Multiple Myeloma Flashcards

1
Q

what is the definition of multiple myeloma?

A
  • Cancer of differentiated B lymphocytes known as PLASMA CELLS (produce antibodies)
  • The accumulation of malignant plasma cells in the bone marrow leads to progressive bone marrow failure
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2
Q

what is the epidemiology of multiple myeloma?

A
  • Peak age is 70 yrs

- More common in AFRO-CARIBBEANS than caucasians

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3
Q

what is the aetiology of multiple myeloma?

A

It’s not known exactly what causes multiple myeloma. However, there is a close link between multiple myeloma and a condition called monoclonal gammopathy of unknown significance (MGUS)

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4
Q

what are the risk factors for multiple myeloma?

A

Age
Male
Black race

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5
Q

what is the pathophysiology of multiple myeloma?

A

Normal plasma cells produce a wide range of immunoglobulins (antibodies) such as IgG,IgA,IgM & IgD
- However in myeloma the malignant plasma cells just produce an EXCESS of one type of immunoglobulin this is known as monoclonal paraprotein:
• IgG (55%)
• IgA (20%)
• Rarely IgM and IgD
- Other immunoglobulin levels are low resulting in immunoparesis resulting in increased susceptibility to infections
- Leads to bone disease, hypercalcaemia and renal failure

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6
Q

what are the key presentations of multiple myeloma?

A

OLD CRAB:
• OLD age
• Calcium elevated
• Renal failure - nephrotic syndrome, since due to raised immunoglobulins which are proteins which precipitate (especially immunoglobulin light chains) and deposit in organs ESPECIALLY the kidneys - results in THIRST due to lack of water retention due to failure
• Anaemia - neutropenia or thrombocytopenia resulting in infection, bleeding and fatigue and pallor
• Bone lytic lesions - back pain: Caused by malignant plasma cells releasing factors which in turn result in:
- The activation of osteoclasts thus increasing bone turnover and resulting in bone breakdown and lytic lesions (RANK ligand and IL-3 result in osteoclast activation)
- The inhibition of osteoblasts thus decreasing new bone formation (HGF and Dkk-1 result in osteoblast inhibition

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7
Q

what are the signs of multiple myeloma?

A

Elevated calcium
Renal failure
Anaemia

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8
Q

what are the symptoms of multiple myeloma?

A
Thirst 
Fatigue 
Pallor 
Back pain 
Recurrent infections
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9
Q

what are the first line investigations for multiple myeloma?

A

Blood - Normocytic normochromic anaemia
• Raised ESR
• Rouleaux formation on blood film

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10
Q

what are the gold standard investigations for multiple myeloma?

A

U & E’s:
• High calcium
• High alkaline phosphatase, Bence-jones protein in urine
- PLAIN X-ray:
• Lytic ‘punched-out’ lesions: Pepper-pot skull, Vertebral collapse
• Fractures
• Osteoporosis
- Serum & urine electrophoresis:
• B2-microglobulin present and is prognostic
- Diagnosis requires:
• Monoclonal protein band in serum or urine
• Increased plasma cells on bone marrow biopsy
• Hypercalcaemia/Renal failure/Anaemia
• Bone lesions on skeletal survey

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11
Q

what are the differential diagnoses for multiple myeloma?

A

Depression · Osteoarthritis · Diabetes mellitus · Polymyalgia rheumatica · Monoclonal gammopathy of unknown significance (MGUS)

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12
Q

how is multiple myeloma managed?

A

Bone pain supported with analgesia, avoid NSAIDs due to risk of renal impairment
- Give all patients bisphosphonate e.g. ZOLENDRONATE as they reduce fracture rates and bone pain
- Anaemia should be corrected with transfusion of RBCs and erythropoietin can be used
- Rehydrate and ensure adequate fluid intake of 3L/day to prevent further renal damage e.g. by immunoglobulin light chains
- Renal dialysis to treat acute renal failure
- Treat infections with broad-spectrum antibiotics quickly
- Chemotherapy:
• CTD - CYCLOPHOSPHAMIDE, THALIDOMIDE and DEXAMETHSONE - max 8 cycles - for less fit people
• VAD - VINCRISTINE, ADRIAMYCIN and DEXAMETHASONE in fitter people - max 6 cycles
- Stem cell transplant

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13
Q

how is multiple myeloma monitored?

A

Monitor people with smouldering myeloma every 3 months for the first 5 years, and then decide the frequency of further monitoring

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14
Q

what are the complications of multiple myeloma?

A

Leads to bone disease, hypercalcaemia and renal failure

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15
Q

what is the prognosis of multiple myeloma?

A

almost 85 out of every 100 (almost 85%) will survive their myeloma for a year or more after diagnosis
more than 50 out of every 100 (more than 50%) will survive their myeloma for 5 years or more after diagnosis
around 30 out of every 100 (around 30%) will survive their myeloma for 10 years or more after they are diagnosed

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