Multiple myeloma is a type of blood cancer involving plasma cells of the blood. Plasma cells are a type of white blood cell, which is normally responsible for making antibodies. In India as per ICMR data,Multiple myeloma is the second most common hematological malignancy after non hodgkins lymphoma and it accounts for 15% of all hematological malignancies.
Due to advancements in modern medicine, the disease is considered as a treatable disease but not a curable disease. Presently chemotherapy remains as the mainstay of treatment. With the advent of Bone Marrow Transplant and Stem Cell Transplant, these have taken up an important place in the treatment protocols. But still, chemotherapy or induction therapy is essential before and later for transplant eligible and only therapy for transplant ineligible.
The median age of occurence of the disease in various single institute data across India reports at around 52-61 years.
The underlying mechanism involves abnormal plasma cells producing abnormal antibodies which can cause kidney problems and overly thick blood. The plasma cells can also form a mass in the bone marrow or soft tissue. When only one mass is present, it is known as a plasmacytoma while more than one is known as multiple myeloma.
Multiple myeloma effects the three major components of our body:
Monoclonal gammopathy of undetermined significance (MGUS) increases the risk of developing multiple myeloma. MGUS transforms to multiple myeloma at the rate of 1% to 2% per year, and almost all cases of multiple myeloma are preceded by MGUS
Smoldering multiple myeloma increases the risk of developing multiple myeloma. Individuals diagnoses with this pre-malignant disorder develop multiple myeloma at a rate of 10% per year for the first 5 years, 3% per year for the next 5 years, and then 1% per year.
Both exposure (environmental or occupational) to particular agents & an individual’s susceptibility to these agents are thought to contribute to one’s risk of developing multiple myeloma
|Alcohol consumption has been linked to increase risk of multiple myeloma|
|Obesity:It is estimated that with each increase of body mass index by 5 points increases the risk by 11%|
|Sudden Weight Loss|
Because many organs can be affected by myeloma, the symptoms and signs vary greatly
Some of the more common symptoms of myeloma can be remembered as
|CRAB: C = calcium (elevated), R = renal (kidney) failure, A = anemia, B = bone lesions|
|Opportunistic infections (e.g., pneumonia)|
|Unexplained Weight loss|
|Joint and Bone Pain|
|Getting Tired /exhausted/Fatigue very quickly without any explanation|
|Neurological symptom (e.g., weakness, confusion, and fatigue)|
Apart from Biopsy and Imaging scans, multiple myeloma is confirmed based on blood and urine tests to find abnormal antibodies. Bone Marrow Aspiration and biopsy helps find cancerous plasma cells and imagining scans help find bone lesions. Advanced stages of myeloma is also associated with high amount of calcium in the blood
|Bone Marrow Biopsy and Aspirations|
|Bone Scans and/or PET/CT Scans|
|Liver and Kidney functioning tests|
|Complete Blood Count (CBC) tests|
|Serum Protein Tests (esp. Serum Protein Electrophoresis test)|
|Urine Ben Jones Protein test|
|Free Light Chain ratio tests|
|BM for cytogenetic/fluorescence in situ hybridization (FISH) studies|
|Key Events in Multiple Myeloma||Description|
|Hypercalcemia||>1 mg/dl higher than upper limit or >11 mg/dl|
|Kidney Functioning tests||Serum cretinine >2mg/dl or cretinin clearance < 40ml/min|
|Anemia||Haemoglobin less than < 10 gm/dl or >2gm/dl below the lower limit of normal|
|PET/CT Scan detected bone lesions||Bone lesion: one or more osteolytic lesions seen in skeletal radiography, CT or PET-CT|
Note: changes in these levels are used to determine staging of multiple myeloma
Multiple myeloma is considered treatable, but generally incurable. Remissions may be brought about with steroids, chemotherapy, thalidomide or lenalidomide, and stem cell transplant. Bisphosphonates and radiation therapy are sometimes used to reduce pain from bone lesions.
Typically asymptomatic plasma cell disorders like MGUS and smoldering myeloma do not require treatment. They are to be kept under strict and regular follow up.
If a patient is having MGU's or smoldering multiple myeloma, then there is no active treatment considered typically. The patient is kept under frequent and active monitoring.
If the patient has active multiple myeloma, treatment is considered for him/her. The course of the actual treatment is decided based on each individual's current health history and discussion with a team of doctors called MDT(multi-disciplinary team).
If the patient has active myeloma, then he/she is considered for active front line (initial) treatment. Typically the decision is driven by multiple factors and is decided by both the patient and the doctor in active discussion:
|Typical Factors for front line treatment|
|If the patient is eligible for stem cell transplant|
|Current health history and patient's health status|
Patients are usually given combination therapies for their front line treatment. The below image gives a basic view of the current guidelines for the treatment of multiple myeloma as well as treatment of relapse patients of multiple myeloma. These are subjected to change as per local health policies and as and when new/more effective treatments are available.
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