Would you recommend radiation to a painful rib fracture in a patient with multiple myeloma on systemic therapy with ongoing response to treatment?

It depends if it’s a newly diagnosed MM setting versus relapsed MM setting with a rib fracture. Some possible scenarios:

• For the ND setting, systemic therapy with adequate pain management early on is preferred.
• For relapsed setting, if the rib fracture heralded the relapse then systemic therapy/pain management is reasonable.
• If rib fracture occurs due to isolated area of active disease on PET while on active therapy, local XRT is reasonable to do.
• If rib fracture occurs in someone with non-acti...

This is a common scenario that we see especially in newly diagnosed myeloma, though my management is to start bridging therapy using dexamethasone until the patient can start systemic therapy. Once they start dexamethasone, I request to contact the patient the day after to discuss if the pain has improved or not, over 95% of the time the pain is either resolved or alleviated. I have no objection using radiation therapy but that is used if the pain is refractory to systemic therapy and other pain...

My practice for multiple myeloma small rib lesions/tumors is 8 Gy x 1. The toxicity is negligible, logistics minimal, and treatment does not interfere with any existing systemic therapies and can be given concurrently. There are pending data that will be presented at this upcoming ASTRO that support that even lower doses can be effective in this disease. Although there has been significant progress in MM systemic therapy, the disease remains incurable in the minds of most, with low percentages o...

I am starting to use single/2 day stereotactic RT developed at our center on protocol for single painful lesions in late advanced myeloma cases, where the systemic disease is or is not well controlled. In late disease, it is less clear whether the next line of therapy will be effective, or if additional line of therapy is even available. It is palliative and temporizing in this setting.

Knowing there are decades of reports on the palliation of bone pain with the use of short courses of radiation, it would not be wrong to do so. However, knowing that there can be significant symptomatic relief with the onset of initial therapy, it would also be reasonable to wait.

A scenario where radiation may be particularly beneficial is when that area is the worst source of pain, and it is creating a need for opioid analgesics. Successful palliation that removes the need for these pain medic...