HAEMATOLOGY - MYELOMA Flashcards

1
Q

What is myeloma?

A

A cancer of plasma cells in the bone marrow
These plasma cells produce non-functional monoclonal paraprotein instead of immunoglobulins = overproduction of M protein

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2
Q

How common is multiple myeloma?

A

The second most common haematological cancer

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3
Q

What age does multiple myeloma usually affect?

A

Older people - about 70

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4
Q

What are the symptoms of multiple myeloma?

A

Bone pain; most commonly back pain
Recurrent infection
Anaemia symptoms
Renal failure symptoms
Symptoms of hypercalcaemia
Rarely, symptoms of hyperviscocity and bleeding due to thrombocytopenia

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5
Q

What causes the anaemia, neutropenia and thrombocytopenia seen in myeloma?

A

Bone marrow infiltration with plasma cells
Kidney failure also causes decreased EPO, decreasing RBC production

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6
Q

What causes recurrent infections in those with myeloma?

A

Paraprotein secretion means there’s a reduction in normal immunoglobulin levels

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7
Q

What causes renal impairment in myeloma?

A

Free light chain (paraprotein) secretion leads to deposition in renal tubules causing cast nephropathy
The hypercalcaemia, NSAID use can also contribute

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8
Q

What causes bone pain in myeloma?

A

Myeloma cells adhere to bone marrow stromal cells. Myeloma cells secrete IL-3 which inhibits osteoblast progenitor cell maturation, decreasing osteoblast activity. The cells also secrete DKK1 which inhibits OPG production by osteoblasts causing an increase in osteclastic activity. Myeloma cells also increase osteoclastic activity through MIP1 alpha and RANKL.
Increased osteoclastic activity without osteoblastic increase causes lytic lesions, usually seen in the spine, skull, long bones and ribs

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9
Q

What are the main antibodies associated with myeloma?

A

IgG and IgA

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10
Q

Why does myeloma cause hypercalcaemia?

A

Bone resorption

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11
Q

What symptoms can hypercalcaemia cause?

A

Nerve problems and dehydration

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12
Q

Whats it called when light chains are found in the urine of those with myeloma?

A

Bence jones proteins

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13
Q

How do you investigate myeloma?

A

Blood tests - anaemia, WCC, Plt, ESR high, increased paraprotein
Blood film - rouleaux formation because of paraprotein
U&Es for kidney function (increased urea, nitrogen and creatinine)
Serum calcium usually raised
Urine tests - bence jones proteins
Bone aspiration
Bone marrow biopsy - >10% plasma cell infiltrate
CT scan - lytic lesions
Free light chain ration >100

(>10% monoclonal plasma cell infiltrate with at least 1 of the four CRAB features; hyperCalcaemia, Renal impairment, Anaemia, Bone involvement)

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14
Q

How is myeloma treated?

A

Transfusions and EPO for anaemia
Hydration, bisphosphonates and high dose steroids for hypercalcaemia and kidney injury
Antibiotics for infections
Radiotherapy and systemic chemotherapy or high dose dexamethasone for bone pain Bisphosphanates can be given too
Preventing pathological fractures by pinning lytic lesions
Stem cell transplants

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15
Q

What proportion of cases of MGUS progress to multiple myeloma?

A

25%

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16
Q

What are the 3 types of multiple myeloma?

A

Smouldering MM - asymptomatic
Symptomatic MM
Non-secretory MM

17
Q

What is the rouleaux formation in myeloma?

A

The stacking of 4 or more RBCs (RBCs coated with immunoglobulins which makes them sticky so they form chains)

18
Q

What can cause rouleaux formation?

A

infections
multiple myeloma
Waldenström’s macroglobulinemia
inflammatory and connective tissue disorders
cancers
diabetes mellitus

19
Q

What is electrophoresis?

A

Electrophoresis is a laboratory technique used to separate DNA, RNA or protein molecules based on their size and electrical charge. It can measure antibodies in blood

20
Q

Whats associated with a poorer prognosis in myeloma?

A

Worse stage
Older age
High beta-2 microglobulin on blood results
Low level of albumin on bloods
High lactate dehydrogenase on bloods
High creatinine on bloods
Chromosome 13 deletion, 17p deletion, chromosome 14 translocation, extra copy of chromosome 1
Poor kidney function

21
Q

How is myeloma staged?

A

International staging system - based on beta 2 microglovuli and albumin levels

22
Q

Whats the median prognosis of myeloma?

A

4-5 years

23
Q

Which patients with myeloma do we treat?

A

Only those symptomatic or very progressive disease