Myeloma (zero to finals)

Question 1

What is myeloma?

Answer 1

Myeloma is a type of cancer affecting the plasma cells in the bone marrow.

Plasma cells are B lymphocytes that produce antibodies.

Question 2

What does cancer in a specific type of plasma cell cause?

Answer 2

Results in the production of large quantities of a specific paraprotein (or M protein), which is an abnormal antibody or part of an antibody.

Question 3

What is multiple myeloma?

Answer 3

Multiple myeloma is where the myeloma affects multiple bone marrow areas in the body.

Question 4

What are plasma cells?

Answer 4

B lymphocytes of the immune system that have developed to produce a specific antibody.

Antibodies are also called immunoglobulins.

They are complex molecules made up of heavy chains and light chains arranged in a Y shape.

Question 5

What is another name for antibodies and what are the 5 types?

Answer 5

Also called immunoglobulins.

The five types of antibodies are A, G, M, D and E.

Question 6

Role of the antibodies?

Answer 6

They help the immune system recognise and fight infections by targeting specific proteins on the pathogen.

Question 7

What paraprotein does myeloma produce?

Answer 7

Myeloma is cancer of a single type of plasma cell, with a genetic mutation that causes them to rapidly and uncontrollably multiply.

They produce a specific paraprotein (or M protein), which is an abnormal antibody (immunoglobulin) or part of an antibody (often the light chain).

There is an abnormally high level of this paraprotein (paraproteinaemia).

Question 8

What are Bence Jones proteins?

Answer 8

The Bence Jones protein refers to free light chains in the urine.

Question 9

What are the 4 main features of myeloma (mnemonic: CRAB)?

Answer 9

C – Calcium (elevated)
R – Renal failure
A – Anaemia
B – Bone lesions and bone pain

Question 10

What is the most common complication of myeloma?

Answer 10

Anaemia

Question 11

How does myeloma lead to anaemia?

Answer 11

The cancerous plasma cells invade the bone marrow (bone marrow infiltration), resulting in suppression of the other blood cell lines, leading to:

Anaemia (low haemoglobin)
Leukopenia (low white blood cells) Thrombocytopenia (low platelets)

Question 12

What type of anaemia is present in myeloma?

Answer 12

Anaemia in myeloma is normocytic (normal size) and normochromic (normal colour).

Question 13

What is the pathology behind myeloma bone disease?

Answer 13

From increased osteoclast activity and suppressed osteoblast activity.

Osteoclasts absorb bone, and osteoblasts deposit bone.

The metabolism of bone becomes imbalanced, with more bone being reabsorbed than constructed.

Question 14

What is the cause of myeloma bone disease?

Answer 14

Caused by cytokines released from abnormal plasma cells and other nearby cells.

Question 15

Common sites of myeloma bone disease?

Answer 15

Skull, spine, long bones and ribs.

Question 16

Patients with myeloma often develop renal impairment, what are some of the various causes?

Answer 16

Paraproteins deposited in the kidneys

Hypercalcaemia affecting kidney function

Dehydration

Glomerulonephritis (inflammation around the glomerulus and nephron)

Medications used to treat the condition

Question 17

What is the range for normal plasma viscosity?

Answer 17

The normal plasma viscosity, or internal friction in blood flow, is between 1.3 and 1.7 times that of water.

Meaning blood should be 1.3-1.7x thicker than water.

Question 18

What can increase the plasma viscosity?

Answer 18

Plasma viscosity increases when more proteins are in the blood, such as the paraproteins found in myeloma.

Question 19

Hyperviscosity syndrome is an emergency, what are some of the issues it can cause?

Answer 19

Bleeding (e.g., nosebleeds and bleeding gums)

Visual symptoms and eye changes (e.g., retinal haemorrhages)

Neurological complications (e.g., stroke)

Heart failure

Question 20

Risk factors for myeloma?

Answer 20

Older age
Male
Black ethnic origin
Family history
Obesity

Question 21

What are clinical features that would raise suspicion of myeloma?

Answer 21

Persistent bone pain (e.g., spinal pain)

Pathological fractures

Unexplained fatigue

Unexplained weight loss

Fever of unknown origin

Hypercalcaemia

Anaemia

Renal impairment

Question 22

What is the list of lab investigations that can be done for myeloma?

Answer 22

FBC (anaemia or leukopenia in myeloma)
Calcium (raised in myeloma)
ESR (increased in myeloma)
Plasma viscosity (increased in myeloma)
U&E (for renal impairment)
Serum protein electrophoresis (to detect paraproteinaemia)
Serum-free light-chain assay (to detect abnormally abundant light chains)
Urine protein electrophoresis (to detect the Bence-Jones protein)

Question 23

What investigation is required for a myeloma diagnosis?

Answer 23

Bone marrow biopsy is required to confirm the diagnosis and perform cytogenetic testing.

Question 24

Why is imaging done for myeloma and what is the order they are done in?

Answer 24

Imaging is used to assess for bone lesions. The order of preference is:

1. Whole-body MRI
2. Whole-body low-dose CT
3. Skeletal survey (x-ray images of the entire skeleton)

Question 25

What are typical x-ray changes seen with myeloma?

Answer 25

Typical x-ray changes seen in patients with myeloma include:

• Well-defined lytic lesions (described as looking “punched-out”)
• Diffuse osteopenia
• Abnormal fractures

Question 26

What is “raindrop skull”?

Answer 26

Raindrop skull (sometimes called pepper pot skull) refers to multiple lytic lesions seen in the skull on an x-ray.

Question 27

Is myeloma curable?

Answer 27

No

Treatment aims to control the disease.

Question 28

What is typical treatment for myeloma?

Answer 28

Treatment usually involves a combination of chemotherapy, which may include:

Bortezomib (a proteasome inhibitor)
Thalidomide
Dexamethasone

Question 29

What is a potential myeloma treatment option for fitter patients?

Answer 29

High-dose chemotherapy followed by a stem cell transplant.

Question 30

What are the stem cell transplantation options?

Answer 30

Autologous (using the person’s own stem cells)

Allogeneic (using stem cells from a healthy donor)

Question 31

What is used for the management of myeloma bone disease?

Answer 31

Bisphosphonates to suppress osteoclast activity

Radiotherapy for bone lesions can improve bone pain

Orthopaedic surgery to stabilise bones (e.g., by inserting a prophylactic intramedullary rod) or treat fractures

Cement augmentation (injecting cement into vertebral fractures or lesions) to improve spine stability and pain

Question 32

What are the many complications of myeloma and its treatment?

Answer 32

Infection
Bone pain
Fractures
Renal failure
Anaemia
Hypercalcaemia
Peripheral neuropathy
Spinal cord compression
Hyperviscosity syndrome
Venous thromboembolism