Multiple myeloma

Question 1

Multiple myeloma is a cancer of which type of cell?

Answer 1

plasma cells in bone marrow

Question 2

myeloma cells stimulate bone marrow stromal cells to produce cytokines which do what?

Answer 2

Promote osteoclast activity
Inhibit osteoblast formation
Leading to bone destruction and hypercalcaemia

Question 3

Myeloma cells can secrete which proteins?

Answer 3

IgG
IgA
Bence-jones proteins

Question 4

what is the acronym for the typical clinical presentation of multiple myeloma?

Answer 4

C- hyperCalcaemia
R - Renal disease
A - Anaemia
B - bone pain

Question 5

‘Stones, bones, groans and moans’ refer to symptoms of?

Answer 5

hypercalcaemia

Question 6

Why do multiple myeloma patients get frequent infections?

Answer 6

Igs secreted by myeloma cells are not functional or useful

Question 7

How does myeloma cause kidney disease?

Answer 7

1. light chains deposit in renal tubules
2. Calcium -> kidney stones
3. Primary amyloidosis (Ig light chains abnormally aggregate in various tissues)
4. Plasmacytomas

Question 8

What would be elevated in a blood test?

Answer 8

serum calcium
urea
creatinine
uric acid

Question 9

Which investigation would you order to determine which myeloma proteins are being predominantly produced?

Answer 9

Serum and urine protein electrophoresis

Question 10

SPEP detects which immunoglobulins?

Answer 10

IgG
IgA

Question 11

UPEP detects which myeloma proteins?

Answer 11

bence-jones proteins

Question 12

which protein’s serum level determines severity of MM?

Answer 12

Beta-2 microglobulin

Question 13

What are these called and which condition are they characteristic of?

Answer 13

Punched-out lytic lesions, multiple myeloma

Question 14

If a bone marrow aspiration and biopsy was performed, what would you see in a patient who has multiple myeloma?

Answer 14

monoclonal plasma cell infiltration in the bone marrow ≥10%

Question 15

Which CT scan would you perform in a patient with suspected multiple myeloma?

Answer 15

whole-body, low dose CT

Question 16

How would you treat anaemia in a multiple myeloma patient?

Answer 16

transfusion and erythropoeitin

Question 17

What are the main steps in supportive management in a patient with multiple myeloma?

Answer 17

• Analgesia - bone pain
• Bisphosphonate
• Local radiotherapy (focal disease)
• Orthopaedic procedures - vertebral collapse
• Transfusion and erythropoietin for anaemia
• Rehydration for renal failure
• Broad-spectrum antibiotics for infection
• Regular IV Ig infusions to prevent infection

Question 18

What are the steps for chemotherapy in a multiple myeloma patient?

Answer 18

• Induction therapy with lenalidomide, bortezomib and dexamethasone
• If fit ie. <65-70 years and good performance status, follow with autologous stem-cell transplantation
• If unsuitable for transplantation, continue induction therapy for 12-18 months until serum paraprotein levels have plateaued
• Hold treatment until paraprotein levels rise -> further chemo or stem cell transplantation required

Question 19

What are the side effects of lenalidomide?

Answer 19

• Teratogenic
• Neutropenia
• Thromboembolism

Question 20

What must you monitor for in a multiple myeloma patient taking lenalidomide?

Answer 20

Sepsis and thromboembolism - consider aspirin or anticoagulation if risk of thromboembolism increases

Question 21

What is the name of this phenomenon and what does it indicate?

Answer 21

rouleaux formation due to Ig proteins attaching to red blood cells : multiple myeloma

Question 22

What would be seen in a full blood count and peripheral smear in a patient with multiple myeloma?

Answer 22

rouleaux formation and normocytic normochromic anaemia