Multiple Myeloma

Question 1

summarise the key features of multiple myeloma?

Answer 1

Bone pain, lethargy, poor renal function, Monoclonal band on serum electrophoresis, Monoclonal globulin protein in urine , rouleux, macrocytic anaemia, high ESR, high Ca, High urea/cr, pepper pot skull, punched out lesion

Question 2

define multiple myeloma?

Answer 2

Haematological malignancy where there is a clonal proliferation of plasma cells-> bone lesions and the production of monoclonal immunoglobulin ( paraprotein, usually IgG or IgA)

Associated with osteolytic bone disease, anaemia and renal failure

Classification based on immunoglobulin product

Question 3

what is an acronym for the key features of mutliple myeloma?

Answer 3

CRAB

Calcium is High

Renal impairement

Anaemia

Bone pain

Question 4

What are the presenting symptoms of multiple myeloma?

Answer 4

Bone Pain- osteolytic bone lesions

• Usually in the back and ribs
• Sudden and severe bone pain may be caused by a pathological fracture
• May get symptoms of hypercalcaemia

Infections - often recurrent bacterial

General

• Tiredness/ other symp of anaemia
• Thirst
• Polyuria – renal impairment due to light chain deposition
• Nausea
• Constipation
• Mental change (due to hypercalcaemia)

Anaemia, neutropenia, or thrombocytopenia may result from marrow infi ltration by plasma cells, leading to symptoms of anaemia, infection and bleeding.

Hyperviscosity

• Bleeding
• Headaches
• Visual disturbance

Question 5

explain the recurrent bacterial infections in multiple myeloma?

Answer 5

due to immunoparesis-> also because of neutropenia due to disease and from chemotherapy

Question 6

explain the renal impairement in multiple myeloma?

Answer 6

light chain deposition-> caused by precipitation of light chains with the Tamm Hors- fall protein in the distal loop of henle

monoclonal immunoglobulins induce changes in glomeruli

Rare type of damage is deposits of light chains in the form of AL-amyloid and subsequent nephrosis

Question 7

what are the signs of multiple myeloma on physial examination?

Answer 7

Pallor

Tachycardia

Flow murmur

Signs of heart failure

Dehydration

Purpura

Hepatosplenomegaly

Macroglossia

Carpal tunnel syndrome

Peripheral neuropathies

Question 8

what are the appropriate investigations

Answer 8

bloods

blood film

serum or urine electrophoresis

bone marrow aspirate and trephine

whole body, low dose CT

Question 9

Describe bloods in multiple myeloma?

Answer 9

FBC - low Hb, normochromic normocytic anaemia

High ESR (and possible high CRP)

U&Es - high creatinine, high Ca2+

Normal ALP

In malignancy you get high Ca with HIGH ALP

However in this it is normal

Question 10

what can be seen in the blood film when investigation mutliple myeloma

Answer 10

rouleaux formation with bluish background ( suggests high protein)

Question 11

describe serum or urine electrophoresis when investigating multiple myeloma?

Answer 11

serum paraprotein spike

Bence- Jones protein ( monoclonal immunologobulin light chain thas found in the urine and suggests multiple myeloma)

increased conc of free light chains in the serum

serum beta2- microglobin levels abnormal

Question 12

describe the bone marrow aspirate in multiple myeloma

Answer 12

High plasma cells (usually > 20%)

Question 13

describe the CT in multiple myeloma?

Answer 13

Osteolytic lesions without surrounding sclerosis e.g. pepper pot skull

Punched out on his skeletal x-rays

Pathological fractures