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Myeloma

 

What Is It? One of the three main types of blood cell cancer- leukemia, lymphoma, and myeloma that in combination account for 10% of all cancers diagnosed in the US. Myeloma is a cancer of the plasma cells (produce antibodies) in the bone marrow that are a part of the immune system.  Myeloma is frequently called multiple myeloma since it affects several different antibody producing cell lines.  It produces disease by crowding out other cells and precursors to cells in the bone marrow. In multiple myeloma, the massively produced antibodies spill out into the systemic blood circulation and cause organ damage. The early symptoms are bone pain (severe) over the chest and especially low back, and less commonly the upper and lower extremities, bone fractures, weakness and numbness in the extremities due to radicular pain from the bone fractures, weakness and fatigue (due to anemia), weight loss (due to nausea/vomiting/loss of appetite from elevated calcium levels.  Frequent urination, increase in thirst, and constipation occur due to elevated calcium levels.  These high levels may cause confusion or even coma. Kidney failure occurs due to elevated proteins from the immunoglobulin hyperproduction and the blood becomes excessively thick (hyperviscosity) producing blurring of the vision, bleeding from the nose, and heart failure. There may be purple lumps under the skin called extramedullar plasmacytomas.  There are frequent infections.

Incidence: 30,300 new cases in the US were diagnosed in 2015 (approximately 10 per hundred thousand population).  The prevalence is 103,463 patients living with the disease (active or in remission) in the US at any one time.

Location: Pain may be global in the bones, but most frequently starts in the low back and chest wall

Anatomy: The replacement of bone marrow by plasma cells causes anemia and fractures due to development of holes in the bone. 

Onset: Gradual

Character: Constant aching bone pain

Intensity: Severe in the back

Worsens: with fractures, when standing

Relieved by: -

Causes: Unknown- cancer of the plasma cells is the mechanism

Diagnosis: Elevated blood calcium, anemia (too few red blood cells), kidney dysfunction, high protein levels in the blood.  Weight loss is due to high calcium levels that produce nausea, vomiting, and loss of appetitie. Electrophoresis is a blood test that measures the antibodies.  Blood uric acid may be elevated if there is a high cell turnover rate. Total protein, albumin, and globulin levels are obtained.  A skeletal survey via xray or CT scan.  Bone scans miss many of the lesions therefore are not indicated. Kidney function will also be tested since this is a frequent organ that will demonstrate dysfunction. Usually a bone marrow biopsy will be required to make the diagnosis.  C-reactive protein and beta-2 microglobulin are both used for determining the prognosis. X-rays typically show punched out round lesions in the skull, spine, ribs, and pelvis.   

Outcome: Myeloma has a 49% 5 year survival rate and 12,650 will die from myeloma in 2016.

Associated with: Age over 65, African American race, having a family member with this, MGUS (monoclonal gammopathy of undetermined significance), other plasmacytoma.

Treatment: Stem cell transplantation is the most effective way to treat this type of cancer.  Chemotherapy is a second line therapy for those that cannot withstand the potential complications from the stem cell transplant. Bisphophonates (e.g. Fosamax, Boniva, etc. ) are used to slow the bone destruction. 

Differential Diagnosis: Leukemia, sarcoma, other carcinoma, other generalized pain, metastatic disease, waldenstrom macroglobulinemia

Complications: Bone fractures, coma, weight loss, death