What is the next best step in managing a patient with multiple myeloma and left rib pain?

Management of Rib Pain in Multiple Myeloma Patient

For a multiple myeloma patient with left rib pain and stable to improved imaging findings, balloon kyphoplasty or vertebroplasty is the treatment of choice for painful rib lesions when conventional pain management is insufficient. 1

Assessment of Current Status

This patient presents with:

• Multiple myeloma with left rib pain
• CT CAP showing resolved left anterior chest wall soft tissue mass with residual irregular radiolucent lesions in the fourth rib
• Stable multiple lytic bony lesions and unchanged pathological rib fractures
• Improved lesions in thoracic and lumbar vertebral bodies on MRI
• PET/CT showing anterior left fourth rib lytic lesion with SUV max 1.1 and healing rib fractures

Pain Management Algorithm

Step 1: Pharmacological Management

• Begin with a stepwise approach based on pain severity 1:
  • For mild pain: Paracetamol up to 1g four times daily
  • For moderate pain: Oral tramadol or codeine
  • For severe pain: Fentanyl or buprenorphine patches or oral oxycodone (always provide laxatives with opioids)
  • For neuropathic pain components: Consider adjuvant medications such as gabapentin, pregabalin, or duloxetine

Step 2: Bone-Targeted Therapy

• Ensure patient is receiving appropriate bone-modifying agents:
  • Bisphosphonates (zoledronic acid or pamidronate) or denosumab should be administered to all patients with symptomatic MM regardless of documented bone disease 2
  • Denosumab is preferred in patients with renal disease 2
  • Continue bone-targeting treatment for up to 2 years; continuation beyond 2 years should be based on clinical judgment 2

Step 3: Interventional Procedures

• For persistent pain despite optimal medical management:
  1. Balloon kyphoplasty/vertebroplasty is indicated for painful vertebral compression fractures and can be considered for painful rib lesions 1
  2. Radiotherapy for extremely painful lytic lesions (typical dose: 3000 cGy in 10-15 fractions) 1
     • Low-dose radiation therapy (8 Gy in 3 fractions) or 20-30 Gy in 5-10 fractions can be used as palliative treatment 2
     • Moderately fractionated courses of 20-25 Gy in 8-10 fractions are generally preferred 2
  3. Surgery may be indicated for fixing pathological fractures of long bones 1

Monitoring and Follow-up

• Regular assessment of pain intensity and character is crucial 1
• Monitor for skeletal-related events (SREs) 2
• Continue bone-modifying agents as recommended 2
• Assess for potential complications such as infections, which are a major cause of morbidity and mortality in myeloma patients 2

Important Considerations

• Avoid NSAIDs due to potential renal toxicity in myeloma patients 1
• Regular monitoring of renal function is essential when using bisphosphonates 1
• Careful dental examination is recommended for patients on bisphosphonate therapy to prevent osteonecrosis of the jaw 1
• Initiation of systemic therapy should not be delayed for radiation therapy and can often be given concurrently 2

Conclusion

Given the patient's persistent left rib pain despite stable to improved imaging findings, a targeted approach with appropriate pain medication and consideration of interventional procedures such as balloon kyphoplasty/vertebroplasty or localized radiation therapy is recommended. Ensure the patient is receiving appropriate bone-modifying agents as part of the comprehensive management plan.