How would you approach the treatment of a single vertebral body involved with multiple myeloma (MM)?

If single level of involvement and no other bony disease (i.e. plasmacytoma of the spine), I would favor standard fractionation to 45-50 Gy as definitive treatment. I usually treat 50 Gy/25 fractions.

If myeloma with other areas of disease, I favor standard palliative RT and cover 1 vertebral body above and below. Usual dose for me is 20 Gy/5 fractions but can also consider 8 Gy/1 fraction or other regimens.

Multiple myeloma (MM) of the spine can be treated in the same way as described in the NRG/RTOG 0631. In a small series of MM with or without spinal cord compression, the median dose was 16 Gy (10-18 Gy) to the painful regions of the spine. The result was >80% pain control of the treated spine and 80% epidural tumor control on MRI at 3 months (1).

Many patients with MM also present with compression fracture with or without bony retropulsion as a results of the due disease course. These cases do not preclude use of radiosurgery for MM of the vertebrae, although it is important to remember that the compressed spines do not regain their height after radiosurgery. Although there initially was much concern of radiation-induced compression fractur...