A Summary Review of Multiple Myeloma
Multiple Myeloma, a rare cancer of the plasma cells, has 30,300 new cases diagnosed each year. With more than 12,650 deaths annually, a quick review is timely:
Although exact causes remain unknown, scientists have made progress in understanding how certain abnormalities and mutations in DNA cause plasma cells to become cancerous:
- In about half of all cases, chromosomal translocation turns on oncogenes.
- Another common finding is that parts of chromosome 13 are missing.
- In some patients interleukin-6 (IL-6) stimulates growth of plasma cells.
- Age – most people diagnosed are 65 or older
- Gender – 17,900 cases are in men; 12,430 in women, but risk of death is about equal
- Race – for unknown reasons, multiple myeloma is more than twice as common in African Americans than white Americans
- Personal history of plasma cell diseases – patients with monoclonal gammopathy of undetermined significance (MGUS) or solitary plasmacytoma will eventually develop multiple myeloma
- Personal history of bladder cancer or birth defect of bladder
- Family history – although most patients have no affected relatives; persons who have an affected sibling or parent are four times more likely to be affected
- Radiation – accounting for a small number of cases, persons exposed to radiation from an atomic bomb blast have a higher risk; exposure to lower levels also increases risk
- Obesity – increases risk
- Exposure to certain chemicals
Although tumor marker urine tests are available, they are not recommended for screening in patients without signs and symptoms, unless the individual is very high risk:
- Personal history of bladder cancer
- Birth defects of the bladder
- Exposed to certain chemicals
Signs and Symptoms
Multiple myeloma is difficult to diagnose early because there are no symptoms until at an advanced stage:
- Bone involvement, causing pain, mainly in back, hips or skull; osteoporosis or plasmacytoma; or fracture
- Low blood count, causing anemia, leukopenia or thrombocytopenia
- Hypercalcemia, causing thirst, urinary problems, dehydration, constipation, abdominal pain, loss of appetite, weakness, drowsiness, confusion, coma
- Spinal cord compression, causing sudden, severe back pain, or numbness or weakness in legs
- Nerve damage, causing weakness/numbness
- Hyperviscosity, causing confusion, dizziness, stroke-like symptoms
- Kidney damage, causing weakness, shortness of breath, itching, leg swelling
- Infections, causing slow response to treatment – pneumonia is common and serious
- Light chain amyloidosis, causing congestive heart failure, enlarged liver and spleen; enlarged tongue; skin color/texture changes; bleeding around eyes; diarrhea; carpal tunnel syndrome
When your patient’s symptoms and your clinical exam suggest multiple myeloma, a number of tests are available, many that you may prefer be ordered by the oncologist to whom you refer your patient:
- Blood Tests: CBC, quantitative immunoglobulins, serum protein electrophoresis, immunoelectrophoresis, free light chains and beta-2 microglobulin (helpful in prognosis), as well as blood chemistry
- Urine: urine protein electrophoresis (or urine immunofixation) conducted over a 24-hour period
- Bone Marrow Biopsy: microscopic exam of aspirate that may then be sent for immunohistochemistry and flow cytometry, as well as cytogenetics (including karyotype and fluorescent in situ hybridization), which may take one to two weeks
- Biopsy: fine needle aspiration (or core needle) of any tissue in which amyloid can build up; most often abdominal fat, but heart or kidney might also be biopsied
- Imaging: bone X-ray, CT scan and CT-guided needle biopsy, MRI, PET scan, and echocardiogram
The value of the Durie-Salmon staging system is somewhat limited due to newer diagnostic methods. The more recently developed International Staging System for Multiple Myeloma, which relies mainly on levels of albumin and beta-2 microglobulin in the blood, divides myeloma into three stages.
- Stage I: serum beta-2 microglobulin is less than 3.5 (mg/L) and the albumin level is 3.5 (g/dL) or greater
- Stage II: neither Stage I or III, meaning either the beta-2 microglobulin level is between 3.5 and 5.5 (with any albumin level) or the albumin level is below 3.5 while the beta-2 microglobulin is less than 3.5
- Stage III: serum beta-2 microglobulin is less than 5.5 (mg/L) or greater
Although for most patients, multiple myeloma is never cured, appropriate treatment is based on staging.
- Patients with solitary plasmacytoma may be treated with radiation or – if it is not in the bone – with surgery.
- Patients with early myeloma (smoldering or Stage I) may be watched closely, as early treatment does not seem to extend life. A bisphosphonate may be prescribed if bone disease is present. One study shows that, depending on other test results, patients with high risk of progressing to active myeloma may benefit for a time from lenalidomide (Revlimid) and dexamethasone.
- Patients with active (symptomatic) myeloma (Stage II or III) or who have light chain amyloidosis are started on chemotherapy, often in combination with bisphosphonate treatment. Supportive treatment includes transfusions, antibiotics and intravenous immunoglobulin (IVIG) and plasmapheresis, all of which may relieve symptoms. Some patients receive stem cell transplant. Patients who undergo stem cell transplant often have consolidation treatment (additional cycles of chemotherapy). Some patients (with or without stem cell transplant) receive maintenance treatment to help delay the return of myeloma, but serious side effects should be considered.
- Patients should be encouraged to ask you (or the cancer treatment team to whom you refer your patient) about complementary or alternative options before starting, so that you may help them determine what may be useful and what may cause harm.
Dr. Faber is a Hematologist/Bone Marrow Transplant physician, and a Principal Investigator for hematologic malignancies, with a focus on multiple myeloma clinical trials, at OHC. To learn more about the OHC clinical trials program, contact Nicole Given, B.S., at 513-751-2273 x27110 or by email.
Source: American Cancer Society