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Dimas Bayu
Definition
! Multiple myeloma : as myeloma or
plasma cell myeloma
! cancer of the Plasma Cell
! Multiple myeloma
! excessive numbers of abnormal plasma
cells in the bone marrow
! overproduction of intact monoclonal
immunoglobulin (IgG, IgA, IgD, or IgE) or
Bence-Jones protein (free monoclonal
and light chains)
Definition
! Normal Plasma Cell Function in
the Immune System
! Stem cells can develop into B
lymphocytes -- >travel to the lymph
nodes, mature, and then travel
throughout the body.
! When foreign substances (antigens)
enter the body -- >B cells develop
into plasma cells that produce
immunoglobulins Ig (antibodies) to
help fight infection and disease.
Incidence
! Multiple myeloma is the second most
prevalent blood cancer after nonHodgkin's lymphoma
! 1% of all cancers and 2% of all
cancer deaths.
! Age 60-65 years most common
! Occurs in men > women
! African Americans and Native Pacific
Islanders have the highest reported
incidence of this disease and Asians
the lowest
Causes
! Genetic causes
! Ongoing research is investigating whether
HLA-Cw5 or HLA-Cw2 may play a role in the
pathogenesis of myeloma.
! Environmental or occupational causes
! significant exposures in the agriculture,
food, silicon ,Benzene, Nickel and
petrochemical industries
! Radiation:
! Radiation has been linked to the
development of myeloma.
! In 109,000 survivors of the bombing of
Nagasaki, 29 died from myeloma from
1950-1976; however, some recent studies do
not confirm that these survivors have an
increased risk of developing myeloma.
Clinical features
! common tetrad of multiple
myeloma is CRAB
C=
R=
A=
B=
Calcium (elevated)
Renal failure
Anemia
Bone lesions
Clinical Features
! Bone pain
! Myeloma bone disease -- >proliferation
of tumor cells and release of IL-6
<osteoclast activating factor :OAF>->stimulates osteoclast to break down
bone-- > leading to hypercalcemia
! These bone lesions in plain
radiographs-- > "punched-out" / lytic
bone lesion
Clinical features
! Bone pain
! Myeloma bone pain -- > involves the
rib ,sternum, spine , clavicle , skull ,
humerus & femur
! The lumbar vertebrae are one of the
most common sites of pain -- >may lead
to spinal cord compression.
! Persistent localized pain may indicate
a pathological fracture
Clinical features
Clinical features
Clinical features
Clinical features
! Hypercalcemia
! Pt. present with confusion, somnolence,
bone pain, constipation, nausea, and
thirst.
! Anemia
! The anemia :normocytic and
normochromic.
! It results from the replacement of
normal bone marrow by infiltrating
tumor cells and inhibition of normal red
blood cell production (hematopoiesis) by
cytokines.
Clinical features
! Bleeding
! bleeding resulting from thrombocytopenia.
! In some patients, monoclonal protein may
absorb clotting factors and lead to bleeding,
but this development is rare.
! Hyperviscosity
! Malignant plasma cells excretes an abnormal
M protein (Para-protein)
! high volume of monoclonal protein -- >
blood viscosity increases-- >complications
such as stroke, myocardial ischemia, or
infarction.
Clinical features
! Infection
Clinical features
! Renal failure
Clinical features
! Neurological symptoms
! Common problems are weakness, confusion
and fatigue due to hypercalcemia.
! Headache, visual changes and retinopathy
may be the result of hyperviscosity of the
blood depending on the properties of the
paraprotein
! Finally, there may be radicular pain, loss of
bowel or bladder control (due to
involvement of spinal cord leading to cord
compression) or carpal tunnel syndrome and
other neuropathies (due to infiltration of
peripheral nerves by amyloid).
! It may give rise to paraplegia in late
presenting cases.
Lab Findings
Anemia ( normochrom )
Rouleaux Formation
Very High ESR (eg. 150 / 160 )
Hypercalsemia
Proteinuria (Bence Jones protein)
n Abnormal Electrophoresis protein
(monoclonal Spike on beta or gamma)
Rouleaux Formation
Kyle RA and Rajkumar SV. Cecil Textbook of Medicine, 22nd Edition, 2004
Diagnostic Criteria
for MM
M Spike on
SPEP
Malignant
Plasma on
BMP
CRAB
MGUS
Less than
10%
Smoldering
Myeloma
Multiple
Myeloma
Management
n 1. Symptomatic (bone-pain, etc)
n 2. Melphalan/Alkeran + prednisone
(alkylating)
n 3. Local Radio tx
n 4. Avoid prolonged immobilization
n 5. Avoid dehidration
Prognosis
n Median survival : 3 yrs
n Worsen in : very high paraprotein spikes, renal
failure, hypercalsemia & extensive bone lessions
n High Tumor Burden :
spike IgG > 7 g/dl
hematocrite < 25 %
ca serum > 12 mg/dl
bone lession > 3 location
median survival 1 yr
Summary
! Consider MM in elderly patients with new
onset bone pain/fatigue/CRAB symptoms not
resolving with treatment
! Basic work up: SPEP/UPEP (+/- immunofixation),
CBC, peripheral smear, BUN/CR, Ca, skeletal
survey
!