Plasmacytoma and Multiple Myeloma

Question 1

difference between plasmacytoma and multiple myeloma

Answer 1

plasmacytoma is a plasma cell neoplasm of the soft tissue or bones and is a solitary lesion while multiple myeloma is a systemic plasma cell neoplasm

Question 2

margins plasmacytoma extra medullary

Answer 2

common for there to be a large margin to encompass the the lymphatics are there is a higher propensity for LN to be involved than in plasmacytma of the bone

Question 3

Plasmacytomas are _% solitary bone lesions and ___% extramedularry (soft tissue tumours)

Answer 3

80% solitary bone primaries and 20% extra medullary soft tissue tumours

Question 4

solitary plasmacytomas of the bone are most often located where?

Answer 4

vertebral bodies or pelvic bones, most pf these tumours end up developing into multiple myeloma

Question 5

where do most extra medullary plasmacytomas occur?

Answer 5

80% occur in the upper aerodigestive tract (nasal cavity, paranasal sinuses, pharynx, larynx, tonsils)

Question 6

what type of plasmacytoma most frequently becomes multiple myeloma?

Answer 6

Osseous plasmacytoma becomes multiple myeloma in 50-80% of cases and extramedularry plasmacytoma becomes multiple myeloma in 10-40% of cases

Question 7

GTV, CTV margins for plasmacytoma

Answer 7

GTV+2-3cm=CTV

CTV+.5-1cm=PTV

Question 8

When is IMRT most often used in the treatment of plasmacytoma? what is used when this is not the case?

Answer 8

IMRT is used when the PTV is close to a critical structure (this is more common in extra medullary plasmacytoma for ex: when the paranasal sinuses are treated we use IMRT to avoid treating the optics) Otherwise a POP is most often used

Question 9

Most common presentation for plasmacytoma ?

Answer 9

bone pain in 70% of cases as most plasmacytomas are single bone plasmytomas (80%)

Question 10

Secretions found in presentation of plasmacytomas/ multiple myelomas

Answer 10

Secrete measurable paraprotein in 99% of cases, Imuunoglobin G found in 50-60% of cases and Immunoglobin A found in 20-25% of cases

Question 11

Indications that a plasmytoma will progress into a multiple myeloma

Answer 11

• Bony subtype
• Greater age is more likely to progress into multiple myeloma
• subclinical bone disease is more likely to develop intto multiple myeloma
• if there is a high level of M protein post XRT there is a higher likelihood of developing into multiple myeloma

Question 12

standard treatment for plasmacytoma

Answer 12

-XRT

Question 13

doses for plasmytoma

Answer 13

35-45Gy

Question 14

surgery in plasmytoma

Answer 14

surgery is used ALONE for small extra medullary plasmyctomas and is used for bone plasmacytomas for structurally unstable bone or RAPIDLY PROGRESSIVE emergencies such as SCC and is followed by XRT

Question 15

small vs large extra medullary plasmacytomas treatment

Answer 15

small may be curatively removed and treated with surgery alone, large may be treated with XRT alone

Question 16

Chemotherapy in plasmacytoma

Answer 16

used adjuvantly after XRT and given for 3 years

Question 17

chemo agents in plasmacytoma

Answer 17

melphalen and prednisone

Question 18

major and minor diagnosis criteria for Multiple Myeloma

Answer 18

need to have at least one major and one minor criteria or 3 minor criteria is required to make a MM diagnosis.
Major: -plasmycytoma on tissue biopsy
-BM plasmycytosis with 30%plasma cells
-monoclonal immunoglobulin spike >3,5g/dL
Minor criteria:
-BM plasmacytosis between 10-30% plasma cells
-lytic bone lesions
-monoclonal immunoglobulin spike but with levels lower than 3.5g/dL

Question 19

most common presentation for MM

Answer 19

bone pain and fatiguability

Question 20

what presentation on lab tests are common on MM

Answer 20

• anemia
• granulocytopenia (low granulocytes)
• thrombocytopenia (low platelet count)
• abnormal monoclonal immunoglobin levels

Question 21

Whats MGUS? What clinically demonstrates MGUS?

Answer 21

MGUS is monoclonal gammopathy of unknown significance- it is a precancerous MM condition. Its clinically significant features are:
monoclonal protein is <3g/dL
Bone marrow clonal plasma cells are <10% with no organ related dammage

Question 22

types of MM and severity

Answer 22

MGUS -monoclonal gammopathy of unknown significance, is a precancerous condition with a low propensity to become MM
Asymptomatic MM- intermediate form of MM, has a 20% of risk per year of becoming MM higher propensity than MGUS
Plasma cell leukemias- very rare and very severe variant of MM

Question 23

causes MM

Answer 23

prior XRT exposure
exposure to petroleum
preceded by MGUS

Question 24

Adverse prognostic indicators for MM 
Platelet count
serum albumin
serum creatinine 
b2 micoglobulin 
hemoglobin 
bone marrow plasma percentage

Answer 24

Platelet <150,000/uL
serum albumin <3g/dL
serum creatinine >2g/dL
b2 microglobulin >4mg/dL
hemoglobin >10g/dL
bone marrow plasma percentage >50%

Question 25

surgeries for MM

Answer 25

• vertebroplasties : when bone cement is injected into the spine to stabilize bone fractures
• Kyphoplasty:are designed to stop the pain caused by a spinal fracture, to stabilize the bone, and to restore some or all of the lost vertebral body height

Question 26

2 reasons for XRT in MM

Answer 26

1. to prepare the patient for ASCT (autogolous stem cell transplant)
2. for palliation

Question 27

palliative doses for MM

Answer 27

10-20Gy in 5-10 Fx

Question 28

preparation for ASCT in MM

Answer 28

Melphalan 140mg2 and 8Gy in 4fx of TBI

Question 29

Initial treatment for patients ineligible for ASCT

Answer 29

chemotherapy melphalan +prednisone +thalimolide (MPT)

Question 30

Gold standard of treatment for MM patients

Answer 30

ASTC for all eligible patients

Question 31

what agents are used to prepare for ASCT?

Answer 31

BD Bortezomib +dexamethasone
or dexamethasone + lenolamide +/- boretoxomib
or thalmilomide +dexamethasone (DT)

Question 32

Whats a tandem transplantation ASCT? when is it used?

Answer 32

It is a second planned ASTC transplant that is performed after the pt has recovered from the first ASTC transplant
it is used when <90% of tumour reduction is seen afte4 the first ASTC

Question 33

relapse after ASCT

Answer 33

usually occurs after 2 years
treatment after relapse is typically with halidomide, bortezomib and lenalidomide
lenalidomide may also be used as a maintenance therapy after ASCT

Question 34

radiation borders rule of thumb when treating solitary plasmacytoma of a vertebral body

Answer 34

to include 2 vertebral bodies above and 2 vertebral bodies below a grossly involved vertebra