Myeloma

Question 1

What is Multiple myeloma

Answer 1

Malignant neoplasm of (bone marrow) plasma cells

Question 2

Pathophysiology of Multiple Myeloma

Answer 2

Clonal proliferation of bone marrow cells, usually capable of monoclonal antibodies (usually IgA or IgG). Can be associated with the excretion of light chains in the urine (Bence Jones protein).
Bone destruction: increased osteoclastic activity -> bone pain and osteolytic lesions Infiltration of bone marrow -> reduced function
AKI: due to light chain and amyloid deposition, hypercalcaemia and hyperuricaemia.
Paraproteins: Can aggregate in the blood to greatly increase viscosity

Question 3

Aetiology of Multiple Myeloma

Answer 3

Mutation.

About half of the cases = translocation placing oncogene into immunoglobulin heavy chain gene on chromosome 14

Question 4

When is peak presentation of Multiple myeloma

Answer 4

60 years

Question 5

Diagnostic tests of Multiple myeloma

Answer 5

Paraproteinaemia
Bence Jones protein in urine
CT
Bone marrow aspirate

Question 6

Treatment of Multiple myeloma

Answer 6

Chemotherapy with autologous stem cell transplant
Paraprotein: plasmapheresis
Blood transfusion for anaemia
Treatment of infection
AKI can be treated by hydration

Question 7

Complications of multiple myeloma

Answer 7

Spinal cord compression
Pathological feature
Hypercalcaemia
AKI
Increased risk of infection
Anaemia
Terminal
With treatment, median survival in 5 years

Question 8

Signs and symptoms

Answer 8

Fatigue
Unintentional weight loss
Pathological fractures
Vertebral collapse (may lead to spinal cord compression)
Hypercalcaemia
Anaemia
Infection
Renal impairment
Bruising

Question 9

Investigations

Answer 9

Bloods
Blood film (rouleaux formation)
Serum and urine electrophoresis
Bone marrow biopsy
Radiology

Question 10

Blood investigations

Answer 10

FBC, U and Es, Creatinine, LFTs, ESR, CRP,
Calcium levels,
Alkaline phosphatase,
Beta-2 microglobulin

Question 11

What type of anaemia would you seen in myeloma

Answer 11

Normocytic, normochromic

Question 12

Serum and urine electrophoresis investigations

Answer 12

Paraprotein (M protein)

Bence Jones proteinuria

Question 13

Radiological investigations

Answer 13

X-ray for bone deformities e.g. pepper pot skull and generalised skeletal osteopenia
MRI scan may be useful

Question 14

Conservative treatment

Answer 14

Patient education

Refer to Macmillan nurses

Question 15

Surgical treatment

Answer 15

Kyphoplasty may be required

Question 16

Medical treatment

<70 and without significant co-morbidities

Answer 16

(Treatment depends on age of patient and their state of health)
Eligible for Autologous Bone Marrow Transplant (most effective treatment):
This involves induction phase using VAD regimen and after transplant, the patient receives long-term therapy with melphalan

Question 17

Medical treatment

if not legible for autologous bone marrow transplant

Answer 17

Long term treatment with melphalan and prednisolone

Question 18

Other medical treatments (not bone marrow transplants)

Answer 18

Analgesia
Bisphosphonates
Prednisolone
Blood transfusion
Radiotherapy may be required to treat bone pain and spinal cord compression

Question 19

Define monoclonal paraprotein

Answer 19

One immunoglobulin which is excessively produced

Question 20

Which electrolyte is raised in patients with myeloma

Answer 20

calcium

Question 21

How much fluid should myeloma patients drink/day

Answer 21

3L/day