Multiple Myeloma

Question 1

What is it?

What are its clinical features?

Answer 1

➊ Plasma cell dyscrasia, in which there’s abnormal proliferation of antibody-producing plasma cells. There’s also a deficiency of functional antibodies, resulting in a relative hypogammaglobulinaemia.

➋ CRAB:
• Calcium (Hypercalcaemia) - due to increased osteoclast activity
• Renal failure - due to light chain deposition and hypercalcaemia
• Anaemia
• Bone pain - osteolytic lesions, leading to pathological fractures and vertebral compression fractures

N.B. Marrow infiltration by the tumour can lead to other cytopenias e.g. thrombocytopenia, leukopenia.

Question 2

Investigations:
What are the initial tests to do?

What are the diagnostic tests to do?

Which tests are used to determine the prognosis?

Answer 2

➊ • Bloods - Calcium, U&E (renal impairment), FBC (anaemia)
• XR/CT/MRI - looking for osteolytic lesions and pathological fractures

➋ • Serum and/or urine electrophoresis - shows a paraprotein spike (typically IgG)
• Bence Jones protein (light chains) - raised
• Bone marrow aspirate and biopsy - myeloma confirmed if > 10% of plasma cells

➌ • CRP - the higher the level, the worse the prognosis
• LDH - the higher the level, the worse the prognosis
• Beta-2 microglobulin - the higher the level, the worse the prognosis
• FISH and cytogenetic analysis

Question 3

Management:
When is a conservative approach the best option?

What are the other options?

What are the supportive options?

Answer 3

➊ If patient has minimal symptoms and no end-organ damage. They may need therapy when there are signs of active disease.

➋ • Stem cell transplant
• Other non-chemotherapeutic drugs

➌ • Analgesia, bisphosphonates, physio for bone disease
• Flu and pneumococcal vaccines for infection prevention
• EPO (± transfusion) for anaemia