Myeloma Flashcards
Define Myeloma
Cancer of the plasma cells;
these are a type of B lymphocyte that produces antibodies
What is the median age at diagnosis for multiple myeloma?
65 years
List the risk factors for myeloma.
- Male sex
- Black African ethnicity
- Family history
- Obesity
What is MGUS, and how is it related to myeloma?
MGUS
(Monoclonal Gammopathy of Undetermined Significance)
is a benign precursor with small amounts of paraprotein. It carries a very low risk of progressing to myeloma
What is the significance of paraproteins in multiple myeloma?
Paraproteins (most commonly IgG, also IgA) are monoclonal antibodies produced by cancerous plasma cells, detected via serum protein electrophoresis.
Bence Jones proteins (light chains) may also appear in urine
What mnemonic helps recall the clinical features of multiple myeloma?
CRAB:
C - HyperCalcaemia
R - Renal impairment
A - Anaemia
B - Bone pain
What is the most common symptom of multiple myeloma?
Bone pain, often in the back, due to vertebral involvement
What causes hypercalcaemia in multiple myeloma?
Increased osteoclast activity due to cytokines released by myeloma cells, leading to bone breakdown
What are the primary investigations for suspected multiple myeloma?
(1) Blood tests
= FBC, U+Es, calcium, CRP, plasma viscosity
(2) Serum protein electrophoresis
= Detects paraproteins
(3) Imaging
= Whole-body MRI or low-dose CT (lytic lesions)
(4) Urine tests
= Bence Jones proteins
What are the first-line treatments for multiple myeloma?
1 - Combination chemotherapy: Thalidomide + melphalan + dexamethasone
2 - Bisphosphonates: For hypercalcaemia and bone pain
3 - Stem cell transplant: For young, fit patients
Why should NSAIDs be avoided in multiple myeloma?
Can exacerbate renal impairment
What imaging findings are typical in multiple myeloma?
Lytic bone lesions, especially in the spine, skull, ribs, and long bones
What are the diagnostic criteria for myeloma?
(1) M protein
(2) Plasma cells on marrow biopsy
(3) End organ damage evidence: Renal impairment, anaemia and hypercalcaemia (lytic bone lesions)
(4) Bone lesions on skeletal survey
What are the factors predicting a poor prognosis in Myeloma?
Multiple osteolytic lesions
Beta-2-microglobulin raised
Low Haemoglobin
Low Albumin
A 60-year-old female is referred to the haematology clinic by the general practitioner. The referral letter is incomplete and the only information you have about the patient is that she was referred after serum electrophoresis revealed an IgG paraprotein spike (IgG 45 g/L) (normal range 5.5-16.5 g/L)
Why would you expect this patient to present with Conjunctival pallor?
C - Hypercalcaemia
R - Renal Impairment
A - Anaemia
B - Bone disease
Anaemia occurs in approximately 70% of patients with multiple myeloma. Examination findings of anaemia include conjunctival pallor and koilonychia
Patient has anaemia
What is the myeloid antigen?
Myeloperoxidase
what are the lymphoid antigens
CD19 - B
CD20 - B
CD3 - T
A 60-year-old female presents to the GP with back pain. Her GP suspects multiple myeloma as the cause.
What is the best investigation to confirm this diagnosis?
Serum protein electrophoresis
A 50-year-old female patient presents to the emergency department with a 48-hour history of confusion and vomiting. She also reports a 1-month history of constipation and back pain.
On physical examination, there is conjunctival pallor, dry mucous membranes, and bone tenderness over the lumbar vertebrae.
Blood tests reveal:
Haemoglobin:
100 g/L | (M) 130 - 170, (F) 115 - 155
Creatinine 220 µmol/L | 60 - 120
Calcium 2.9 mmol/L | 2.2 - 2.6
What accurately describes the pathogenesis of the most likely diagnosis?
Post-germinal B cell dyscrasia with monoclonal immunoglobulin fragment
= The patient presents with clinical features consistent with multiple myeloma
A 75-year-old male presents with diffuse bone pain and weakness. His labs reveal normocytic anaemia, raised creatinine and hypercalcaemia. Bone marrow biopsy demonstrates >10% plasma cells in the bone marrow.
How does the above case indicate myeloma?
- Diffuse Bone Pain and Weakness
= common symptoms of myeloma - Normocytic Anaemia
- Raised Creatinine
- Hypercalcaemia
- Bone Marrow Biopsy with >10% Plasma Cells
A 75-year-old male presents with diffuse bone pain and weakness. His labs reveal normocytic anaemia, raised creatinine and hypercalcaemia. Bone marrow biopsy demonstrates >10% plasma cells in the bone marrow.
Give the likely diagnosis, what is the most appropriate management? and explain why haematopoietic stem cell transplantation is unsuitable
MPT (melphalan, prednisolone and thalidomide) chemotherapy protocol
= Given this patient’s age, he is likely unsuitable for haematopoietic stem cell transplantation and will require treatment with chemotherapy
What are fluorescence in situ hybridisation (FISH) and cytogenetic analysis used for?
useful for risk stratification in confirmed multiple myeloma, but are not the initial diagnostic test
A 55-year-old male patient presents to the general practitioner with a 1-month history of back pain and fatigue. He has no past medical history of note but has suffered from 2 episodes of pneumonia in the last 6 months.
On physical examination, there is bone tenderness in the lumbar region
What is the best diagnostic investigation for the most likely diagnosis?
Bone marrow aspirate and biopsy
What is the first-line imaging in suspected multiple myeloma to assess for bony involvement?
Whole body MRI
This patient has myeloma. A blood film is performed, which shows Rouleaux’s formation. What is the most likely cause of this condition?
Proliferation of plasma cells
A 65-year-old man presents to his GP with tiredness, lower back pain and constipation. His symptoms started a few months ago and have been getting progressively worse. The GP arranges a set of blood tests which reveal anaemia, hypercalcaemia and new renal impairment. The patient undergoes further investigations including serum electrophoresis which shows a paraprotein.
Which type of paraprotein is most commonly associated with the suspected diagnosis?
IgG
Why is Serum protein electrophoresis first-line investigation rather than whole-body MRI?
A whole-body MRI may be done to assess the extent of bony lesions and help stage multiple myeloma
Serum protein electrophoresis is first-line because it directly detects paraproteins (monoclonal antibodies), the hallmark of multiple myeloma
Initial investigations for suspected multiple myeloma include
(1) FBC, U+Es, LFTs
(2) calcium
(3) ESR
(4) serum immunoglobulins
(5) protein electrophoresis
(6) free light chain assay
What are initial investigations for suspected multiple myeloma?
(!) FBC
(2) U+Es
(3) LFTs
(4) calcium
(5) ESR
(6) serum immunoglobulins
(7) protein electrophoresis
(8) Free light chain assay
Proliferation of plasma cells is seen in myeloma. Where is proliferation of B cells seen?
Waldenström macroglobulinaemia
Key blood finding to indicate multiple myeloma
raised calcium - (C)rab
A 65-year-old woman is investigated for bony pains and worsening renal function. Urinary tests have found Bence-Jones proteins and a whole-body MRI scan has revealed osteolytic lesions. Her doctor requests a bone marrow aspirate to confirm the diagnosis.
The bone marrow investigation is looking for which cells?
B cells
B cells = plasma cells
