Multiple Myeloma

Question 1

What is multiple myeloma?

Answer 1

proliferation of plasma cells resulting in bone lesions + production of a monoclonal immunoglobulin (paraprotein, usually IgG or IgA)

Question 2

Describe the aetiology of multiple myeloma

Answer 2

UNKNOWN

Chromosomal aberrations are frequent

Question 3

Describe the epidemiology of multiple myeloma

Answer 3

Annual incidence: 4/100,000
Peak incidence: 70 yrs
Afro-Caribbean > White > Asians

Question 4

What acronym is used to remember features of multiple myeloma?

Answer 4

CRAB
Calcium HIGH
Renal impairment
Anaemia
Bone pain

Question 5

Describe the presentation of multiple myeloma

Answer 5

May be an INCIDENTAL finding on routine bloods

Question 6

Describe the bone pain experienced in multiple myeloma

Answer 6

Usually in back + ribs

Sudden + severe pain may be caused by a pathological fracture

Question 7

List 4 general symptoms of multiple myeloma

Answer 7

Infections: often recurrent bacterial
FLAWS
Foamy urine (Bence Jones proteins)
Symptoms of hypercalcaemia

Question 8

List 3 symptoms caused by hyper viscosity in multiple myeloma

Answer 8

Headaches
Visual disturbance
Mucousal bleeding

Question 9

List 6 signs of multiple myeloma

Answer 9

Pallor    
Dehydration  
Purpura   
Bone tenderness
Hepatomegaly
Peripheral neuropathies e.g. CTS

Question 10

What bloods are seen in multiple myeloma?

Answer 10

FBC: normochromic normocytic anaemia
High ESR/CRP
U+Es: high creatinine, high Ca2+ 
Normal ALP
Increased conc. free light chain in the serum

Question 11

What may be seen on a blood film in multiple myeloma?

Answer 11

Rouleaux formation with bluish background (suggests high protein)

Question 12

What is seen on urine electrophoresis in multiple myeloma?

Answer 12

Bence-Jones proteins

Monoclonal immunoglobulin light chains

Question 13

What is seen on whole body low dose CT in multiple myeloma?

Answer 13

Osteolytic lesions without surrounding sclerosis (pepper pot skull)
Punched out holes on skeletal x-rays
Pathological fractures

Question 14

List 5 investigations performed in multiple myeloma

Answer 14

Bloods
Blood film
Serum/ urine elecrtophoresis
Bone marrow aspirate/ trephine biopsy
Whole body low dose CT

Question 15

List 3 environmental factors multiple myeloma is associated with

Answer 15

Ionising radiation
Agricultural work
Occupational chemical exposures

Question 16

How does ALP in multiple myeloma differ from other malignancies

Answer 16

Malignancy: HIGH Ca with HIGH ALP
MM: HIGH Ca with NORMAL ALP

Question 17

What symptoms of hypercalcaemia may be seen in multiple myeloma?

Answer 17

Nephrolithiasis
Bone pain
Polyuria 
Constipation, abdo pain, N+V
Mental changes; fatigue, anxiety, depression

Question 18

What is the initial test in suspected myeloma?

Answer 18

Serum protein electrophoresis

Paraprotein spike

Question 19

What is the confirmatory diagnostic test in suspected myeloma?

Answer 19

bone marrow aspirate/ trephine biopsy

High plasma cells (usually > 20%)

Question 20

Why is ALP normal in multiple myeloma?

Answer 20

Osteoblasts produce ALP

Plasma cells in MM suppress osteoblasts