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Multiple Myeloma

Multiple myeloma is a plasma cell dyscrasia, in which there’s abnormal proliferation of antibody-producing plasma cells. There’s also a deficiency of functional antibodies, resulting in a relative hypo-gammaglobulinaemia and immunosuppression.

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“Myeloma cells produce monoclonal proteins of varying types, most commonly immunoglobulins (antibodies) and free light chains” © www.scientificanimations.com (Licensed under CC-BY 4.0) https://creativecommons.org/licenses/by/4.0/


Presentation

CRAB:

  • Calcium (Hypercalcaemia) - due to increased osteoclast activity

  • Renal failure - due to light chain deposition and hypercalcaemia

  • Anaemia

  • Bone pain - osteolytic lesions, leading to pathological fractures and vertebral compression fractures


N.B. Marrow infiltration by the tumour can lead to other cytopenias e.g. thrombocytopenia, leukopenia.


Investigations

Initial investigations to do include:

  • Bloods - Calcium, U&E (renal impairment), FBC (anaemia)

  • XR/CT/MRI - looking for osteolytic lesions and pathological fractures


Diagnostic tests:

  • Serum and/or urine protein electrophoresis - shows a paraprotein spike (typically IgG)

  • Bence Jones protein (light chains) - raised

  • Bone marrow aspirate and biopsy - myeloma confirmed if > 10% of plasma cells

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“Diagram of protein electrophoresis showing monoclonal gammopathy (paraprotein, M-peak) in a patient with multiple myeloma (Kahler's disease)” © Steven Fruitsmaak (Licensed under CC-BY 3.0) https://creativecommons.org/licenses/by/3.0/


There are multiple tests that help determine the prognosis. These include:

  • CRP - the higher the level, the worse the prognosis

  • LDH - the higher the level, the worse the prognosis

  • Beta-2 microglobulin - the higher the level, the worse the prognosis

  • FISH and cytogenetic analysis


Management

A conservative approach is the best option if the patient has minimal symptoms and no end-organ damage. They may need therapy when there are signs of active disease.


Other options include stem cell transplant, and other non-chemotherapeutic drugs.


Supportive options:

  • Analgesia, bisphosphonates, and physio for bone disease

  • Flu and pneumococcal vaccines for infection prevention

  • EPO (± transfusion) for anaemia



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