Review Question - QID 217745

The patient presents with an acute-onset, low-energy compression fracture with concurrent imaging and laboratory studies consistent with multiple myeloma. Figure E demonstrates a sheet of cells with large, eccentric clockface nuclei and abundant basophilic cytoplasm consistent with multiple myeloma.

Multiple myeloma (MM) is a plasma cell neoplasm that results in lytic bone lesions that can present in multiple locations throughout the body. It is the most common primary bone malignancy and affects typically patients >40 years of age. When it presents in a single location, it is called a solitary plasmacytoma. Plasma cells produce monoclonal immunoglobulin, which can be identified in SPEP and UPEP studies. Plasma cells will also produce RANKL, inducing osteoclast-mediated bone resorption. This can result in low-energy fractures in affected bones. Unlike osteoporotic vertebral body fractures, MM fractures have poor healing potential and are prone to progressive vertebral body height loss. Kyphoplasty can be used to restore vertebral body height, correct sagittal plane deformity, prevent progressive height loss, and minimize pain.

Xiao et al. performed a retrospective consecutive series on risk factors for vertebral compression fracture compression in MM patients. The authors found that patients with vertebral body fractures had a high risk of progressive vertebral body height loss, especially with comorbid hypertension, dyslipidemia, osteoporosis, greater body mass index, and increased time since the first follow-up. The authors concluded that MM patients with these risk factors may benefit from early intervention to prevent progressive disability.

Papanastassiou et al. wrote a letter responding to Xiao et al. expressing their opinion of vertebral augmentation in MM patients. They argued that, given the high progression rate, poor outcomes with late augmentation, and increased sagittal imbalance predisposing to more compression fractures, early vertebral augmentation should be considered in these patients. They further proposed a retrospective study comparing the outcomes of early to late vertebral augmentation.

Julka et al. performed a retrospective study of outcomes after kyphoplasty for MM-related vertebral compression fractures. Their study found that kyphoplasty had a significant improvement in vertebral compression fracture Genant grades and that a 37.5% cement extravasation rate was not clinically significant in any of the affected patients. They concluded that kyphoplasty remains a safe and effective procedure for pain relief and for improving radiographic alignment in vertebral compression fractures in MM patients.

Figure A depicts a lateral radiograph of the lumbar spine with a vertebral compression fracture in the thoracic spine.
Figure B is a histologic slide of chondrosarcoma, showing an abundance of extracellular matrix with signet cells and atypical cells with lightly eosinophilic or clear cytoplasm.
Figure C is a histologic slide of a hemangioma of bone with lakes of blood with epithelial cells interspersed within areas of bone.
Figure D is a histologic slide of osteosarcoma demonstrating lace-like osteoid with pleomorphic cells in between.
Figure E: is a histologic slide of multiple myeloma with a sheet of basophilic cytoplasm and large clockface nuclei.
Figure F is a histologic slide of synovial sarcoma with hyperchromatic, monophasic spindle cells tightly packed together and monotonous in appearance.

Incorrect Answers:
Answer 1-3,5: These are chondrosarcoma, hemangioma, osteosarcoma, and synovial sarcoma, respectively. Chondrosarcoma, osteosarcoma, and synovial sarcoma are atypical for vertebral body presentations, while hemangiomas can present within the vertebral body. However, these all would not likely present with multiple punched-out lesions or have an associated M-spike as this patient does.