Solitary Bone
Bone and
Extramedullary Plasmacytoma
Raymond Alexanian, M.D.
Donna Weber, M.D.
Department of Lymphoma and Myeloma
M. D. Anderson Cancer Center
Solitary Plasmacytoma Bone: Diagnosis
· One Area
Area Bone
Bone Destruction
Normal Bone Survey
Normal Magnetic Resonance Imaging (MRI) Spine
· Normal Bone Marrow
No kappa or lambda clonality
· Low or Absent M Protein
Protein
Serum< 2.2 g/dL, BJP<0.7 g/dL
· P
d
reserve Ui
Uni
l
nvo ved I'
Ig's, HbC
Hgb, Ca++
SPB: Sites
(No. 76)
30
nts 20
ofpatie
10
No.
0
e
is
b
a
ll
s
r
ia
in
um
ul
ru
u
p
lv
Ri
p
n
p
ku
rn
p
S
e
m
ib
Jaw
S
S
T
Pe
e
a
m
Fe
St
Sc
Hu
SPB: P t
ro i
e n Types
IA
IgA (7%)
(7%)
IgG (54%)
k only (13%)
l only (2%)
Nonsecretory (24%)
SPB: Treatment Guidelines
United Kingdom Myeloma Forum
Forum (UKMF)
· Tumors < 5 cm
> 40 Gy in 20 fractions
· Tumors > 5 cm
50 Gy in 25 fractions
· All Patients
> 2 cm beyond MRI Margin
Guidelines Working Group of the UKMF
Br J Haematology 2004; 124: 717-726
SPB: M P t
ro i
e n L
l
eve s
N4
N= 6
46
N1
N= 2
12
> 2.0
/dL)
(g/day)
(g 1.6-2.0
.51-.75
1.1-1.5
Protein
sProtein
M
.26-.50
0.6-1.0
Jone
Serum 01
0.1-05
ence
0.5
<2
<. 5
25
B
0
5
10
15
20
25
0
246
8
No. of Patients
Post-Therapy Outcome of SPB
XRT
XR Dose
Dose 10y MM Free
-
OS
Series
No Pts.
(GY)
Survival (%)
(med yrs)
Wilder
60
30 70
-
38
11
(MDACC)
Frassica
46
25
93
9.3
Tsang
32
<30-50
36
10
Bolek
27
28-60
46
10
Wilder et al, Cancer 2001; 94: 1532
Frassica et al, Int J Rad Oncol 1989; 16: 43-48
Tsang et al, Int J Rad Onc Bio Phys 50; 113-120
Bolek et al, Int J Rad Onc Bio Phys 1996; 36: 329
Si
Survi l
va
Cause-Si
Spec fi
ific Survi l
va
M Protein Resolved (17)
100
M Protein Resolved (17)
80
p<.01
p<.01
M Protein Persisted (41)
ntLiving
60
n
M Protein Persisted (41)
40
Perce
20
Nonsecretory (18)
Nonsecretory (18)
10
20
30
10
20
30
SPB: Effect of XRT on Serum Myeloma Protein
3
>1.0 gm/dl
1.0 gm/dl
l)
(g/d
otein
2
Pr
eloma
My
1
erumS
0
Pre
Post
Pre
Post
XRT
XRT
XRT
XRT
Duration of Stability
100
M Protein Resolved (17)
80
Pk 1.0 + Disap(17)
60
ntStable
Nonsecretory (18)
n
p<.01
40
p<.01
Perce
Pk >1.0 +NO Disap(11)
20
M Protein Persisted (41)
Pk 1.0 +NO Disap(30)
10
20
30
10
20
30
Years from Radiotherapy
SPB: Effect of XRT on Serum Myeloma Protein
3
>1.0 gm/dl
1.0 gm/dl
l)
(g/d
otein
2
Pr
eloma
My
1
erumS
0
Pre
Post
Pre
Post
XRT
XRT
XRT
XRT
Added Criteria for "True SPB"
Preserved uninvolved Ig
No focal lesions on MRI spine
Serum myeloma protein 1.0 gm/dl
Proposed Treatment for "Other SPB"
40 GY XRT to symptomatic lesion
Options:
· Ni
No mai t
n enance
· Cytostatic treatment until disease progression
· Chemotherapy followed by intensive therapy
Conclusions
Modern staging has led to less frequent
diagnosis of true SPB
Projected higher cure fraction with XRT
Monotypic
CD38+
or
Extramedullary Plasmacytoma (EMP)
Diff
Dif erential Di
Diagnosis
Reactive
Plasma Cell Granuloma
Immunoblastic
Plasmacytosis
Lymphoma
EMP: Sites
(No. 25)
8
6
tients
pa
4
o.of
2
N
0
s
y
x
n
a
il
u
t
n
lo
al
nx
tid
iv
in
avi
ry
in
ry
ro
g
ngue
S
a
Co
node
n
o
Tons
y
C
h
k
p
La
rasp
Pa
c
Gi
t
sal
a
of
illar
a
P
e
x
N
aso
lne
N
a
s
N
Ma
ic
Ba
rv
Ce
EMP: Protein Types
IgG (8%)
IgA (8%)
k only (8%)
Nonsecretory (76%)
EMP: Survival
Progression-Free
Cause Specific
100
80
Cause-specific
60
Living
ntStable
nt
n
40
Overall
Perce
Perce
20
10
515
20
10
515
20
Years from Radiotherapy