Fragile bones in a young male.

To the Editor: Multiple myeloma is a clonal B cell malignancy characterized by accumulation of plasma cells. (1) It can result in bone destruction leading to pain, hypercalcemia, osteopenia, pathologic fractures and spinal cord compression. Skeletal manifestations are not only due to deposition of plasma cells in the bones, but also secondary to increased osteoporotic activity. (2)

We present the case of a 39-year-old white male with no past significant history, who presented with severe back and neck pain of several weeks duration. His skeletal survey showed multiple lytic lesions, urine protein electrophoresis demonstrated more than 2 g of free kappa light chains, and a bone marrow aspirate and biopsy demonstrated 68% plasma cells.

A diagnosis of multiple myeloma was established, and he was started on a regimen of vincristine, Adriamycin, dexamethasone and pamidronate. The next day he developed hiccups accompanied by pain and a popping sensation in his chest. On examination he had pectus excavatum deformity which was new. A lateral chest x-ray confirmed a sternal fracture (Fig.).

Several studies have demonstrated that bisphosphonates are beneficial in the treatment of skeletal disease caused by multiple myeloma. In 2002, the American Society of Clinical Oncology set forth some practice guidelines for the use of bisphosphonates in myeloma. Recommendations have been made to use either pamidronate or zoledronic acid every 3 to 4 weeks in patients who have one or more lytic lesions on skeletal roentgenograms. (3)

Bisphosphonates prevent bone loss by binding to active sites of bone remodeling, inhibiting osteoclast-mediated bone resorption and eventually causing osteoclast apoptosis. (4) The efficacy of bisphosphonates has traditionally been judged mainly by their ability to reduce skeletal-related events (SREs), such as pathologic fractures, surgery or radiotherapy for bone metastasis, spinal cord compression and hypercalcemia. The first in this class was Clodronate, which was approved in Europe in an oral formulation. Newer generations of these drugs include pamidronate, zoledronic acid and ibandronate. (5)

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In summary, it should be kept in mind that in young individuals with multiple myeloma, pathologic fractures can occur spontaneously without any trauma. Bisphosphonates are an important class of drugs, as they can help in delaying the onset of SREs as well as have an analgesic role in bone pain. They should be used early on in the disease to improve the quality of life for these patients.

Umbreen Hasan, DR, MD, FACR 

Haleem Rasool, DR, MD, FACP 

Department of Oncology

University of Missouri

Columbia, MO

References

1. Desikan KR Dhodapkar MV Munshi NC, et al. Recent advances in the treatment of multiple myeloma. Curr Opin Hematol 1999;6:216-221.

2. Kyle R. The role of bisphosphonates in multiple myeloma. Ann Intern Med 2000;132:734-736.

3. Berenson JR, Hillner BE, Kyle RA, et al. American Society of Clinical Oncology clinical practice guidelines: the role of bisphosphonates in multiple myeloma. J Clin Oncol 2002;20:3719-3736.

4. Body JJ. Bisphosphonates for malignancy-related bone disease: current status, future developments. Support Care Cancer 2006;14:408-418. Epub 2006 Feb 1.

5. Bell R. Efficacy of ibandronate in metastatic bone disease: review of clinical data. Oncologist 2005; 10 (Suppl):8-13.