Transcript Multiple Myeloma

Multiple Myeloma
By Dr. Navinee Vongsupathai
Multiple Myeloma
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Definition
Causes and incidence
Clinical feature
Physical examination
Diagnosis
Classification and staging
Threatment
Prognosis
Definition
• Multiple myeloma : as myeloma or plasma cell
myeloma
• cancer of the plasma cell
• Multiple myeloma
– excessive numbers of abnormal plasma cells in the
bone marrow
– overproduction of intact monoclonal immunoglobulin
(IgG, IgA, IgD, or IgE) or Bence-Jones protein (free
monoclonal κ and λ light chains)
Definition
• Normal Plasma Cell Function in the
Immune System
– Stem cells can develop into B lymphocytes -- >travel
to the lymph nodes, mature, and then travel
throughout the body.
– When foreign substances (antigens) enter the body
-- >B cells develop into plasma cells that produce
immunoglobulins Ig (antibodies) to help fight
infection and disease.
Figure legend: In multiple myeloma, the B cell is damaged and gives rise to
too many plasma cells (myeloma cells). These malignant cells do not function
properly and their increased numbers produce excess immunoglobulins of a
single type that the body does not need along with reduced amounts of
normal immunoglobulins.
Figure legend: Bone marrow stromal cells and myeloma cells produce cytokines
that help myeloma cells grow and survive. Myeloma cells also produce growth
factors that stimulate new blood vessel formation through a process called
angiogenesis. New blood vessels provide nutrients and oxygen to the tumor,
allowing it to grow. The natural immune response that attacks myeloma cells is
suppressed.
Definition
• These myeloma cells travel through the bloodstream and
collect in the bone marrow, where they cause permanent
damage to healthy tissue.
• As tumors grow, they invade the hard outer part of the
bone, the solid tissue.
• In most cases, the myeloma cells spread into the cavities
of all the large bones of the body, forming multiple small
lesions. This is why the disease is known as "multiple"
myeloma.
Incidence
• Multiple myeloma is the second most prevalent
blood cancer after non-Hodgkin's lymphoma
• 1% of all cancers and 2% of all cancer deaths.
• Age 60-65 years most common
• Occurs in men > women
• African Americans and Native Pacific Islanders
have the highest reported incidence of this
disease and Asians the lowest
Causes
• Genetic causes
– Ongoing research is investigating whether HLA-Cw5
or HLA-Cw2 may play a role in the pathogenesis of
myeloma.
• Environmental or occupational causes
– significant exposures in the agriculture, food, silicon
,Benzene, Nikel and petrochemical industries
• Radiation:
– Radiation has been linked to the development of
myeloma.
– In 109,000 survivors of the bombing of Nagasaki, 29
died from myeloma from 1950-1976; however, some
recent studies do not confirm that these survivors
have an increased risk of developing myeloma.
Clinical features
• common tetrad of multiple myeloma is
–C=
–R=
–A=
–B=
Calcium (elevated)
Renal failure
Anemia
Bone lesions
CRAB
Clinical features
• Bone pain
– Myeloma bone disease -- >proliferation of tumor cells
and release of IL-6 <osteoclast activating factor
:OAF>-- >stimulates osteoclasts to break down bone- > leading to hypercalcemia
– These bone lesions in plain radiographs-- >
"punched-out" / lytic bone lesion
Clinical features
• Bone pain
– Myeloma bone pain -- > involves the rib ,sternum,
spine , clavicle , skull , humerus & femur
– The lumbar vertebrae are one of the most common
sites of pain -- >may lead to spinal cord compression.
– Persistent localized pain may indicate a pathological
fracture.
Clinical features
Clinical features
Clinical features
Clinical features
• Hypercalcemia
– Pt. present with confusion, somnolence, bone pain,
constipation, nausea, and thirst.
• Anemia
– The anemia :normocytic and normochromic.
– It results from the replacement of normal bone
marrow by infiltrating tumor cells and inhibition of
normal red blood cell production (hematopoiesis) by
cytokines.
Clinical features
• Bleeding
– bleeding resulting from thrombocytopenia.
– In some patients, monoclonal protein may absorb
clotting factors and lead to bleeding, but this
development is rare.
• Hyperviscosity
– high volume of monoclonal protein -- > blood
viscosity increases-- >complications such as stroke,
myocardial ischemia, or infarction.
Clinical features
• Infection
– Organism : polysaccharide encapsulated
<strep.pneumoniae, H.influenzae>
– Common pneumonia pathogens :S pneumoniae, S
aureus, and K pneumoniae
– Common pathogens causing pyelonephritis : E coli
and other gram-negative organisms.
– The increased risk of infection is due to immune
deficiency resulting from diffuse
hypogammaglobulinemia, which is due to decreased
production and increased destruction of normal
antibodies.
Clinical features
• Renal failure
– Renal failure may develop both acutely and
chronically.
– It is commonly due to hypercalcemia.
– It may also be due to tubular damage from excretion
of light chains, which can manifest as the Fanconi
syndrome (type II renal tubular acidosis).
– Other causes include glomerular deposition of
amyloid, hyperuricemia, recurrent infections
(pyelonephritis), and local infiltration of tumor cells.
Clinical features
• Neurological symptoms
– Common problems are weakness, confusion and
fatigue due to hypercalcemia.
– Headache, visual changes and retinopathy may be the
result of hyperviscosity of the blood depending on the
properties of the paraprotein.
– Finally, there may be radicular pain, loss of bowel or
bladder control (due to involvement of spinal cord
leading to cord compression) or carpal tunnel
syndrome and other neuropathies (due to infiltration
of peripheral nerves by amyloid).
– It may give rise to paraplegia in late presenting cases.
Physical Examination
• Pallor : anemia
• Ecchymoses or purpura : thrombocytopenia
• Bone pain without tenderness is typical :
lytic destructive bone lesions or pathologic
fracture.
Physical Examination
• Neurologic findings
– Sensory level change (ie, loss of sensation below a
dermatome corresponding to a spinal cord
compression)
– Weakness
• Extramedullary plasmacytomas :soft tissue
masses of plasma cells, are not uncommon.
Physical Examination
• Amyloidosis
– The shoulder pad sign is defined by bilateral swelling
of the shoulder joints secondary to amyloid
deposition-- >swelling as hard and rubbery.
– Macroglossia is a common finding in patients with
amyloidosis.
Diagnosis
• Lab Studies:
– CBC: anemia, thrombocytopenia, leukopenia
– Peripheral blood smear : rouleaux formation
Rouleaux formation : high plasma protein
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Diagnosis
– total protein, albumin and globulin, BUN, creatinine,
and uric acid, which is high if the patient has high cell
turnover or is dehydrated
– Serum protein electrophoresis, urine protein
electrophoresis, and immunofixation
• Serum protein electrophoresis is used to determine the type
of each protein present and may indicate a characteristic
curve (ie, where the spike is observed).
• Urine protein electrophoresis is used to identify the presence
of the Bence Jones protein in urine.
• Immunofixation is used to identify the subtype of protein (ie,
IgA lambda).
Diagnosis
• A 24-hour urine collection for the Bence Jones
protein (ie, lambda light chains), protein, and creatinine
– Quantification of proteinuria is useful for diagnosis
(>1 g of protein in 24 h is a major criterion) and for
monitoring the patient's response to therapy.
– Creatinine clearance can be useful for defining the
severity of the patient's renal impairment.
Diagnosis
• Imaging Studies
– Skeletal series
• skull (a very common site ), the long bones ( for
impending fractures), and the spine.
• Diffuse osteopenia may suggest myelomatous
involvement before discrete lytic lesions are
apparent.
• Do not use bone scans to evaluate myeloma
– MRI scan
• MRI to obtain a clear view of the spinal column
and to assess the integrity of the spinal cord.
Diagnosis
• Procedures
– bone marrow aspirate & biopsy
• samples to calculate the percent of plasma cells in
the aspirate (reference range, <3%) and to look
for sheets or clusters of plasma cells in the biopsy
specimen.
Bone marrow aspirate : plasma cells of multiple myeloma.Note
the blue cytoplasm, eccentric nucleus, and perinuclear pale zone (or
halo).
Bone marrow biopsy : sheets of malignant plasma cells in MM
Diagnostic criteria
• Durie-Salmon criteria
Dx : 1 major & 1 minor or 3 minor criteria
– Major criteria
• Plasmacytoma on tissure biopsy
• BM plasmacytosis with > 30% plasma cell
• Monoclonal globulin spike on serum
electrophoresis 3.5 g/dl for Ig G ,> 2g/dl for IgA
• Or urine Bence Jones > 1g/24 hr
Diagnostic criteria
• Durie-Salmon criteria
– Minor criteria
• Marrow plasmacytosis 10-29 %
• Monoclonal globulin spike present ,but less
than above
• Lytic bone lesion
• Normal Ig M< 0.05g/dl , IgA <0.1g/dl ,
IgG<0.6 g/dl
Staging
• Durie-Salmon staging system
1. High tumor mass <stage III > one of
a.
b.
c.
d.
following abnormalitie mus be present
Hb <8.5 g/dl, Hct < 25 %
Sr Ca > 12 gm/dl
Very high Sr or Urine myeloma protein production
rate
1. Ig G peak >7 gm/dl
2. IgA peak > 5 gm/dl
3. Bence Joneprotein > 12 gm/ 24 hr
> 3 lytic bone lesion on bone survey
Staging
• Durie-Salmon staging system
2. Low tumor mass <stage I>
all of following must be present
a. Hb > 15 gm/dl, Hct> 32%
b. Sr Ca normal
c. Low Sr myeloma protein production rate 1. Ig G peak<
5 gm/dl
2. IgA peak < 3 gm/dl
3. Bence Jone protien < 4 g/ 24 hr
d. No bone lesion or osteoporosis
Staging
• Durie-Salmon staging system
3. Imtermediate tumor mass <stage II>
a. no renal failure <Cr < 2 mg/dl>
b. Renal failure <Cr > 2 mg/dl>
Staging
• The International Staging System (ISS)
– Stage I : β2-microglobulin (β2M) < 3.5 mg/L, albumin
>= 3.5 g/dL
– Stage II : β2M < 3.5 and albumin < 3.5; or β2M
between 3.5 and 5.5
– Stage III : β2M > 5.5
Threatment
• Active care
– Chemotherapy
– Autologous / Allogenic stem cell transplamtation
– Drug : Arsenic trioxide, Thalidomide &
Immunomodulator
– Interferon
• Supportive care
– Radiation therapy
– Bisphosphonate
– Kayphoplasty
Threatment
• Radiation therapy <palliative>
– Rx : plasmacytoma post surgery
• Chemotherapy
– Melphalan & Prednisolone
– VAD < vincristine, adriamycin,
dexamethasone>
– VMCP < vincristine , melphalan,
cyclophosphamide, prednisolone>
Threatment
• Arsenic trioxide : inhibit leukemic growth
factor & + apoptosis
• Thalidomide : Antiangiogenesis->apoptosis of MM cell
• Bisphosphonate <Pamidronate,Zoledronic
acid> -- > inhibit osteoclast
Prognosis
• The International Staging System can help to
predict survival
– Stage 1 : 62 months
– Stage 2 : 45 months
– Stage 3 : 29 months