Multiple myeloma Flashcards by Adele Schiff

What is multiple myeloma?

neoplastic monoclonal proliferation of bone marrow plasma cells resulting in excessive monoclonal immuboglobulin production

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What are RF for multiple myeloma?

MGUS
Abnormal free light-chain ratio
Age >70
Afrocaribbeans
Ionising radiation
Agricultural work
HIV

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What are symptoms and signs of multiple myeloma?

High calcium
Renal failure
Anaemia (60-70% patients)
Bone lesions (60-70% mostly in back)
- CRAB

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What is differential diagnosis for multiple myeloma?

MGUS
Solitary plasmacytoma
Amyloidosis
Heavy chain disease
NHL

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What bloods would you do for multiple myeloma?

ESR
CRP
Urea
Creatinine
Normal ALP
Serum Calcium
FBC
Albumin
Serum beta4-microglobulin
blood film

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What would ESR be in multiple myeloma?

high

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What would serum calcium be in multiple myeloma?

hyper in 30%

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What does blood film show in multiple myeloma?

rouleaux formation

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What special tests are done for multiple myeloma?

Whole-body lost dose CT
Skeletal survey
Serum free light-chain assay
Bone marrow aspirate and biopsy
Serum/urine electrophoresis

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What test is diagnostic for multiple myeloma?

Serum/urine electrophoresis:

serum paraprotein (IgG or IgA)
Urinary Bence Jones proteins

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What does bone marrow aspirate and biopsy show in multiple myeloma?

monoclonal plasma cell infiltration in the bone marrow ≥10%

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What is treatment for acute multiple myeloma transplant candidate?

1st line: Induction therapy
Plus: DVT prophylaxis and SCT
Adjunct: Stem cell mobilisation and conditioning regimen and supportive care
Bone disease: bisphosphonates or denosumab and analgesics

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What is acute management for multiple myeloma non-transplant candidate?

1st line: non transplant therapy
Plus: DVT prophylaxis
Adjunct: analgesics
Bone disease: bisphosphonates or denosumab and analgesics

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What is chronic treatment for multiple myeloma?

1ST LINE: Maintenance strategies

DVT prophylaxis and supportive care

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What are possible complications ofr multiple myeloma?

Bone pain
Fractures of vertebral bodies
Hypercalcaemia
Anaemia

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What staging system is used in multiple myeloma?

Durie and Salmon staging system

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What does the high calcium in MM lead to?

bones, stones, abdominal groans

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How common is renal failure in MM and what does it mean?

20% and worse prognosis

Why is there anaemia in MM?

Anaemia due to bone marrow crowing and production of monoclonal Ig also crowds out production of normal polyclonal Ig so recurrent infections

Why are there bone lesions in MM?

increased osteoclast activation so back/rib pain

What happens in MM with which cells?

Proliferation of plasma cells

2. Production of a monoclonal immunoglobin (IgG or IgA) – not polyclonal like normal

Why is ALP important in MM?

normal in MM but high in blood cancers so good to differentiate

What would you see is serum/urine electrophoresis in MM?

Urinary Bence Jones proteins

How does rouleaux formation actually look like on blood film?

RBC stacked up like coins

What does bone arrow aspirate show on MM?

plasma cells bone marrow ≥10%

What does MGUS stand for?

monoclonal gammopathy of unknown significance

What is MGUS?

premalignant condition with accumulation of some monoclonal plasma cells

What can MGUS lead to?

1% acquire additional mutations so can lead to multiple myeloma

What is absent if MGUS but present in MM?

ABSENT CRAB features

Why is there renal failure in MM?

- cast nephropathy | - due to high Serum free light chains and Bence jones proteinuria

How does cast nephropathy happen?

1. FLCs activate inflammatory mediators in the proximal tubule epithelium leads to proximal tubule necrosis 2. Fanconi syndrome (renal tubules acidosis) with FLC crystal deposition

What may you see on x ray for MM?

punched out lesions

What may be seen in special tests?

M spike or paraprotein

Why is there an M spike in MM?

Produce excess of monoclonal (kappa or lamda) serum free light chains)

What are urinary bence jones?

urine monoclonal free light chains

What would blood results be in MM?

1. Macroctyic anaemia 2. Low reticulocytes, low WBC, low lymphocytes, low neutrophils and low platelets 3. High ESR 4. High creatinine 5. low albumin 6. high globulins 7. high Ca

What is paraprotein and immune paresis?

1. Paraprotein: monoclonal excess of intact Ig molecule | 2. Immune paresis: get lower levels of other Ig e.g. lower IgA and IgM

How do you manage the cord compression?

MRI scan and dexamethasone

How may hypercalcaemia present?

drowsiness, constipation, fatigue, muscle weakness, AKI

What is the management for hypercalcaemia?

fluids, steroid, zolendronic acid

What medications can be used in MM?

1. Steroids 2. Classic cystostatic drugs e.g. melphalan 3. IMIDs 4. MoAbs i.e. daratumumab 5. Proteasome inhibitors (velcade)

What are examples of IMIDs?

(immunomodulatory drugs): e.g. thalidomide (teratogenic), lenalidomide, pomalidomide

How does an autologous haematopoetic stem cell transplant work?

1. Stem cell collection from the blood and storage 2. High dose melphalan to kill myeloma cells 3. Re-infusion of stem cells to rescue blood formation

What blood test should you not forget for MM and why?

Sometimes only sign of myeloma is light chains!