Multiple Myeloma

Question 1

What is a myeloma protein?

Answer 1

An abnormal monoclonal antibody

Question 2

What is multiple myeloma?

Answer 2

A condition in which a clone or multiple clones of malignant plasma cells over-produce and secrete into the bloodstream an abnormal monoclonal antibody

Question 3

What is the second most common haematological malignancy?

Answer 3

Multiple myeloma

Question 4

Antibodies are composed of heavy and light chains. What are the five types of heavy chains?

Answer 4

M
A
D
G
E

Question 5

Antibodies are composed of heavy and light chains. What are the two type of light chains?

Answer 5

Lambda

Kappa

Question 6

What are the two steps in the pathophysiology of multiple myeloma?

Answer 6

1) Development of monoclonal gammopathy of undetermined significance (MGUS)
2) Progression of MGUS to multiple myeloma

Question 7

Almost all cases of multiple myeloma arise from what precursor?

Answer 7

Monoclonal gammopathy of undetermined significance (MGUS)

Question 8

Most cases of monoclonal gammopathy of undetermined significance (MGUS) progress to multiple myeloma. T/F?

Answer 8

False

Question 9

What is the term for the intermediate state between MGUS and multiple myeloma?

Answer 9

Smouldering or asymptomatic multiple myeloma

Question 10

What constitutional features of malignancy may be present in cases of multiple myeloma?

Answer 10

Fever
Weight loss
Fatigue
Loss of appetitie
Generalised weakness

Question 11

Describe the ‘CRAB’ acronym for the key presenting features of multiple myeloma?

Answer 11

C - calcium levels high
R - renal impairment
A - anemia
B - bone disease

Question 12

Describe the occurrence of bone disease in patients with multiple myeloma

Answer 12

This can be widespread due to clonal proliferation within the bone marrow
Bone disease is seen as lytic lesions on imaging
Can cause pathological fractures

Question 13

Describe the occurrence of renal impairment in patients with multiple myeloma

Answer 13

> 50% have raised creatinine at diagnosis
Kidneys can be affected due to light chain nephropathy where the kidney tubules are blocked by light chain casts
Kidneys can also be affected by proximal tubule necrosis due to the toxic effects of Bence Jones proteins in the urine

Question 14

Describe the occurrence of anaemia in patients with multiple myeloma

Answer 14

This is caused by destruction of the normal bone marrow due to the proliferation of malignant plasma cells
Renal disease may also contribute due to EPO deficiency

Question 15

How does multiple myeloma cause hypercalcaemia?

Answer 15

It induces bone demineralisation

Question 16

Why is recurrent or persistent bacterial infection common in multiple myeloma?

Answer 16

Normal bone marrow is destroyed by the malignant plasma cell infiltrate which leads to immune dysfunction

Question 17

When there are high paraprotein levels in multiple myeloma, hyper viscosity syndrome can occur. What are the typical symptoms of this?

Answer 17

Blurred vision
Headaches
Mucosal bleeding
Dyspnoea (due to heart failure)

Question 18

What is the function of electrophoresis and immunofixation in screening for multiple myeloma?

Answer 18

Electrophoresis determines either there is an increased number of antibodies
Immunofixation determines which type of antibody has increased

Question 19

Which type of antibodies are usually overproduced and secreted in multiple myeloma?

Answer 19

IgG
IgA
(or the accompanying light. chain)

Question 20

Rather than multiple myeloma, the presence of IgM monoclonal antibody suggest which condition?

Answer 20

Waldenstrom macroglobulinaemia

Question 21

Describe the use of the serum free light chain (SFLC) test in the screening of multiple myeloma?

Answer 21

SFLC looks at the amount of light chain in the blood which exists unbound to heavy chains. An elevated ratio between the kappa and lambda light chains is suggestive of multiple myeloma

Question 22

What is the name of monoclonal light chain which are often detected in the urine in multiple myeloma?

Answer 22

Bence Jones protein

Question 23

What test can be used to detect Bence Jones protein in multiple myeloma?

Answer 23

Urine electrophoresis

Question 24

What are the three aspects of diagnostic testing for multiple myeloma?

Answer 24

Identifying a monoclonal antibody
Identifying bone marrow infiltration
Assessing for myeloma related end-organ damage

Question 25

What tests can be used to detect monoclonal antibodies in multiple myeloma?

Answer 25

Protein electrophoresis
Serum free light chain analysis
Urine electrophoresis

Question 26

What test can be used to detect bone marrow infiltration in multiple myeloma?

Answer 26

Bone marrow aspirate and trephine with cytogenetics

Question 27

What tests can be used to detect myeloma related end-organ damage?

Answer 27

FBC - assess for anaemia
U&Es - assess kidney function
Bone profile - assess for bone disease
Imaging (CT/MRI)

Question 28

If multiple myeloma is confirmed, what test results can be used as prognostic markers?

Answer 28

Beta-2-microglobulin

Albumin

Question 29

Compare and contrast the investigation findings in monoclonal gammopathy of undetermined significance and multiple myeloma?

Answer 29

MGUS - monoclonal protein low, bone marrow plasma cells <10%, no organ damage
Multiple myeloma - monoclonal protein present, bone marrow plasma cells >10%, organ damage

Question 30

Multiple myeloma is an incurable condition. T/F?

Answer 30

True

Question 31

What are the four keys areas of management of multiple myeloma?

Answer 31

Induction therapy
Autologous stem cell transplant
Maintenance therapy
Managing relapse / refractory disease

Question 32

What are the possible complications of multiple myeloma?

Answer 32

AL amyloidosis
Renal failure
Infection
Cord Compression
Hyperviscosity syndrome