Multiple Myeloma

Question 1

Definition of multiple myeloma

Answer 1

Is a haematological malignancy that is characterised by proliferation of PLASMA CELLS that would infiltrate bone marrow and there would be the presence of monoclonal immunoglobulins (IgG or IgA) (due to presence of more plasma cells)

Question 2

Aetiology/risk factors of multiple myeloma

Answer 2

No clear cause, but some risk factors are:
• Age >70
• Genetic inheritance
• Exposure to ionising radiation

Question 3

Pathophysiology of multiple myeloma

Answer 3

• Arises from the B cells in the lymph nodes
• Normal IgG production is impaired, which can predispose the patient to infections
• When in the bone marrow, an inflammatory process would trigger osteoclastogenesis and osteoclast activity and in the meanwhile impair osteoblast formation.
◦ This would lead to osteolytic bone disease and hypercalcaemia

Question 4

History and Examination of Multiple myeloma

Answer 4

• Anaemia: very common symptom, due to bone marrow crowding (plasma cells infiltration of the bone marrow)
• Bone pain: typically localised as BACK PAIN, can be rib pain. Occurs in most patients. If sudden and severe bone pain, then likely pathological fracture
• Infections: often recurrent due to IgG production being impaired and hence leading to hypogammaglobulinaemia
• Renal impairment: marker of poor prognosis
• Fatigue: associated or hypercalcaemia

Question 5

Investigations for multiple myeloma

Answer 5

• FBC: Would see normocytic and normochromic anaemia
• ESR: raised
• U&Es: would have high creatinine and urea (kidney dysfunction)
• Serum calcium: HYPERCALCAEMIA
• Serum albumin
• LFTs: ALP is NORMAL, differentiates multiple myeloma from bone cancer
• Serum/urine protein electrophoresis: Test used to diagnose multiple myeloma. Negative means absence of detectable monoclonal proteins. May see Bence Jones Proteins
• Bone marrow aspirate and biopsy: high amount of plasma cell infiltration

Question 6

Treatment for multiple myeloma

Answer 6

Newly diagnosed transplant candidates:
1) Induction therapy: Required prior to stem cell transplant (includes conventional chemotherapy)
+ Deep vein thrombosis prophylaxis: complication of therapy (give aspirin)
+ Stem cell transplant
+ Bisphosphonates for bone disease, consider analgesics (avoid NSAIDs)

Question 7

Prevention and prognosis of multiple myeloma

Answer 7

• Should undergo pneumonia and flu vaccination
• Maintain good hydration to reduce risk of renal complications
• Reduce NSAID use

Will relapse within a few years of treatment (is incurable)
Causes of death are infection and renal failure

Question 8

Complications of multiple myeloma

Answer 8

• Bone pain
• Fracture of vertebral bodies: pathological fractures
• Hypercalcaemia
• Anaemia
• Thrombocytopenia