Surgical Procedure for Multiple Myeloma of Left Proximal Humerus: Tumor Excision Step by Step
For multiple myeloma involving the left proximal humerus, surgical excision with appropriate reconstruction is recommended based on the extent of bone involvement, with cement augmentation during fixation to improve stability and function.
Pre-operative Assessment and Planning
- Complete imaging workup including WBLD-CT (whole-body low-dose computed tomography) as the standard procedure for evaluating lytic lesions 1
- MRI of the affected area to accurately assess bone marrow involvement and soft tissue extension 1
- PET/CT may be useful for better definition of disease extent and metabolic activity 1
- Laboratory tests including complete blood count, renal function, calcium levels, and myeloma markers 1
- Assessment of patient's overall health status and expected survival 1
Surgical Technique for Tumor Excision
Step 1: Patient Positioning and Preparation
- Position patient in beach chair or supine position with affected shoulder elevated 2
- Prepare and drape the entire upper extremity, shoulder, and lateral neck 2
- Administer appropriate prophylactic antibiotics 1
- Consider VTE prophylaxis according to ASCO, ASH, and ICM-VTE guidelines 1
Step 2: Surgical Approach
- Make a deltopectoral or extended anterolateral approach depending on tumor extent 2, 3
- Identify and protect the axillary nerve and brachial plexus 2
- Expose the proximal humerus while preserving as much healthy soft tissue as possible 2, 3
Step 3: Tumor Excision
- Perform intra-lesional curettage of the myeloma lesion, removing all visible abnormal tissue 1
- Use high-speed burr to extend the margins of the cavity 3
- Collect specimens for histopathological examination 1
- Irrigate the cavity thoroughly to remove residual tumor cells 3
Step 4: Reconstruction Options (based on extent of involvement)
For limited involvement:
- Fill the cavity with bone cement (polymethylmethacrylate) for structural support 1
- Stabilize with plate or nail construct depending on location and extent of bone loss 1
For extensive involvement:
- Perform en bloc resection of the affected proximal humerus 1
- Reconstruct with endoprosthetic replacement or graft-prosthetic composite 2, 3
- Consider reverse shoulder arthroplasty if rotator cuff and glenoid are compromised 2
Step 5: Fixation and Stabilization
- Apply internal fixation using plate or intramedullary nail depending on location and extent 1
- Cement augmentation is recommended to enhance fixation stability 1
- Ensure adequate fixation to prevent implant failure 3
Step 6: Soft Tissue Reconstruction
- Reattach rotator cuff tendons and deltoid to prosthesis or remaining bone when possible 2
- Achieve meticulous hemostasis 3
- Place surgical drain if necessary 3
- Close wound in layers with attention to soft tissue coverage 2, 3
Post-operative Management
- Initiate appropriate pain management protocol 1
- Begin early passive range of motion exercises as tolerated 3
- Consider adjuvant radiation therapy based on surgical margins and disease characteristics 1, 3
- Resume systemic anti-myeloma therapy as soon as wound healing permits 1, 4
- Continue bisphosphonate therapy to reduce bone resorption and potentially prolong survival 1
Special Considerations and Pitfalls
- Avoid performing surgery without adequate pre-operative imaging and systemic disease assessment 1
- Beware of potential pathologic fracture during manipulation - handle the affected limb with care 3
- Consider the patient's overall disease status and prognosis when planning the extent of surgery 1
- Remember that multiple myeloma lesions are highly vascular - be prepared for significant blood loss 4, 3
- Ensure that the reconstruction provides immediate stability to allow early mobilization 1, 3
- Monitor for complications including infection, implant failure, and disease progression 5, 3