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Understanding Symptomatic Multiple Myeloma: Diagnosis, Symptoms & Treatment Options

Learn about the neoplastic proliferation of plasma cells, diagnostic criteria, staging, differential diagnosis, and treatment of Symptomatic Multiple Myeloma. Find out about the signs, symptoms, and important clinical findings associated with this condition.

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Understanding Symptomatic Multiple Myeloma: Diagnosis, Symptoms & Treatment Options

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  1. Justin A. Crocker AM Report 2/2/10

  2. Symptomatic Multiple Myeloma

  3. 1 of the monoclonal gammopathies • Neoplastic proliferation of immunoglobulin producing plasma cells (single clone), often resulting in extensive skeletal destruction with focal lytic lesions, bone pain, and hypercalcemia • Cause unknown • 1% of all malignant disease and slightly more than 10% of hematologic malignancies in the US • Median age 66 (range 20 to 92) • Survival median is 3 years

  4. Signs/Symptoms

  5. Symptoms • Bone pain: back, chest, extremities • Weakness • Fatigue • Weight loss • Symptoms of hypercalcemia, renal insufficiency or amyloidosis

  6. Signs • Pallor • Rare to have HSM or LAD • Extramedullary plasmacytoma: large, purplish, subcutaneous mass seen in the late course of the disease

  7. Other Clinical Findings • Neurologic disease- radiculopathy, cord compression (plasmacytoma or vertebral body fracture), rare peripheral neuropathy • ID- strep pneumo, GN infections common • Lytic bone lesions- pathologic fracture, bone pain

  8. Diagnosis

  9. Workup • CBC w/ diff • BMP including BUN/Cr and Ca • U/A • SPEP/UPEP • Bone survey (plain films) not bone scan • CT/MRI • b2 microglobulin, CRP and LDH, • Measurement of free monoclonal light chains if available • Bone marrow aspirate

  10. Diagnostic criteria: International Myeloma Working Group • Calcium elevation • Renal insufficiency (Cr >1.7) • Anemia (<10) • Bone lesions (lytic lesions seen on CT or MRI)

  11. Diagnostic criteria: International Myeloma Working Group cont. • M-protein in serum and/or urine • Bone marrow (clonal) plasma cells or plasmacytoma

  12. WHO criteria • Major Criteria • BM plasmacytosis > 30% • Plasmacytoma on bx • Mspike in serum or urine: IgG > 3.5 g/dL or IgA > 2 g/dL or Urine Bence-Jones > 1g/24 hrs • 1 major and 1 minor OR 3 minor criteria • Minor Criteria • * BM plasmacytosis of 10- 30 % • * Monoclonal protein • Lytic bone lesions • Reduced normal immunoglobulins to < 50% nml • * required if using “3 minor”

  13. Staging

  14. International Staging System • Based on the serum beta-2 microglobulin and serum albumin levels. • Stage I: beta-2 <3.5 (mg/L) and the albumin is > 3.5 (g/dL). • Stage II: Neither stage I or III, meaning that either: beta-2 is between 3.5-5.5 (with any albumin level) OR the albumin is < 3.5 while the beta-2 is < 3.5 • Stage III: Serum beta-2 is > 5.5

  15. Differential Diagnosis

  16. Other hematologic malignancies (lymphoma/leukemia) • Solid masses • Sarcoid • Cirrhosis • Parasitic diseases • RA • Pyoderma gangrenosum • Sjogren’s syndrome • Cold agglutinin disease

  17. Is it Symptomatic Multiple Myleoma? • 20% of monoclonal gammopathies are secondary to another systemic illness • 13.5% are due to plasma cell neoplasms (myeloma, solitary plasmacytoma, extramedullary plasmacytoma, osteosclerotic plasmacytoma • 66% are MGUS

  18. Other gammopathies Smoldering Mulitiple Myeloma • Serum monoclonal protien > 3 g/dL • Bone marrow plasma cells > 10% • No end organ damage related to plasma cell dyscrasia MGUS • Serum monoclonal protein < 3 g/dL • Bone marrow plasma cells < 10% • No end organ damage related to plasma cell dyscrasia

  19. Other causes of osteolytic lesions • Renal cell cancer • Melanoma • Squamous cell cancers of the aerodigestive tract • Non-SC Lung CA • Thyroid CA • Non Hodgkins Lymphoma

  20. Variations on Multiple Myeloma • Nonsecretory: 3% have no M- protein in serum or urine and remains nonsecretory in 76% in follow up- limits renal failure, no light chain excretion. No survival dif. • Light chain myeloma: 20% of MM is only light chain, no immunoglobulin heavy chain. Increased incidence of renal failure, ? Survival differences.

  21. Treatment

  22. Therapies • High dose steroids • Chemo: Melphalan, alkylating agent Thalidomide • Stem cell transplant • No cure

  23. Preventing complications • Treat hypercalcemia with IVF, natriuresis, steroids. Also can use calcitonin and/or IV zoledronic acid (bisphosphonate) • Radiation therapy to lytic lesions • Vaccinate for infection prevention • Renal failure- avoid contrast, maintain hydration • Erythropoietin for anemia improvement

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