JH IM Board Review - Plasma Cell Dyscrasias Flashcards
7 categories of plasma cell dyscrasias:
- MGUS.
- MM.
- Plasmacytoma.
- POEMS.
- AL amyloidosis.
- Waldenstrom.
- Cryoglobulinemia.
What else can lead to the production of monoclonal Igs, but is NOT malignant and is distinct from plasma cell dyscrasias?
Autoimmune disorders and chronic inflammatory conditions:
- CTDs.
- TB, endocarditis, hepatitis, HIV.
Monoclonal Igs are seen in approx. …% of adults.
1%.
==> Prevalence increases with age.
==> IgG > IgM > IgA.
MM - Poor prognostic factors:
- Renal insufficiency.
- Elevated beta-2 microglobulin.
- Genetic abnormalities including:
==> 1q amplification, t[4;14], t[14,16], t[14;20], p53 microdeletions, 13q del, complex karyotype.
What is requires to diagnose MM?
Presence of one or more of the CRAB criteria (hypercalcemia, renal insufficiency, anemia, bone disease).
Diagnostic criteria for MM - Smoldering myeloma:
- Clonal bone marrow plasma cells 10% of higher OR
2. Presence of serum and/or urinary monoclonal protein 3g/dL or higher.
Diagnostic criteria for MM - Active:
Above criteria with addition of end-organ damage attributable to the underlying plasma cell proliferative disorder, specifically the CRAB criteria.
CRAB criteria:
- Calcium >11.5 g/dL.
- Renal insufficiency (creatinine greater than 2mg/dL).
- Anemia (Hb <10).
- Bone disease (osteopenia or lytic lesions).
IV contrast in patients with known or suspected MM?
AVOID, UNLESS ABSOLUTELY NECESSARY.
Bone scan in patients with myeloma?
Typically normal ==> Shows only blastic lesions.
Evaluation of a monoclonal immunoglobulin - 4 steps - Step 1:
Define and quantitate abnormal immunoglobulin production.
- SPE + immunofixation.
- UPE + immunofixation.
==> If BOTH negative and high index of suspicion, check serum light chain assay.
Evaluation of a monoclonal immunoglobulin - 4 steps - Step 2:
Define and quantitate organ system dysfunction.
- CBC and differential ==> r/o anemia, pancytopenia.
2. r/o renal dysfunction with BUN/Cr; obtain serum calcium.
Evaluation of a monoclonal immunoglobulin - 4 steps - Step 3:
r/o MM ==>
- Bone marrow aspirate and bx.
- Skeletal x-ray series to r/o lytic or sclerotic bone lesions.
Evaluation of a monoclonal immunoglobulin - 4 steps - Step 4:
Define other characteristics of disorder:
- Serum viscosity if IgM gammopathy, or suggestive symptoms.
- r/o CTD or chronic inflammatory disorder if no plasma cell dyscrasias found.
Tx of smoldering myeloma:
Investigational.
MM Tx:
Chemo ==> not curative.
Should be instituted when pts are symptomatic or demonstrate end-organ dysfunction.
MM Tx - Initial Tx decision based on eligibility for stem cell transplantation ==> For TRANSPLANT INELIGIBLE:
- Melphalan, prednisone, and thalidomide.
- Melphalan, prednisone, and bortezomib.
- Lenaldiomide + dexamethasone.
- Bortezomib + dexa.
MM Tx - Initial Tx decision based on eligibility for stem cell transplantation ==> For TRANSPLANT ELIGIBLE:
- Lenaldiomide + dexa.
- Bortezomib + dexa.
- Lenaldiomide + borte + dexa.
- Borte + dexa + Cyclophosphamide.
MM Tx - BM transplantation:
- Autologous ==> incr. survival by 12-18 months. Eventually, relapse.
- Allogenic ==> potentially curative (25-30%) but has greatest tox.
MM - VZV prophylaxis if on …?
BORTEZOMIB.
Plasmacytomas:
Proliferations of monoclonal plasma cells forming a mass at extramedullary or osseous sites.
==> No evidence of multiple myeloma or end-organ dysfunction.
50% of osseous plasmacytomas and 15% of extraosseous …?
DEVELOP INTO OVERT MYELOMA.
Solitary plasmacytoma:
Single tumor of plasma cells resulting in localized complaints (bone pain, pathologic fracture).
==> No evidence of diffuse plasma cell overgrowth throughout remainder of bone marrow.
Extramedullary plasmacytoma:
Plasma cell tumor arising outside of the bone marrow.
==> most commonly found in URT (nasal passages, sinuses, nasopharynx, larynx).
==> Occasionally described in the lower extremity, GI, lung, lymph nodes.
==> Can be associated with HIV infection.
Plasmacytomas - Tx:
- Radiation therapy to the involved area.
2. 15-25% are disease-free at 10yrs.
Clinical manifestations of MM - Hyperviscosity:
- Retinal bleeds.
- Bruising.
- HF.
- Cerebral ischemia.
Clinical manifestations of MM - Amyloid:
- Panda eyes.
- Nephrotic syndrome.
- Carpal tunnel syndrome.
Clinical manifestations of MM - Bone:
Pain + Fx + lytic lesions.