Oncology

Question 1

What is myeloma ?

Answer 1

Cancer in a specific type of plasma cell results in large quantities of a single type of antibody being produced

Question 2

What is multiple myeloma ?

Answer 2

Myeloma effects multiple areas of the body.

Question 3

What is MGUS ?

Answer 3

Excess of a single type of antibody or antibody component without the other features of myeloma or cancer. Often incidental and may be a precursor to myeloma.

Question 4

What is smouldering myeloma ?

Answer 4

Progression of MGUS with higher levels of antibodies or antibody components. It is pre-malignant and is more likely to progress to myeloma than MGUS.

Question 5

What is walderstroms macroglobinemia ?

Answer 5

smouldering myeloma IgM specific.

Question 6

What is bence jones protein ?

Answer 6

Found in the urine of many patients with myeloma. Subunit of light chains.

Question 7

What is the initial investigation in myeloma and what will it show ?

Answer 7

Serum electrophoresis IgG Kappa peak

Show paraprotein spike.

Question 8

What is used to confirm the diagnosis of Myeloma ?

Answer 8

Bone marrow aspirate and biopsy.

Question 9

What are the signs in blood tests in myeloma ?

Answer 9

Anaemia
Neutropenia
Thrombocytopenia
Hypercalcaemia
Deranged kidney function tests.

Question 10

What is myeloma bone disease ?

Answer 10

Increased osteoclast activity (absorb) and decreased osteoblast (deposit)
This leads to patchy bone density, leading to osteolytic lesions and pathological fractures

Question 11

What are common places of myeloma bone disease ?

Answer 11

Skull (raindrop apperance on Xray) , spine, long bones and ribs.

Question 12

What is the most common raised immunoglobulin in myeloma ?

Answer 12

IgG

Question 13

Patients with multiple myeloma have hyperviscocity. What are the symptoms of this ?

Answer 13

• Easy bruising and bleeding
• Reduced or loss of sight due to vascular eye disease
• Purple discolouration of the extremities
• Heart failure.

Question 14

What are the CRAB - AR features in myeloma ?

Answer 14

• Calcium
• Renal failure
• Anaemia (normochromic, normocytic)
• Bone lesions/pain
• Amyloidosis
• Recurrent infections

Question 15

When should myeloma be suspected ?

Answer 15

Suspect in any patient over the age of 60 with persistent bone pain (particularly back pain) or unexplained fractures. Initial investigations include ….

Question 16

What are the initial tests when suspecting myeloma ?

Answer 16

• FBC - Low WCC
• Raised calcium
• Raised ESR
• Raised plasma viscocity.

If any are raised/positive the do urgent serum protein electrophoresis and urine bence jones protein test

Question 17

What investigations should be initiated to confirm diagnosis of myeloma ?

Answer 17

• B - Bence jones protein (urine electrophoresis)
• L - Serum free light chain assay
• I - Serum immunoglobulins
• P - serum protein electrophoresis.

Confirm diagnosis - Bone marrow biopsy

Question 18

What imaging should be commenced in myeloma ?

Answer 18

Assess for bone lesions (order of pref)

• Whole body MRI
• Whole body CT
• Skeletal survey (whole body X-ray)

Question 19

What is present on X-ray in patients with myeloma ?

Answer 19

• Punched out lesions
• Lytic lesions
• Raindrop skull - Punched out lytic lesions throughout the skull giving the appearance of raindrops splashing on the surface.

Question 20

How is multiple myeloma managed ?

Answer 20

Control of the disease, usually takes a relapsing/remitting course. MDT approach

1. Combination chemotherapy - Bortezomoid, Thalidomide and dexamethasone.
2. Stem cell transplantation in clinical transplantation
3. VTE prophylaxis whilst on certain chemo like thialidomide.

Question 21

How is myeloma bone disease managed ?

Answer 21

• Biphosphonates
• Radiotherapy can improve bone pain
• Orthopaedic surgery can stabalise bones
• Cement augmentation - cement into fractures or lesions

Question 22

What are the complications of myeloma ?

Answer 22

• Infection
• Pain
• Renal failure
• Anaemia
• Hypercalcaemia
• Peripheral neuropathy
• Spinal cord compression
• Hyperviscocity

Question 23

What will be present on bone biopsy in myeloma ?

Answer 23

Foci of plasma cells

Question 24

What are the most common causes of SVC obstruction ?

Answer 24

Dyspnoea
Orthopnoea
Facial plethora
Dilated/engorged veins
Pemberton’s test- where lifting the arms over the head for more than 1 minute will precipitate facial plethora and cyanosis.

Question 25

How to diagnose SVC obstruction ?

Answer 25

CT thorax

Question 26

How is SVC obstruction managed ?

Answer 26

Symptomatic management is critical using oral dexamethasone 8mg BD. The patient will require an urgent contrast enhanced CT. Once the patient has stabilised alternative management options including IVC stenting may be considered.