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Malignant haematology > Multiple myeloma > Flashcards

Multiple myeloma Flashcards

1
Q

Who gets myeloma

A

Elderly - median age presentation is 70

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2
Q

What is multiple myeloa

A

Plasma cell proliferation haem malignancy from mutation as B lymphocytes -> mature plasma cells

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3
Q

Clinical features of MM

A

CRABBI
Calcium high
Renal impairment
Anaemia
Bleeding - TP
Bones Pain + fractures
Infection

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4
Q

What causes hypercalcemia in myeloma

A

Increased osteoclast bone resorption due to cytokines from myeloma cells
Renaldysfuctnion

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5
Q

Hypercalcemia features

A

Constipation, nausea, anorexia, confusion

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6
Q

Renal problems in myeloma cause

A

Monoclonal productuon IgGs -> light chain deposition in renal tubules
Renal damage -> dehydration and thirst
also amyloidosis, nephrocalcinosis, nephrolithiasis

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7
Q

What causes bone pain and pathological fractures in myeloma

A

Bone marrow infiltration by plasma cells and cytokine mediated osteoclast activity -> lytci bone lesions

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8
Q

Other features of myeloma not pneumonic

A

Amyloidosis eg macroglossia
Carpal tunnel
neuropathy
Hyperviscosity

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9
Q

How assess for myeloma in over 60s

A

FBC, calcium, plasma viscosity or ESR

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10
Q

When assess for myeloma

A

General screen - >60, persistent bone pain esp back pain or unexplained fracture

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11
Q

When urgent electrophoresis for myeloma

A

> 60
Hypercalcemia or leukopenia
Presentation suggests myeloma
OR
pllasma viscosity or ESR and presentation consistent

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12
Q

How investigate for myeloma initially

A

FBC, calcium (bone profile), plasma viscoity, ESR
Consider - blood silm, U+Es
Urgent plasma electrophoresis and bence jones protein urine test within 48 hrs

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13
Q

When refer for myeloma

A

When electrophoresis/bence jones test +

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14
Q

Blood film in myeloma

A

Rouleaux formation

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15
Q

What see on electrophoresis in myeloma

A

IgA/IgA proteins in serum, bence jones in urine

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16
Q

Further investigations myleoma

A

Bone marrow aspiration - plasma cells raised
Skeletal survey
Whole body MRI
X rays -> rain drop skull

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17
Q

What see on X ray in myeloma

A

Rain drop skull - splashing = dark spots random
V SIMILAR TO PEPPER POT SKULL IN PRIMARY HYPERPARATHYROIDISM
Look at x rays to differntiate

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18
Q

Diagnostic criteria for myeloma

A

1 - clonal bone marrow plasma cells >10% OR biopsy proven plasmacytoma
2 - one or more myeloma defining events:
->60% plasma cells in marrow
-Light chain ration >100
2 > focal lesions on MRI >5mm
-Hypercalcemia >2.75mmol/l or o.25 over normal
-Renal insuff - >177 umol/l creatinine or clearance <40ml/min
-Anaemia <100g/l or 20 below normal
-1 or more lytic bone lesion on X ray, CT or PET/CT >5mm

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19
Q

Why is allogeneic stem cell transplant not used in myeloma

A

Hgh overall mortatlity and GvHD

20
Q

What is autologous HSCT

A

Removal of paitents own stem cells prior to chemo, replaced afterwards
Porlongs event free and overall survival

21
Q

Induction regime myeloma

A

Targeted drugs eg thalidomide, lenalidomide, bortezomib daratumumab
Chemo eg cyclophosphamide or melphalan
Steroids eg pred or dex

22
Q

Complications fo myeloma

A

Pain
Pathological fracture
Infection
VTE
Fatigeu

23
Q

Supportive managmenet myeloma

A

Analgesia
Zoledronic acid = manage osteoporosis
Infection - flu vaccine, IgG repllacemetn
VTE prophylaxis
Fatigue - consider EPO

24
Q

What is staging of myeloma based on

A

B2 microglobulin
Albuin levels

25
Q

Stage I -III myeloma

A

I - B2 microglobulon <3.5mg/l
Albumin >35g/L
II - not either
III - B2 microglobulin >5.5mg/l

26
Q

Poor prognosis cytogenetic abnormalities for myeloma

A

t4:14, 14:16, 14:20
del 17p and gain 1q

27
Q

How measure performance status

A

Eastern Cooperative Oncology Group (ECOG) scale or the Karnofsky Performance Scale (KPS)

28
Q

Poor prognostic factors

A

Specific cytogenetics
Performance status
Age and comborbities
Response to treatmnet initially (Complete, v good partial = better)
Albumin
Peripheral blood plasma cells (abnormal to see out of marrow)
LDH level
Serum B2 micoglobulin (high = bad)
Eligible for autologous stem cell transplantation
Minimal residual disease

29
Q

What assess after treatment for myeloma

A

MRD assess for residual myeloma cells after treatment
Negativity ass w prolonged progression free survival and overall survival

30
Q

Prognostic models myeloma

A

Revised international staging system - ISS stafe, risk cytogenetics, LDH level - I-III
Myeloma risk stratification -

31
Q

Risks for myeloma

A

Radiation, agriculture, metals, rubber, chemicals and combustion fuel prodyucts
FH, genetics implicated
Dont know cause

32
Q

What is myelomas premalignant phase

A

Monoclonal gammopathy of uncertain significance

33
Q

Myeloma cells on blood film

A

Perinuclear halo
Large cells
Eccentric nucelus
Large amounts ble cytoplasms

34
Q

What is myeloma characterised by

A

Monoclonal protein in serum/urine
Lytic bone lesions
Excess plasma cell sin bone marrow

35
Q

What is electrophoresis testing for

A

The ‘antibodies’ OR only light chain proteins released by myelomas (cancerous plasma B cells) causing the symptoms

36
Q

What are lytic lesions

A

Destruction of bone tissue around myeloma tumours

37
Q

What does M protein cause

A

Neuropathy and renal compromise

38
Q

Renal damage mechainsm myeloma

A

Light cahins filtered into glomerulus- not all light chains reabsorbed -> loop of henle -> jelly/cast formation in loop of henle destroying a nephron -> casts

39
Q

Preventing renal damage in myeloma

A

Early diagnosis
High fluid intake at least 3 litres/day
Bring down calcium
Potentially nephrotoxic drugs eg aminoglycosides, NSAIDs avoided, monitor bisphosphonates closely
Treat infection

40
Q

Complication of pathological fractures in back

A

sPINAL CORD compression

41
Q

Bone disease in myeloma pathology

A

Increased osteoclast bone resorption due to cytokines from myeloma cells -> increased bone resorption, hypercalcemia, decreased osteoblastic activity and impaored glomerual filtration

42
Q

Bone disease and hypercalcemia emergency treatment

A

IV fluids, steroids, bisphosphonates

43
Q

Benefits of bisphosphonates in myeloma

A

Prevent vertebral fractures amerlioration of pain
Prolong PFS, OS
reduction in m non vertebral fractures and hypercalcemia

44
Q

Can you cure multiple myeloma

A

No

45
Q

What infections are myeloma patients particuarly at risk of

A

Strep pneumoniae
H.influenzae
VZV recurrence shingles

Malignant haematology (16 decks)

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