Myeloma

Question 1

What is a myeloma?

Answer 1

There is abnormal clonal proliferation of post germinal B cells (plasma cells).
AKA - cancer of the plasma cells

Question 2

what are plasma cells?

Answer 2

They develop from B cells that have been activated and they produce antibodies.

Question 3

How does cancer of plasma cells manifest?

Answer 3

they produce large quantities of a single type of antibody.

Question 4

What is MGUS?

Answer 4

Monoclonal gammopathy of undetermined significance

When theres an excess of a single type of antibody WITHOUT other features or myeloma or cancer.

Question 5

What is smouldering myeloma?

Answer 5

When MGUS progresses with higher levels of antibodies but its not a full myeloma.
Classed as a premalignant condition
More likely to progress to a myeloma than MGUS.

Question 6

Where do they secrete the antibodies?

Answer 6

into the serum and urine

Question 7

what is waldenstrom’s macroglobulinaemia?

Answer 7

A type of smouldering myeloma which excess IgM specifically.

Question 8

Where are plasma cells found?

Answer 8

In the bone marrow.

Question 9

What is an antibody made of?

Answer 9

2 heavy chains
2 light chains
arranged in a Y shape

Question 10

What are the different types of immunoglobulins?

Answer 10

IgA
IgG (50% of myelomas) 
IgM
IgD
IgE

Question 11

what is a monoclonal paraprotein?

Answer 11

The complex protein (made from a single type of immunoglobulin) - the SAME type of antibody is produced by all of the identical cancerous plasma cells.

Question 12

What is myeloma bone disease and where is it commonly found?

Answer 12

When increased osteoclast activity and decreased osteoblast activity leads to bone resorption.
Caused by the plasma cells secreting cytokines.

Skull
Spine
Long bones
Ribs

There is patches of osteolytic lesions which lead to pathological fractures.

Question 13

What blood changes does the plasma cells create?

Answer 13

anaemia
neutropenia
thrombocytopenia
hypercalcaemia

Question 14

How does myelomas caused renal disease?

Answer 14

The high levels of immunoglobulins block the flow through the tubules and hypercalcaemia blocks renal function.

Question 15

What is hyperviscosity?

Answer 15

Normal blood viscosity = 1.3-1.7 x water.
Increased immunoglobulins leads to increased viscosity.

Signs:
increased bruising
easy bleeding
reduced or loss of sight (vascular disease of eyes)
Purple discolouration of extremities 
Heart failure

Question 16

What are the main signs of myeloma?

Answer 16

CRAB HAI:
Hypercalcaemia (increased osteoclasts) 
Renal impairment (light chain deposit and hypercalcaemia)
Anaemia (bone marrow infiltration)
Bone pathology (osteolytic lesions)

Hyperviscosity (headache, visual disturbances, thrombosis)
Amyloidosis
Infection (due to leukopenia)

Question 17

Which investigations should be done?

Answer 17

Bence jones protein - positive in urine
Raised calcium
Raised ESR
raised viscosity

^If these are positive - urgent serum electrophoresis

Question 18

What type of anaemia is present?

Answer 18

normochromic, normocytic.

Question 19

What are risk factors for hypercalcaemia?

Answer 19

Increased age
male
black african
family history
obesity

Question 20

which investigation confirms myeloma?

Answer 20

Bone marrow biopsy

Question 21

What imaging can be done?

Answer 21

1 - whole body MRI
2 - Whole body CT
3 - Skeletal survey (full body X-ray)

^Only go on to the next if the first is not possible

Question 22

What will be seen on x-ray?

Answer 22

Punched out lesions, lytic lesions, pepper pot skull.

Question 23

What course does myelomas take?

Answer 23

Relapsing remitting

Question 24

What is the treatment for myeloma?

Answer 24

1st line - chemo + bortezomid, thalidomide or dexamethasone

+ Venous thromboembolism prophylaxis (aspirin or low molecular weight heparin).

Question 25

What are other treatments for myeloma?

Answer 25

Bone disease - bisphosphonates
bone lesions - radiotherapy
orthopaedic surgery
vertebral fractures - cement augmentation

Question 26

What are complications of myelomas?

Answer 26

Infection
Pain
Renal failure
Anaemia
Hypercalcaemia
Peripheral neuropathy
spinal cord compression 
Hyperviscosity