Myeloma Awareness Week at the RNOH

Mr Sean Molloy, Spinal Consultant

Myeloma is a type of cancer arising from abnormal plasma cells found in the bone marrow. It weakens bone in areas where marrow is active such as the spine, skull, pelvis, rib cage and around the shoulders and hips. This can lead to significant bone pain and fractures, making it difficult for people with myeloma to walk, breathe and eat.

In support of Myeloma Awareness Week this week we spoke to Mr Sean Molloy, Consultant Spinal Surgeon at the RNOH, about the effects of spinal myeloma and some of the latest treatments available.

When are myeloma patients referred to the RNOH?

At the RNOH, we see patients with spinal fractures caused by myeloma that have been referred by their haematologist for a specialist opinion. We see younger patients in their 30s with quite an aggressive form of the disease who require urgent attention and treatment initially, both from the haematologists and from RNOH spinal surgeons. Then we have older patients where the disease is less aggressive but who are at higher risk of fracture because their bone density is already compromised.

Why do spinal fractures occur?

We normally have remodelling of bones all the way through our lives where we resorb some of the bone we have and we lay down more. In spinal myeloma, cells called ‘osteoclasts’ are activated which set off a cascade to eat away some of the bone leaving the vertebral body weaker, and prone to fractures. In addition, part of the treatment of myeloma itself is to give people steroids that are needed to treat the cancer but can also weaken the bone a little bit further.

Spinal myeloma patients often present with a rounded back called a ‘kyphosis’. This can be a very progressive phenomenon; where there’s one fracture patients are at more risk of getting a further fracture and so we have to try and get these patients stabilised quickly. Sometimes this will involve the patient wearing a plastic brace. These are very good because they hold the spine in place, lower the risk of further fractures occurring, and give bones a chance to strengthen with drugs called ‘bisphosphonates’, which stop the resorption of bone.

What treatment is available for spinal myeloma patients?

Traditionally, we used to insert a lot of metal work into the spine but we’re moving away from that now. We have a number of modalities that we didn’t have in the past which make patients a lot more comfortable and prevent spinal deformity.

The fundamental things we can do now are minimally invasive techniques called ‘percutaneous vertebroplasty’ and ‘balloon kyphoplasty’. These are essentially very small operative procedures which take about 15-20 minutes to perform. In the case of balloon kyphoplasty, we place a trocar (a hollow metal tube) into the vertebral body from the back and blow up a balloon to create a void. We then safely remove the balloon and inject acrylic cement into the void. The cement acts as a stabilising filler and restores the strength of the vertebral body.

We tend to prefer the balloon kyphoplasty than the percutaneous vertebroplasty because the void created by the balloon makes it safer for the cement and stops it leaking during the procedure. Albeit that it’s a spinal operation, it’s actually a minimally invasive treatment with a low risk of complication. It has been very beneficial for patients and works really well to alleviate their pain.

Is the treatment available to all spinal myeloma patients?

We have a Spinal Myeloma Working Group, comprising spinal surgeons, haematologists and radiologists from various units throughout the county. Our aim is to make sure that the best treatment is widely available for all patients and we have just had a paper accepted for publication containing guidelines for the treatment of spinal myeloma. We’re hoping to show that by treating these people early and having them referred from the haematologists early we can actually stop them getting a progressive deformity.

We are delighted with the collaboration from the Spinal Myeloma Working Group. We used to see ten myeloma patients a year and we now see 25 every Monday – national as well as international patients.

How can I get involved in spinal myeloma research?

We’ve had an international myeloma meeting here at Stanmore for the last two years, which has been very well attended with representatives from Europe, the States and the UK. We’ve had some excellent speakers and are planning our next event for spring 2016, which will be advertised on the RNOH website.

We’re also setting up a prospective study looking at spinal myeloma patients and treatment. We will be accepting patients from anywhere in the UK for the trial, as long as their haematologists are happy to refer them.

What’s next for spinal myeloma research at the RNOH?

We set up a spinal myeloma unit here at the RNOH about 6 years ago, and began by collaborating with haematologists who referred patients initially locally – from Northwick Park, UCLH, Royal Free, and now it’s expanded to include a lot of areas. We get requests for opinions from patients in Cornwall, Scotland, North of England, Ireland and even Italy. We’ve also had doctors train in this country and go back to Spain and Italy and refer patients back to us.

There may be a possibility in the future of setting up Telemedicine where we would be able to look at patients and images on screen and give opinions on it anywhere in the world. This would massively reduce the referrals waiting time – hugely benefiting our patients.

Further information

We are currently working on a myeloma patient information video, which will be published under our myeloma information section soon.

For more information about myeloma, visit Myeloma UK.

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