Multiple Myeloma

Dr mukhtar jama nour, MBBSAmoud university for health and

science institute

04/28/23 Dr mukhtar jama nour,MBBS 1

• What is multiple myeloma?

• It is a malignant disease of the plasma cells of bone marrow.

• Remains an incurable disease.

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• What is the most common monoclonal protein found in MM?

• IgG (55%)• IgA (20%)

• In approximately 20% there is no paraproteinaemia, only light chains in the urine.(Bence jones proteins)

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• What are the risk factors for MM?• Age >60.• Exposure to pesticides.• Radiation• Benzene• HSV8 (Kaposi’s sarcoma Herpes Virus)

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• What are the clinical features of MM?• Disease of elderly.• Median age >60• More common in black Africans.

• Bone destruction• Renal failure• Bone marrow infiltration04/28/23 Dr mukhtar jama nour,MBBS 5

• May be symptomatic or asymptomatic.

• Symptomatic myeloma characterized by presence of ROTI and CRAB.

• Myeloma Related Organ or Tissue Impairment.

• Calcium levels increased• Renal failure• Anemia• Bone lesion

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• What is the cause for renal failure in MM?• Deposition of light chains in the tubules (most

common).

Also:• hypercalcaemia, hyperuricaemia, use of

NSAIDs (rarely) and deposition of amyloid.

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• What is the consequence of bone marrow infiltration with plasma cells?

• anaemia• neutropenia• Thrombocytopenia• Production of paraproteins.

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• What is the consequence of bone destruction in MM?

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• Fracture of long bones• Vertebral collapse• Hypercalcemia

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• In MM which bone activity is increased?• Osteoblast or osteoclast?

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• Increased osteoclastic activity.

• That is why biphosphonates is useful in MM because it inhibits osteoclastic activity.

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• Why do patients with MM get recurrent infections?

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• Because there is a reduction in the normal immunoglobulin levels (immuneparesis), contributing to the tendency for patients with myeloma to have recurrent infections.

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diagnosis

• What are the imaging studies used to diagnose MM?

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• Skeletal survey-lytic lesion. easily seen in skull.• CT, MRI and PET are used in plasmacytomas

(bone or soft tissue deposits).• MRI spine- may show imminent

compression/collapse.

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Thoracic compresion fracture due to MM

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• Myeloma affecting the skull. Note the rounded lytic translucencies produced by infiltration of the skull with myeloma cells.

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• FBC- normal or low.• ESR, CRP-almost always raised.• U&Es, Cr-renal failure• Raised LDH• Serum calcium- normal or raised.• Serum ALP-normal• Uric acid-normal or raised• Bone marrow aspirate or trephine shows infiltration

by plasma cells Amyloid may be found.

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Two out of three diagnostic features should be present:

• paraproteinaemia or Bence Jones protein• radiological evidence of lytic bone lesions• an increase in bone marrow plasma cells.

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• What is the treatment for MM?

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• supportive care • chemotherapy • Autologous or allogeneic stem cell

transplantation.

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• What is the supportive therapy?

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• Treat the anemia-erythropoetin helps.• Treat the infection• Radiotherapy/sytemic chemo/high dose for

bone pain.• vertebroplasty for treating vertebral fractures.• Biphosphonates (pamidronate/zoledronic

acid).

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For elderly

• What are the chemo options?• If not fit for transplant, treat with Melphalan

+ Prednisone + Thalidomide (MPT).

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For younger patients

• High-dose dexamethasone based induction.

• Followed by high-dose melphalan with peripheral blood stem cell rescue (auto transplantation)

• Stem cell transplant- improves survival but not curative.

• median survival increasing to 6 years.

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