Multiple Myeloma

Question 1

What is Multiple Myeloma (MM)

Answer 1

plasma cell neoplasm characterized by clonal proliferation of malignant cells in the bone marrow, monoclonal protein in the blood and urine, and associated end organ dysfunction

Question 2

Diagnosis criteria for MM

Answer 2

Presence of > 20% plasma cells in bone marrow (or biopsy of a tissue with monoclonal plasma cells)
Monoclonal protein in the serum or urine
and
Evidence of end organ damage (CRAB criteria: calcium elevation, renal insufficiency, anemia, or bone marrow lesions)

Question 3

MM incidence

Answer 3

Peak incidence in the 70s, medican age 70 years old
Blacks most affected, men more affected
Most common primary bone malignancy

Question 4

S and S of MM

Answer 4

• Bone pain: mostly in back and thoracic and pathologic fxs from osteolytic lesions
• anemia
• recurrent infections
• nausea and vomiting
• delirium from hypercalcemia
• neuro complications: blurred vision, spinal cord compression
• purpura and epistaxis from thrombocytopenia
• paresthesia
• weight loss
• generalized weakness

Question 5

peripheral smear for MM

Answer 5

Normochromic, normocytic anemia

rouleaux formation

Question 6

labs for MM

Answer 6

• hypercalcemia
• elevated BUN, creat, uric acid, total protein
• Proteinuria from overproduction and secretion of free monoclonal kappa or lambda chains (bence jones protein)
• Increased IgG and IgA
• hyponatremia
• nests and sheets of plasma cells in bone marrow
• Serum beta 2 microglobulin >8
• elevated serum lactate (poor prognosis)
• abnormal chromosomes

Question 7

Durie-Salmon MM Staging: stage 1

Answer 7

Hemoglobin >10
Calcium <12
normal bone xray or 1 lesion
Low M component production
IgG <5
IgA<3
Urine light chain < 4 g/24h

Question 8

Durie-Salmon MM Staging: stage 2

Answer 8

doesn’t fit stage 1 or 3

Question 9

Durie-Salmon MM Staging: stage 3

Answer 9

One or more of the following:
Hemoglobin< 8.5
Calcium >12
Advanced lytic bone lesions
High M component production
IgG >7
IgA> 5
Urine light chains >12/24h

Question 10

xrays for MM

Answer 10

areas of pain usually have punched out lesions on xray or osteoporosis, use CT if unclear

Question 11

MRI fo MM

Answer 11

preferred method of imaging for spinal compression or soft tissue plasmacytomas.

Question 12

MM tx

Answer 12

All transplant eligible pts should be considered for 12 week induction chemo with triplet regimens.

If response good then move on to stem cell mobilization and collection

PAtients with high risk characteristics should be offered autologous stem cell transplant (ASCT) up to age 75

Single ASCT improves survival by 12 months

Question 13

Induction therapy for transplant eligible pts

Answer 13

VRD regimen: dexamethasone, lenalidomide, and bortezomib)
OR
CyBorD: cyclophosphamide, lenalidomide, dexamethasone

Question 14

MM survival

Answer 14

median survival, 10 years in patients with no lytic bone lesions and serum myeloma protein concentration <3