Fracture rate after conventional external beam radiation therapy to the spine in multiple myeloma patients

Jens P. te Velde, Hester Zijlstra, Amanda Lans, Chirayu G. Patel, Noopur Raje, Diyar Delawi, Diederik H. R. Kempen, Jorrit-Jan Verlaan, Barend J. van Royen, Joseph H. Schwab

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Background Context: Conventional external beam radiation therapy (cEBRT) is used in multiple myeloma (MM) to treat severe pain, spinal cord compression, and disease-related bone disease. However, radiation may be associated with an increased risk of vertebral compression fractures (VCFs), which could substantially impair survival and quality of life. Additionally, the use of the Spinal Instability Neoplastic Score (SINS) in MM is debated in MM. Purpose: To determine the incidence of VCFs after cEBRT in patients with MM and to assess the applicability of the SINS score in the prediction of VCFs in MM. Study Design: Retrospective multicenter cohort study. Patient Sample: MM patients with spinal myeloma lesions who underwent cEBRT between January 2010 and December 2021. Outcome Measures: Frequency of new or progressed VCFs and subdistribution hazard ratios for potentially associated factors. Methods: Patient and treatment characteristics were manually collected from the patients’ electronic medical records. Computed tomography (CT) scans from before and up to 3 years after the start of radiation were used to score radiographic variables at baseline and at follow-up. Multivariable Fine and Gray competing risk analyses were performed to evaluate the diagnostic value of the SINS score to predict the post-radiation VCF rate. Results: A total of 127 patients with 427 eligible radiated vertebrae were included in this study. The mean age at radiation was 64 years, and 66.1% of them were male. At the start of radiation, 57 patients (44.9%) had at least one VCF. There were 89 pre-existing VCFs (18.4% of 483 vertebrae). Overall, 39 of 127 patients (30.7%) reported new fractures (number of vertebrae (n)=12) or showed progression of existing fractures (n=36). This number represented 11.2% of all radiated vertebrae. Five of the 39 (12.8%) patients with new or worsened VCFs received an unplanned secondary treatment (augmentation [n=2] or open surgery [n=3]) within 3 years. Both the total SINS score (SHR 1.77; 95% confidence interval (CI) 1.54–2.03; p<.001) and categorical SINS score (SHR 10.83; 95% CI 4.20–27.94; p<.001) showed an independent association with higher rates of new or progressed VCFs in adjusted analyses. The use of bisphosphonates was independently associated with a lower rate of new or progressed VCFs (SHR 0.47 [95% CI 0.24–0.92; p=.027]). Conclusions: This study demonstrated that new or progressed VCFs occurred in 30.7% of patients within 3 years, in a total of 11.2% of vertebrae. The SINS score was found to be independently associated with the development or progression of VCFs and could thus be applied in MM for fracture prediction and possibly prevention.

Original languageEnglish
Pages (from-to)137-145
Number of pages9
JournalSpine Journal
Issue number1
Early online date2023
Publication statusPublished - Jan 2024


  • Multiple myeloma
  • Radiotherapy
  • Spinal instability neoplastic score
  • Vertebral compression fractures

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