Myeloma

Question 1

What is myeloma?

Answer 1

Cancer of plasma cells (type of B-cell that produces antibodies)

Question 2

When you measure immunoglobulins, what will it show?

Answer 2

• Plasma cells will only produce one type of antibody

- One of the types (A, G, M, D or E) will be abundant (monoclonal paraprotein).

Question 3

What is multiple myeloma?

Answer 3

Myeloma affects multiple areas of the body

Question 4

What are the features of myeloma?

Answer 4

CRAB
•	C - Calcium elevated
•	R - Renal failure
•	A - Anaemia (normocytic, normochromic) from replacement of bone marrow)
•	B - Bone lesions/pain

Question 5

How does calcium increase in myeloma?

Answer 5

Proliferating nests of plasma cells may deposit in bones, where they typically cause osteolytic lesions on x-ray.

This is due to the release of cytokines from plasma cells causing increased osteoclast activity (absorption of bone) and suppressed osteoblast activity (deposition of bone).

Question 6

Does myeloma cause pancytopenia?

Answer 6

Yes

Question 7

How can myeloma cause renal impairment?

Answer 7

• High levels of immunoglobulins can block flow through tubules
• Hypercalcaemia impairs renal function
• Dehydration
• Medications such as bisphosphonates can be harmful to the kidneys

Question 8

How does plasma viscosity increase?

Answer 8

When there are more proteins (immunoglobulins and fibrinogen) in the blood.

Question 9

What are the consequences of increased plasma viscosity?

Answer 9

• Easy bruising
• Easy bleeding
• Reduced or loss of sight due to vascular disease in the eye
• Purple discolouration to the extremities
• HF

Question 10

What should raise suspicion of myeloma?

Answer 10

Persistent back pain or unexplained fractures in an older subject
- Particularly when associated with anaemia and hypercalcaemia

Question 11

What test do you perform for suspected myeloma?

Answer 11

• FBC (low WCC and Hb)
• Calcium (raised)
• ESR (raised)
• Plasma viscosity (raised)

Question 12

How do you diagnose myeloma?

Answer 12

BLIP
o	Bence-Jones protein (urine electrophoresis)
o	Serum-free Light-chain assay
o	Serum Immunoglobulins
o	Serum Protein electrophoresis 

• Bone marrow biopsy
• Imaging

Question 13

What are Bence-Jones proteins?

Answer 13

Monoclonal globulins that may be detected in urine in patients with multiple myeloma

Question 14

What is myeloma associated with?

Answer 14

Amyloidosis

Question 15

What is the management of myeloma focussed on?

Answer 15

• Controlling symptoms
• Reducing complications
• Prolonging survival

Question 16

What are the management options for myeloma?

Answer 16

1. For patients suitable for autologous stem cell transplantation induction therapy consists of Bortezomib and Dexamethasone
2. For patients who are unsuitable for autologous stem cell transplantation, induction therapy consists of thalidomide and an alkylating agent and dexamethasone

Question 17

What do patients require when on thalidomide?

Answer 17

VTE prophylaxis with aspirin or LMWH