multiple myeloma/waldenstrom

Question 1

multiple myeloma/plasma cell myeloma

definition

Answer 1

Malignancy of hematopoietic stem cells differentiated as plasma cells. Characterized by infiltration of bone marrow, bone destruction, and paraprotein formation (monoclonal immunoglobulin)

Question 2

multiple myeloma

clin man

Answer 2

Asymptomatic
Cytopenia
Anemia
Leukopenia – Recurrent or frequent infections
Neutropenia
Underproduction of normal immunoglobulins
Strep. Pneumoniae and H. influenzae
Thrombocytopenia – bleeding

Lytic Lesions: most common Sx
Pain back, hips, and skull
Bone weakness – osteoporosis or plasmacytoma
Fractures

Question 3

multiple myeloma

lytic lesions

Answer 3

• Bony destruction caused by accumulation of plasma cells
• Plasma cells increase bone absorption resulting in bony destruction
  “Punch out” lesion
  Hypercalcemia
  Pathologic fractures

Question 4

multiple myeloma

Tx for lytic lesions

Answer 4

Treatment with IV bisphosphonates
Help inhibit osteoclastic activity
Decrease bone resorption
Example: Zometa

Question 5

Multiple myeloma

S/Sx of nervous system

Answer 5

Nervous Systems Symptoms
Severe back pain
Spinal cord compression
Compression fracture
Numbness
Muscle weakness

Question 6

multiple myeloma

S/Sx of hypercalcemia

Answer 6

Hypercalcemia:
Extreme thirst
Increased urination
Dehydration
Kidney injury
Severe constipation
Abdominal Pain
Confusion

Question 7

multiple myeloma

Kidney injury S/Sx

Answer 7

Kidney injury:
Weakness
Pruritus
SOB
Peripheral edema

Question 8

multiple myeloma

Hyper viscosity S/Sx

Answer 8

Hyper viscosity
Confusion
Dizziness
CVA symptoms

Question 9

Multiple myeloma

labs to order

Answer 9

CBC
Quantitative Immunoglobulins
Measures blood levels of different antibodies
IgA
IgG
IgM

Question 10

Multiple myeloma labs

SPEP

Answer 10

Serum Protein Electrophoresis (SPEP)
Measures immunoglobulins in blood
Will find a monoclonal immunoglobulin (i.e. antibody)

Question 11

multiple myeloma

Immuno fixation electropheresis (IFE)
UPEP

Answer 11

Immunofixationelectropheresis (IFE) measures the exact type of abnormal antibody

The immunoglobulins are made up of 2 protein chains:
2 heavy
2 light chains.
May find Bence-Jones protein in urine
24-hour Urine Protein Electrophoresis (UPEP) and Urine Immunofixation

Question 12

Multiple myeloma labs

Free Light Chains

Answer 12

Measures the amount of light chains in the blood
Helpful in rare cases where no monoclonal antibody protein is found by SPEP
SPEP only measures intact whole immunoglobulins

Question 13

Multiple myeloma labs

Beta 2 Microglobulin

Answer 13

Another protein produced by malignant cells
Does not cause problems but is used for prognosis
Higher levels
More advanced disease
Worse prognosis

Question 14

multiple myeloma

Dx

Answer 14

• Bone Marrow Biopsy
  Plasma cells
  Aspirate is sent for immunohistochemistry, flow cytometry, and chromosome analysis
• Immunohistochemistry from sample
  Bone biopsy sample is treated with special antibodies that attach only to specific molecules on the cell surface. These antibodies cause color changes seen under the microscope

Question 15

multiple myeloma

Question 16

Multiple myeloma

bm biopsy: Flow cytometry

not testable just good to know

Answer 16

• Looks for certain substances on the outside surface of the cell that help identify what types of cells they are
• Cells are treated with special antibodies that stick to cells with only certain substances
• The cells are passed in front of a laser beam. The cells give off light which are than measured and analyzed by a computer
• These different cell and cell types have different antigens on their surface
• This helps determine if there are abnormal cells in the BM such as myeloma, lymphoma, etc

Question 17

Multiple myeloma

Cytogenetics

Answer 17

Helps mostly with prognosis
Find deletions and translocations
Example: t(11;14)

Question 18

multiple myeloma

diagnostic imaging

Answer 18

Skeletal X-rays
Computed Tomography Scans (CT)
Magnetic Resonance Imaging (MRI) Scans
Brain and spinal cord
Plasmacytomas
Bone Marrow
Positron Emission Tomography Scans (PET)

Question 19

multiple myeloma

CRAB criteria

Answer 19

Question 20

multiple myeloma

Tx (Dip)

Answer 20

Triplet therapy
* Immunomodulatory
Lenalidomide (Revlimid) PO
* Proteosome Inhibitor
Bortezomib (Velcade) SC/IV
Neuropathy
* High dose dexamethasone PO

Newer drug Daratumumab (Darzalex)- Monoclonal antibody
Palliative radiation
Autologous HSCT

Question 21

plasmacytoma

3 Types

Answer 21

1. Solitary tumor of the bone
   Lytic lesions of the bone
2. Extramedullary
   Usually the lungs
3. Multiple Plasmacytomas
   Primary or recurrent
   Progress to Multiple Myeloma

Question 22

Smoldering Myeloma

general

Answer 22

Early MM that is not causing symptoms

At least 10% plasma cell in the BM
A high M protein level

Normal :
CBC
Calcium
Kidney function
No bone or organ damage
No treatment unless symptoms or problems develop

Question 23

Waldenstrom Macroglobulinemia

general

Answer 23

IgM hypergammaglobulinemia
Will initially worsen with treatment
with
Low grade NHL(nonhidgkin lymphoma)
Lymphocytes
Plasma cells

Question 24

Waldenstrom Macroglobulinemia

S/Sx

Answer 24

Hyperviscosity
Most commonly causes issues in this disease *
Plasmapheresis
Anemia
Cold agglutinin
No lytic lesions!

Question 25

Waldenstrom
Tx

Answer 25

Rituximab
Btk inhibitor-ibrutnib