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Multiple Myeloma

Background Knowledge ๐Ÿง 

Definition

  • Multiple myeloma is a malignant proliferation of plasma cells in the bone marrow
  • Characterised by the production of abnormal monoclonal immunoglobulins (paraproteins)
  • Associated with end-organ damage: CRAB criteria (hyperCalcaemia, Renal impairment, Anaemia, Bone lesions)

Epidemiology

  • Incidence: 4-5 per 100,000 per year in the UK.
  • More common in older adults (median age at diagnosis: 70 years).
  • Slightly more common in men.
  • Higher incidence in African-Caribbean populations.

Risk Factors

  • Exact cause is unknown.
  • Age
  • Male gender
  • Family history
  • Radiation exposure
  • Certain chemicals

Pathophysiology

  • Monoclonal gammopathy of undetermined significance (MGUS) can progress to multiple myeloma.
  • Bone marrow infiltration by malignant plasma cells causes cytopaenia and bone destruction.
  • Paraproteins can cause renal damage and hyperviscosity.

Clinical Features ๐ŸŒก๏ธ

Symptoms

  • Bone pain (especially back and ribs)
  • Fatigue
  • Recurrent infections
  • Weight loss
  • Pallor
  • Nausea and vomiting (due to hypercalcemia)
  • Neurological symptoms (if spinal cord compression)

Signs

  • Pallor
  • Bone tenderness
  • Signs of infection (e.g. fever)
  • Peripheral neuropathy
  • Pathological fractures
  • Signs of hypercalcemia (e.g. dehydration)
  • Renal impairment (e.g. peripheral oedema)

Investigations ๐Ÿงช

Investigations

  • Blood tests: Full blood count, renal function, calcium, serum protein electrophoresis
  • Urine tests: Bence Jones protein
  • Bone marrow biopsy: Clonal plasma cells >10%
  • Imaging: Skeletal survey, MRI, or CT for bone lesions
  • Serum free light chain assay
  • Cytogenetic analysis for risk stratification

Management ๐Ÿฅผ

Management

  • Induction therapy: Chemotherapy (e.g., bortezomib, lenalidomide, dexamethasone)
  • Autologous stem cell transplantation for eligible patients
  • Maintenance therapy: Lenalidomide
  • Bisphosphonates for bone disease
  • Supportive care: Analgesia, infection prophylaxis, blood transfusions
  • Management of complications (e.g., hypercalcaemia, renal impairment)

Complications

  • Renal failure
  • Hypercalcaemia
  • Pathological fractures
  • Infections
  • Spinal cord compression
  • Hyperviscosity syndrome
  • Anaemia and pancytopenia

Prognosis

  • Variable prognosis depending on stage and response to treatment.
  • Median survival: 3-5 years.
  • Better outcomes with newer therapies.
  • Regular monitoring and follow-up required.

Key points

  • Multiple myeloma is a serious haematological malignancy.
  • Early diagnosis and treatment are crucial.
  • Multidisciplinary approach required.
  • Regular monitoring for disease progression and complications.
  • Advances in therapy have improved outcomes.

References

  • NICE Guidelines: Myeloma (https://www.nice.org.uk/guidance/ng35) NICE Guidelines
  • British Society for Haematology Guidelines: Diagnosis and Management of Multiple Myeloma (https://b-s-h.org.uk) BSH Guidelines
  • Myeloma UK: Patient Information and Support (https://www.myeloma.org.uk) Myeloma UK

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