Multiple myeloma

Question 1

What is multiple myeloma

Answer 1

type of cancer that affects plasma cells that are responsible for producing antibodies

arises due to genetic mutations which occur as B -lymphocytes differentiate into mature plasma cells

Question 2

What is the epidemiology of this disease

Answer 2

rare

median age at presentation is 70 years old

agricultural work

african descent

Question 3

What is seen on history and examination of someone with multiple myeloma

Answer 3

CRABBI

• calcium
  hypercalcaemia - leads to constipation,nausea,anorexia and confusion

-renal
light chain deposition within renal tubules
presents as dehydration and polydipsia

-anaemia
bone marrow crowding suppresses erythropoiesis leading to anaemia
causes fatigue and pallor

-bleeding
bone marrow crowding results in thrombocytopenia which puts patients at increased risk of bleeding and bruising

-bones
lytic bone lesions created from osteoclast overactivity
presents as back pain and increases risk of pathological fractures

• infection
  reduction in production of normal immunoglobulins results in increased susceptibility to infection

Question 4

What investigations are needed

Answer 4

bloods
protein electrophoresis
bone marrow aspiration
imaging
skeletal survey

Question 5

What bloods are needed

Answer 5

FBC- anaemia

peripheral blood film - rouleaux formation

urea and electrolytes - renal failure

bone profile - hypercalcaemia

Question 6

What biochemical patterns are usually seen in early stages of myeloma disease

Answer 6

raised calcium
normal/high phosphate
normal alkaline phosphate

Question 7

What will be seen on protein elctrophoresis

Answer 7

raised concentrations of monoclonal IgA/IgG proteins will be present in the serum

in urine , known as Bence Jones proteins

Question 8

What is seen on bone marrow aspiration investigation

Answer 8

confirms diagnosis if number of plasma cells is significantly raised (30%)

Question 9

What imaging is required for multiple myeloma

Answer 9

whole body MRI
X-rays – rain drop skull

Question 10

What is a rain drop skull

Answer 10

presence of well defined lytic lesions of various size scattered throughout the skull

Question 11

What is first line of treatment

Answer 11

Bortezomib , lenalidomide or daratumumab – either alone or in combination with other drugs

Question 12

What are some supportive care measures

Answer 12

bisphosphonate therapy - prevents bone loss
blood transfusions- manage anaemia

kidney dialysis/ transplantation - address kidney damage

Question 13

What is a complication of multiple myeloma and how does it occur

Answer 13

osteolytic features in multiple myeloma can lead to fractures/ vertebral collapse which compress the spinal cord

Question 14

What are some features of spinal cord compression

Answer 14

back pain
limb weakness/numbness
urinary/bowel incontinence

Question 15

How do you diagnose spinal cord compression

Answer 15

whole body x-ray/MRI

Question 16

How do you manage spinal cord compression

Answer 16

analgesia and surgical decompression

Question 17

What are red flag symptoms that are associated with back pain

Answer 17

weight loss
no improvement after 2 months
progressive/nocturnal pain
fever
pain at rest
night sweats
morning stiffness
neurological disturbance
sphincter disturbance
history of malignancy

Question 18

How does a patient with a myeloma usually present

Answer 18

back pain , anemia , hypercalcemia and acute renal failure

Question 19

How should the hypercalcaemia be managed

Answer 19

Bisphosphonates - hydration required first though

haemodialysis
hydration
start loop diuretics
stop thiazide diuretics

Question 20

What are potential myeloma-specific causes of renal failure

Answer 20

amyloid
hypercalcaemia
hypercalciuria
light chain deposition
plasma cell deposition
renal stones