anti-
K
Can be fast acting
appropriate. In general, three to four vertebrae per
myeloma therapy
intervention is considered reasonable and feasible during
K
May or may not relieve severe local pain
a single procedure (if required). As many as 16 augmenta-
related to bone fragment movement
tions have been performed on an individual myeloma
K
Does not correct structural integrity
patient in separate sessions or stages.
Bisphosphonates
K
Can give rapid pain relief
Vertebral augmentation for adjacent or suspect vertebrae
K
May or may not relieve pain from bone
fragments
without fracture may be necessary. Such augmentations
K
Gives systemic benefit
can be considered when there is a fracture with kyphosis in
K
Generally very safe
the thoracolumbar region because the stress due to the
deformity in this region is very high. It is particularly
Analgesics
K
Can be rapid acting and effective
common to consider the performance of an additional
K
Efficacy relative to augmentation awaits
augmentation procedure in a vertebra when it is located
the results of CAFE trial (Table 8).
between two fractured vertebrae such as T11 and L1
Abbreviation: PMMA, polymethyl methacrylate.
requiring treatment for T12 to avoid post-procedure T12
collapse.
assessed. Computed tomography scanning in addition may
5. The highest level of augmentation to be performed was
be helpful especially if some combined surgical procedure
briefly discussed. It was decided that experienced operators
plus PMMA injection procedure is being considered. It is
can perform vertebral augmentation to levels as high as the
helpful to know to what extent systemic antimyeloma
cervical area and that this can be effective and safe. For
therapy will be required and assess absolute or relative
practical purposes, T3L5 is the range that can be performed
contraindications as summarized in Table 5.
safely by the percutaneous route.
Leukemia
The role of vertebral augmentation in multiple myeloma
MA Hussein et al
4
6. The method of vertebral augmentation: The risk of
Table 8
International Myeloma Working Group Consensus State-
complications, especially the risk of PMMA leakage, is
ments
greater with vertebroplasty. However, it was agreed that both
the utility and the likelihood of clinically significant
Article
Reference
complications are very much dependent upon the experi-
ence of the operator. It is therefore recommended that the
Criteria for classification of
Br J Haematol 2003;
monoclonal gammopathies
121:74957
choice of balloon kyphoplasty versus vertebroplasty be left to
Myeloma Management
Hematology Journal
the discretion of the operator and be based upon the goals of
Guidelines
2003;4:37998
the procedure.
International Staging System
JCO 2005; 23(15):19
7. Use of vertebral augmentation versus radiation therapy:
(ISS) for myeloma
Vertebral augmentation is considered the procedure of
International Uniform Response
Leukemia 2006 (17)
choice to improve quality of life for painful VCFs. However,
Criteria for Multiple Myeloma
Use of Bisphosphonates in
Mayo Clinic Proceedings
external beam radiotherapy (EBR) is a valid option that
Myeloma
2007; 85:51622
requires careful consideration. EBR is simple and can be
Prevention of Thalidomide and
Leukemia 2008; 22:41423
performed in one session without risks of anesthesia,
Lenalidomide associated
bleeding, infections or compromise of vital structures. Local
Thrombosis in Myeloma
marrow stem cell damage is most likely minimally different
Myeloma in Patients Under Age
Blood, April 2008; 111(8):
with 30 Gy of EBR versus the impact of heated PMMA
50
403947
injected into one to three vertebral bodies. Thus, if discreet
plasmacytomata exist within a vertebra and/or there is a
symptomatic extramedullary mass or impending/overt spinal
Currently, there are no specific guidelines or contraindica-
cord compression occurs, the use of EBR can be the option of
tions regarding factors such as kyphosis, retropulsion and caudal
choice. Systemic antimyeloma therapy is an alternative for
compromise or degree of vertebral body collapse. The issue of
rapid reduction in myeloma tumor burden. In addition,
spinal instability and its effect on overall decision making need
medical pain therapy can provide helpful relief as necessary.
to be determined on an individual basis by the treating spine
8. Physical rehabilitation: To maximize the recovery from
expert. The unstable spine is at risk of progressive deformity or
augmentation, a physical rehabilitation program is recom-
impairment of the neural elements. Generally, operative care
mended. Ideally, this should be in the form of water aerobics
with open surgery rather than percutaneous augmentation
and thoracolumbar stabilization with an extension direc-
techniques is most valuable in the setting of spinal instability.
tional focus, under the supervision of a physical therapist.
In addition, the number of fractures that can be treated at each
9. Further trials are still required to clarify the role of vertebral
intervention or stage; the amount of methylmethacrylate to be
augmentation in a variety of situations including the
injected; the need to treat adjacent or intervening nonfractured
following:
segments; the issue of unilateral or bilateral, transpedicular or
extra-pedicular; open or percutaneous approaches under local
prevention of further fractures in asymptomatic patients;
or general anesthesia all need to be determined by the treating
treating asymptomatic fractures; and
surgeon or radiologist. However, it is recommended that not
treating asymptomatic fractures compromising the spinal
more than three or four fractures are treated per stage as the risk
structure or pulmonary capacity
of pulmonary complications increases with the number of
treated fractures. The advisory board delegated the details of this
decision making, related to numbers and methodology, to the
selected operators of the augmentation procedures.
Discussion
In general, vertebral augmentation is not recommended for
asymptomatic fractures unless there is documented increased
This International Myeloma Working Group Consensus State-
collapse and deformity progression or in the context of an
ment is the latest in a series of publications from the working
adjacent or intervening segment. This could be documented by
group as summarized in Table 8. Additional consensus
follow-up radiologic studies performed every 3 months or
statements scheduled for 2008 include the role of free light-
sooner if the clinical picture dictates. The role of skeletal
chain analysis; guidelines for use of Epoetin; the role of imaging;
augmentation for sacral or iliac fractures in patients with
and a new genetic classification for myeloma.
myeloma is currently unknown.
Vertebral augmentation techniques discussed as part of this
As noted above, vertebral augmentation should be considered
consensus statement can be used for both acute and chronic
as the procedure of choice to improve quality of life for painful
fractures. Myeloma patients with mechanical pain, that is pain
compression spinal fractures in myeloma patients instead of EBR
that is most significant in the upright position, standing or
or placement of intrathecal morphine pumps. In patients with
walking and significantly decreased in a reclining position,
plasmacytomata in bone or extramedullary plasmacytomata
which anatomically correlates with the area of the fracture, are
extending into the epidural space, open surgical decompression
most likely to benefit from vertebral augmentation. Other types
or radiation therapy with or without augmentation may be
or causes of pain (radicular, dysesthetic, discogenic or
appropriate. In patients with a stable spine without fracture or
degenerative) should be carefully assessed as they can coexist
progressive deformity, radiotherapy should be considered first.
with pain related to compression fractures and are unlikely to
Receiving radiation therapy does not preclude future augmenta-
respond to vertebral augmentation interventions.
tion. Vertebral augmentation and radiation can be viewed as
Absolute contraindications to augmentation including myelo-
complementary, with augmentation restoring anatomy and
pathy or cauda equine syndrome are listed in Table 5. Relative
radiation ablating symptomatic disease. Augmentation has the
contraindications include coagulopathy, neutropenia, allergy to
advantage of rapid relief in a single sitting, which should allow
substances used for the procedure and high anesthetic risks
patients requiring radiation to be treated in a more comfortable
(Table 5).
state. This is particularly important for individuals undergoing
Leukemia
The role of vertebral augmentation in multiple myeloma
MA Hussein et al
5
radiosurgery where treatment time approaches an hour and
10 Atalay B, Caner H, Gokce C, Altinors N. Kyphoplasty: two years of
immobility is crucial for accuracy.
experience in a neurosurgery department. Surg Neurol 2005; 64
In summary, patients with plasmacytomata, extramedullary
(S2): 7276.
masses and cord compromise should be considered for use of
11 Crandall D, Slaughter D, Hankins PJ, Moore C, Jerman J. Acute
versus chronic vertebral compression fractures treated with
up-front radiotherapy. Vertebral augmentation is a developing
kyphoplasty: early results. Spine J 2004; 4: 418424.
field with current and future trials being necessary to further
12 Fourney DR, Schomer DF, Nader R, Chlan-Fourney J, Siki D, Ahrar
define what constitutes an `impending fracture' and establish the
K et al. Percutaneous vertebroplasty and kyphoplasty for painful
role of pre-emptive augmentation procedures. Having all
vertebral body fractures in cancer patients. J Neurosurg 2003; 98 (1
options available for multiple myelomas, patients insures
suppl): 2130.
optimal therapeutic intervention to improve both quality of life
13 Gaitanis IA, Hadjipavlou AG, Katonis PG, Tzermiadianos MN,
Pasku DS, Datwardhan AG et al. Balloon kyphoplasty for the
and overall survival.
treatment of pathological vertebral compression fractures. Eur
Spine J 2005; 14: 250260.
14 Gerszten PC, Germanwala A, Burton SA, Welch WC, Ozhasoglu
C, Vogel WJ. Combination of kyphoplasty and spinal radiotherapy:
References
a new treatment paradigm for pathological fractures. Neurosurg
Focus 2005; 18: e8.
1 Jemal A, Siegel R, Ward E, Murray T, Xu J, Thun MJ. Cancer
15 Hentschel SJ, Burton AW, Fourney DR, Rhines LD, Mendel E.
Statistics 2007. CA J Clin 2007; 57: 4366.
Percutaneous vertebroplasty and kyphoplasty performed at a
2 Boyle P, Ferlay J. Cancer incidence and mortality in Europe 2004.
cancer center: refuting proposed contraindications. J Neurosurg
Ann Oncol 2005; 16: 481488.
Spine 2005; 2: 440446.
3 Durie BGM, Kyle R, Belch A, Bensinger W, Blade J, Boccadoro M
16 Kose KC, Cebesoy O, Akan B, Altinel L, Dincer D, Yazar T.
et al. Myeloma management guidelines: A consensus report from
Functional results of vertebral augmentation technique in patho-
the scientific advisors of the international myeloma foundation.
logical vertebral fractures of myelomatous patients. J Natl Med
Hematol J 2003; 4: 379398.
Assoc 2006; 98: 15431548.
4 Durie BGM. New approaches to treatment for multiple myeloma:
17 Lane JM, Hong R, Koob J, Kiechle T, Niesvizky R, Pearse R et al.
durable remission and quality of life as primary goals. Clin
Kyphoplasty enhances function and structural alignment in multi-
Lymphoma Myeloma 2005; 6: 181190.
ple myeloma. Clin Orthop 2004; 426: 4953.
5 Dudeney
S,
Lieberman
IH,
Reinhardt
MK,
Hussein
M.
18 Ledlie JT, Renfro MB. Kyphoplasty treatment of vertebral body
Kyphoplasty in the treatment of osteolytic vertebral compression
compression fractures: 2-year outcomes show sustained benefits.
fractures as a result of multiple myeloma. J Clin Oncol 2002; 20:
Spine 2006; 31: 5764.
23822387.
19 Lieberman I, Reinhardt MK. Vertebroplasty and kyphoplasty for
6 Pflugmacher R, Beth P, Schroeder RJ, Schaser KD, Melcher I.
osteolytic vertebral collapse. Clin Orthop 2003; 415S: S176S186.
Balloon kyphoplasty for the treatment of pathological fractures in
20 Weber CH, Krotz M, Hoffmann RT, Euler E, Heining S, Pfeifer KJ
the thoracic and lumbar spine caused by metastasis: one year
et al. CT-guided vertebroplasty and kyphoplasty: comparing
follow-up. Acta Radiol 2007; 48: 8995.
technical success rate and complications in 101 cases. Rofo
7 Pflugmacher R, Kandziora F, Schroeder RJ, Melcher I, Haas NP,
2006; 278: 610617. (Article in German, abstract in English).
Klostermann CK et al. Percutaneous balloon Kyphoplasty in the
21 Vrionis FD, Hamm A, Stanton N, Sullivan M, Obadia M, Muiguel
treatment of pathological vertebral body fracture and deformity in
R. Kyphoplasty for tumor-associated spinal fractures. Tech Reg
multiple myeloma: a one-year follow-up. Acta Radiol 2006; 47:
Anesth Pain Manag 2005; 9: 3539.
369376.
22 Eck JC, Nachtigall D, Humphreys SC, Hodges SD. Comparison of
8 Khanna AJ, Reinhardt MK, Togawa D, Lieberman IH. Functional
vertebroplasty and balloon kyphoplasty for treatment of vertebral
outcomes of Kyphoplasty for the treatment of osteoporotic and
compression fractures: a meta-analysis of the literature. The Spine
osteolytic vertebral compression fractures. Osteoporos Int 2006;
Journal 2007, 110.
17: 817826.
23 Kado DM, Browner WS, Palermo L, Nevitt MC, Genant HK,
9 Gerszten PC, Welch WC. Combined percutaneous transpedicular
Cummings SR. Vertebral fractures and mortality in older women: a
tumor debulking and Kyphoplasty for pathological compression
prospective study. Study of Osteoporotic Fractures Research
fractures. Technical note. J Neurosurg Spine 2007; 6: 9295.
Group. Arch Intern Med 1999; 159: 12151220.
Appendix
Michele Cavo, Universita di Bologna, Bologna, Italy
Wen Ming Chen, MM Research Center of Beijing, Beijing,
International Myeloma Working Group:
China
Ray Alexanian, MD Anderson, Houston, Texas, USA
Tony Child, Leeds General Hospital, Leeds, United Kingdom
Kenneth Anderson, DFCI, Boston, Massachusetts, USA
James Chim, Department of Medicine, Queen Mary Hospital,
Michael Attal, Purpan Hospital, Toulouse, France
Hong Kong
Herve Avet-Loiseau, Institute de Biologie, Nantes, France
Ray Comenzo, Memorial Sloane-Kettering, New York City,
Ashraf Badros, University of Maryland, Baltimore, Maryland,
New York, USA
USA
John Crowley, Cancer Research and Biostatistics, Seattle,
Leif Bergsagel, Mayo Clinic Scottsdale, Scottsdale, Arizona,
Washington, USA
USA
William Dalton, H Lee Moffitt, Tampa, Florida, USA
Joan Blade´, Hospital Clinica, Barcelona, Spain
Faith Davies, Royal Marsden Hospital, London, England
Bart Barlogie, MIRT UAMS Little Rock, Arkanas, USA
Ca´rmino de Souza, Univeridade de Campinas, Caminas,
Regis Batille, Institute de Biologie, Nantes, France
Brazil
Meral Beksac, Ankara University, Ankara, Turkey
Michel Delforge, University Hospital Gasthuisberg, Leuven,
Andrew Belch, Cross Cancer Institute, Alberta, Canada
Belgium
Bill Bensinger, Fred Hutchinson Cancer Center, Seattle,
Meletios
Dimipoulous,
Alexandra
Hospital,
Athens,
Washington, USA
Greece
Mario Boccadoro, University of Torino, Torino, Italy
Angela Dispenzieri, Mayo Clinic, Rochester, Minnesota, USA
Leukemia
The role of vertebral augmentation in multiple myeloma
MA Hussein et al
6
Hermann Einsele, Universita¨tsklinik Wu¨rzburg, Wu¨rzburg,
Nikhil Munshi, Diane Farber Cancer Institute, Boston,
Germany
Massachusetts, USA
Theirry Facon, Centre Hospitalier Regional Universitaire de
Antonio Palumbo, Cathedra Ematologia, Torino, Italy
Lille, Lille, France
Santiago Pavlovsky, Fundaleu, Buenos Aires, Argentina
Dorotea Fantl, Socieded Argentinade Hematolgia, Buenos
Ruben Niesvizky, Weill Medical College of Cornell
Aires, Argentina
University, New York, New York, USA
Jean-Paul Fermand, Hopitaux de Paris, Paris, France
Yana Novis, Hospital Si´rioLibane^s, Bela Vista, Brazil
Rafael Fonseca, Mayo Clinic Scottsdale, Scottsdale, Arizona,
Amara Nouel, Hospital Rutz y Paez, Bolivar, Venezuela
USA
Raymond Powles, Leukaemia & Myeloma, Wimbledon,
Gosta Gahrton, Karolinska Institute for Medicine, Huddinge,
England
Sweden
Linda Pilarski, University of Alberta, Alberta, Canada
Morie Gertz, Mayo Clinic, Rochester, Minnesota, USA
S Vincent Rajkumar, Mayo Clinic, Rochester, Minnesota, USA
John Gibson, Royal Prince Alfred Hospital, Sydney, Australia
Donna Reece, Princess Margaret, Toronto, Canada
Hartmut Goldschmidt, University Hospital Heidelberg,
Tony Reiman, Cross Cancer Institute, Alberta, Canada
Heidelberg, Germany
Paul Richardson, Dana Farber Cancer Institute, Boston,
Philip Greipp, Mayo Clinic, Rochester, Minnesota, USA
Massachusetts, USA
Roman Hajek, Brno University, Brno, Czech Republic
Angelina Rodriquez Morales, Bonco Metro Politano de
Izhar Hardan, Tel Aviv University, Tel Aviv, Israel
Sangre, Caracas, Venezuela
Jean-Luc Harousseau, Institute de Biologie, Nantes, France
Orhan Sezer, Department of Hem/Onc, Universitatsklinikum
Hiroyuki Hata, Kumamoto University Hospital, Kumamoto,
Charite, Berlin, Germany
Japan
John Shaughnessy, M.I.R.T. UAMS, Little Rock, Arkansas,
Yutaka Hattori, Keio University School of Medicine, Tokyo,
USA
Japan
Kazayuki Shimizu, Nagoya City Midori General Hospital,
Joy Ho, Royal Prince Alfred Hospital, Sydney, Australia
Nagoya, Japan
Vania Hungria, Clinica San Germano, Sao Paolo, Brazil
David Siegel, Hackensack, Cancer Center, Hackensack, New
Mohamad Hussein, Cleveland Clinic Taussig Cancer Center,
Jersey, USA
Cleveland, Ohio, USA
Guido Tricot, M.I.R.T. UAMS, Little Rock, Arkansas, USA
Shinsuke Ida, Nagoya City University Medical School,
Jesus San Miguel, University of Salamanca, Salamanca, Spain
Nagoya, Japan
Seema Singhal, Northwestern University, Chicago, Illinois,
Peter Jacobs, Constantiaberg Medi-Clinic, Plumstead, South
USA
Africa
Pieter Sonneveld, Erasmus MC, Rotterdam, The Netherlands
Sundar Jagannath, St Vincent's Comprehensive Cancer
Chaim Shustik, McGill, Toronto, Canada
Center, New York, New York, USA
Andrew Spencer, The Alfred Hospital, Melbourne, Australia
Hou Jian, Shanghai Chang Zheng Hospital, Shanghai, China
Keith Stewart, Mayo Clinic Scottsdale, Scottsdale, Arizona,
Douglas Joshua, Royal Prince Alfred Hospital, Sydney,
USA
Australia
Patrizia Tosi, Italian Cooperative Group, Istituto di Ematologia
Michio Kawano, Yamaguchi University, Ube, Japan
Seragnoli, Bologna, Italy
Shaji Kumar, Department of Hematology, Mayo Clinic,
Ingemar Turesson, Department of Hematology, Malmo
Minnesota, USA
University, Malmo, Sweden
Robert Kyle, Department of Laboratory Med. and Pathology,
Brian Van Ness, University of Minnesota, Minneapolis,
Mayo Clinic, Minnesota, USA
Minnesota, USA
Juan Lahuerta, Grupo Espanol di Mieloma, Hospital
Ivan Van Riet, Brussels Vrija University, Brussels, Belgium
Universitario, Madrid, Spain
Robert Vescio, Cedars-Sinai Outpatient Cancer Center, Los
Jae Hoon Lee, Gachon University Gil Hospital, Incheon,
Angeles, California, USA
Korea
David Vesole, St Vincent's Comprehensive Cancer Center,
Henk Lokhorst, University Medical CenterUtrecht, Utrecht,
New York, New York, USA
The Netherlands
Anders Waage, University Hospital, Trondheim, Norway
Heinz Ludwig, Wilhelminenspital Der Stat Wien, Vienna,
NSMG
Austria
Michael Wang, M.D. Anderson, Houston, Texas, USA
Xavier LeLeu, Hospital Huriez, CHRU Lille, France
Donna Weber, MD Anderson, Houston, Texas, USA
Angelo Maiolino, Rua fonte da Saudade, Rio de Janeiro,
Jan Westin, University of Lund, Lund, Sweden
Brazil
Keith Wheatley, University of Birmingham, Birmingham,
Jayesh Mehta, Northwestern University, Chicago, Illinois,
United Kingdom
USA
Dina B Yehuda, Department of Hematology, Hadassah
GianPaolo Merlini, University of Pavia, Pavia, Italy
University Hospital, Hadassah, Israel
Philippe Moreau, University Hospital, Nantes, France
Jeffrey Zonder, SWOG, Department of Hem/Onc., Karmanos
Gareth Morgan, Royal Marsden Hospital, London, England
Cancer Institute, Michigan, USA
Leukemia
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