Expert’s comment concerning Grand Rounds case entitled “Total spondylectomy for solitary bone plasmacytoma of the lumbar spine in a young woman. A case report and review of the literature” (by N. von der Hoeh, S.K. Tschoeke, J. Gulow, A. Voelker, U. Siebolts and C.-E. Heyde)

Excerpt

The authors rightly point out in their review of the literature that the current treatment of a solitary plasmacytoma of bone (SBP) is local radiotherapy [1]. Guidelines recommend that SBP be treated with radical radiotherapy, encompassing the tumour volume shown on MRI with a margin of at least 2 cm and with a dose of 40 Gy in 20 fractions [2]. As detailed in the above case report and review of the literature, SBPs are highly radiosensitive and the aim of radical radiotherapy is cure. Knobel et al. [3] reported excellent local disease control with radiotherapy alone in their review of 206 patients with SBP. Local relapse occurred in 21 (14 %) out of 148 patients who received radiotherapy alone compared with four (80 %) out of five patients who were treated with surgery ± chemotherapy. The argument for doing a total spondylectomy in this case, with a solitary malignant but unknown (despite multiple biopsies) vertebral body tumour was understandable. However, the imaging was highly suggestive of an SBP. In addition, if biopsies had diagnosed a SBP prior to starting treatment then the decision to do a total spondylectomy would have been incorrect in our opinion. Even after the first stage procedure in this case, where all of the posterior elements had been removed and the diagnosis established by intra-operative biopsies, we would have argued against the second stage anterior spondylectomy being required. If the authors were concerned about progressive fracture of the L3 vertebral body after the first stage posterior procedure then they could have augmented the vertebral body with cement to strengthen and stiffen it [4]. The use of a balloon to create a void and high-viscosity cement should be considered for augmentation of a VCF in SBP and multiple myeloma (MM) to decrease the risk of cement leakage. …