Multiple Myeloma

Dr mukhtar jama nour, MBBS

Amoud university for health and
science institute
6/29/2014 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.
6/29/2014 Dr mukhtar jama nour,MBBS 2
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)
6/29/2014 Dr mukhtar jama nour,MBBS 3
What are the risk factors for MM?
Age >60.
Exposure to pesticides.
Radiation
Benzene
HSV8 (Kaposis sarcoma Herpes Virus)

6/29/2014 Dr mukhtar jama nour,MBBS 4
What are the clinical features of MM?
Disease of elderly.
Median age >60
More common in black Africans.

Bone destruction
Renal failure
Bone marrow infiltration


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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


6/29/2014 Dr mukhtar jama nour,MBBS 6
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.
6/29/2014 Dr mukhtar jama nour,MBBS 8
What is the consequence of bone destruction
in MM?
6/29/2014 Dr mukhtar jama nour,MBBS 9
Fracture of long bones
Vertebral collapse
Hypercalcemia

6/29/2014 Dr mukhtar jama nour,MBBS 10
In MM which bone activity is increased?
Osteoblast or osteoclast?
6/29/2014 Dr mukhtar jama nour,MBBS 11
Increased osteoclastic activity.

That is why biphosphonates is useful in MM
because it inhibits osteoclastic activity.
6/29/2014 Dr mukhtar jama nour,MBBS 12
Why do patients with MM get recurrent
infections?

6/29/2014 Dr mukhtar jama nour,MBBS 13
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?
6/29/2014 Dr mukhtar jama nour,MBBS 15
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.

6/29/2014 Dr mukhtar jama nour,MBBS 16
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?
6/29/2014 Dr mukhtar jama nour,MBBS 21
supportive care
chemotherapy
Autologous or allogeneic stem cell
transplantation.
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What is the supportive therapy?
6/29/2014 Dr mukhtar jama nour,MBBS 23
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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