MULTIPLE MYELOMA

MULTIPLE MYELOMA• Multiple myeloma is a cancer

that begins in plasma cells, a type of white blood cell & produce abnormally high amounts of a special protein.

• The special proteins are typically monoclonal paraprotein (M protein) and other compounds such as immunoglobulins. 

• B lymphocytes start in the bone marrow and move to the lymph nodes. As they progress, they mature and display different proteins on their cell surface.

• When they are activated to secrete antibodies, they are known as plasma cells.

• are white blood cells that secrete large volumes of antibodies

• Plasma cells, also called plasma B cells

Risk factors• common in older people (>65yrs)

and African-Americans.• Male:Female 2:1•  Radiation- exposure to petroleum

products• Having a family member affected by

multiple myeloma

PATHOPHYSIOLOGYExcessive production of plasma cells

Abnormal and excessive amount of immunoglobulins (myeloma proteins)-unhealthy

Excessive and abnormal production of cytokines (interleukins)

Pathologic process of bone destruction leads to hypercalcemia

• Collections of abnormal plasma cells accumulate in the bone marrow,

• interfere with the production of normal blood cells

Signs and symptoms• the common tetrad of multiple

myeloma is CRAB: • C = Calcium (elevated), • R = Renal failure, • A = Anemia, • B = Bone lesions

• Bone painMyeloma bone pain usually involves

the pelvis spine and ribs, and worsens with activity.

Increased osteoclastic activity and decreased osteoblastic activity through release of cytokines

Persistent localized pain may indicate a pathological bone fracture.

Involvement of the vertebrae may lead to spinal cord compression.

• Symptoms of hypercalcemia – Nausea – Fatigue – Thirst 

• Infection The most common infections

are pneumonias and pyelonephritis.

Common pathogens include S. pneumoniae, S. aureus,  K. pneumoniae,  E. coli and other gram-

negative organisms

• Renal failureIt is commonly due

to hypercalcemia It may also be due to tubular

damage bye myeloma cells infiltration

HyperuricemiaGlomerular deposits of amyloid

• Anemia (hemoglobin <10 g/dL)– Usually normocytic and normochromic – Can be megaloblastic due to either folate or vitamin B12

deficiency – Due to

• Replacement of normal marrow by expanding tumor cells • Inhibition of hematopoiesis by factors made by the tumor • Mild hemolysis

• Neurological symptoms weakness, confusion and fatigue.  Headache, visual changes and retinopathy  paraplegia 

Diagnostic criteria• Bone marrow biopsy• Radiographic studies- shows

demineralization osteoporosis • CBC- shows

anemia ,leucopenia ,thrombocytopenia, • ESR (elevated) • Urine examination- presence of Bence

Jones protein• RFT – Inc. creatinine

Management • Currently no cure for multiple

myeloma• Aim- early detection and

treatment

Medical management• ChemotherapyCombination therapy is usedEg : 1 melphelan given orally for

Prednisone 4-7 days and repeated 4-6 week interval

2 melphelan, Cyclophosphamide, Carmustin, Chlorambucil

3 vincristin, Doxorubicin, Dexamethasone

2. Radiation• Myeloma is radiosensitive Relieves pain• Can be used for control of local

disease• Total body irradiation not advised

3. Bone marrow transplantation

• To reduce serum calcium level Corticosteroid Hydration

•  Red Blood Cell transfusions or erythropoietin can be used for management of anemia.

• Surgical options

– Compression of intraspinal nerves – laminectomy,removal of myelomatous tissue and post-op irradiation•

– In cases with instability - spinal fusion

•  Supportive therapy•– Erythropoetin•– Biphosphonates: (pamidronate) – Antibiotics and GM-CSF•– Anti-virals esp. herpes

Nursing management• Assess for bone involvement• Assess for hypercalcemia, measure

the calcium level frequently• Fluids are administered to increase

urinary output• Caution should be taken while moving

or transferring the patient, because there is risk of pathologic fracture

• Analgesics should be given to reduce bone pain

• Braces (especially spinal braces ) may also help to reduce pain

• Monitor intake and output• Administer IV fluids• Small frequent diet should be given to

reduce nausea• Closely monitor the clients mental

status• Counseling should be given to the

patient and family