Myeloma

Question 1

What is Myeloma

Answer 1

Cancer of the plasma cells - B lymphocyte that produce antibodies

Multiple myeloma is where the myeloma affects multiple areas of the body

Question 2

Monoclonal gammopathy of undetermined significance (MGUS)

Answer 2

Excess of a single type of antibody or antibody components without other features of myeloma

May progress to myeloma and patients are often followed up routinely

Question 3

Smouldering myeloma

Answer 3

Progression of MGUS with higher levels of antibodies or antibody components

Premalignant and more likely to progress to myeloma than MGUS

Question 4

Waldenstrom’s macroglobulinemia

Answer 4

Type of smouldering myeloma where there is excessive IgM specifically

Question 5

Which immunoglobulin is most commonly affected in myeloma?

Answer 5

IgG (>50%)

Question 6

What protein in urine is seen in myeloma?

Answer 6

Bence Jones

Question 7

How does anaemia occur in myeloma?

Answer 7

Plasma cells invade the bone marrow

Causes suppression of the development of other blood cell lines

anaemia
neutropenia thrombocytopenia

Question 8

Myeloma bone disease

Answer 8

Increased osteoclast activity
Suppressed osteoblast activity

More bone (+calcium) is being reabsorbed than constructed

Caused by cytokines released from the plasma cells and the stromal cells

Question 9

Common sites of bone disease

Answer 9

Skull
Spine
Long bones
Ribs

Question 10

What are plasmacytomas?

Answer 10

Individual tumours made up of the cancerous plasma cells

In bones or in soft tissue

Question 11

Why do myeloma patients get renal impairment?

Answer 11

High levels of immunoglobulins (antibodies) can block the flow through the tubules

Hypercalcaemia

Dehydration

Medications used to treat the conditions such as bisphosphonates can be harmful to the kidneys

Question 12

Key features of myeloma

Answer 12

C – Calcium (elevated)

R – Renal failure

A – Anaemia (normocytic, normochromic) from replacement of bone marrow.

B – Bone lesions/pain

Question 13

RF for myeloma (5)

Answer 13

Older age

Male

Black African ethnicity

Family history

Obesity

Question 14

Initial investingations in myeloma

Answer 14

Consider myeloma in 60+ with persistent bone pain, particularly back pain, or an unexplained fractures

FBC (low white blood cell count in myeloma)
Calcium (raised in myeloma)
ESR (raised in myeloma)
Plasma viscosity (raised in myeloma)

Question 15

What is used to conform the diagnosis?

Answer 15

Bone marrow biopsy

Question 16

Signs of myeloma on xray

Answer 16

Punched out lesions

Lytic lesions

“Raindrop skull” caused by many punched out (lytic) lesions throughout the skull that give the appearance of raindrops splashing on a surface

Question 17

Investigating when myeloma suspected

Answer 17

B – Bence–Jones protein (request urine electrophoresis)

L – Serum‑free Light‑chain assay

I – Serum Immunoglobulins

P – Serum Protein electrophoresis

Question 18

Management of myeloma

Answer 18

Aim of treatment is to control disease

First line treatment usually involves a combination of chemotherapy with:

Bortezomid
Thalidomide
Dexamethasone

Question 19

Management of myeloma bone disease

Answer 19

Myeloma bone disease can be improved using bisphosphonates - suppress osteoclast activity

Radiotherapy to bone lesions can improve bone pain

Orthopaedic surgery can stabilise bones (e.g. by inserting a prophylactic intramedullary rod) or treat fractures

Cement augmentation involves injecting cement into vertebral fractures or lesions and can improve spine stability and pain

Question 20

Complications with myeloma

Answer 20

Infection

Pain

Renal failure

Anaemia

Hypercalcaemia

Peripheral neuropathy

Spinal cord compression

Hyperviscocity