MULTIPLE MIELOMA

Multiple mieloma is the most common of the plasma cell dyscrasias (usually with a monoclonal gammopathy) affecting the hematopoietic, musculoskeletal, and renal systems. Synonyms: Myeloma; Plasmacytoma

CLASSIFICATION
Solitary

myeloma Multiple myeloma Osteosclerotic myeloma

EPIDEMIOLOGY

Rare in patients <40 years old The Male:Female ratio is ~2:1. The peak age is the 6th decade of life. ~15,000 new cases (United States) annually

RISK FACTOR

Age >40 years

DIAGNOSIS
SIGN AND SYMPTOMS Bone pain (usually of 6 months' duration) is the most frequent complaint at diagnosis. Constitutional symptoms of weakness, lethargy, and weight loss often occur. Back pain and rib pain are the 2 most frequent initial skeletal symptoms at presentation. Pathologic fracture usually results in sudden-onset pain. Peripheral neuropathy may be present. Tendency toward bleeding and fever Hypercalcemia is common. Monoclonal gammopathy is revealed by serum electrophoresis and urine immunoelectrophoresis

PHYSICAL EXAMINATION

Local pain and tenderness may be present. A palpable mass may be found, secondary to extraosseous extension of the tumor or hemorrhage related to it. Peripheral neuropathy may be detected in some patients with osteosclerotic myeloma.

LABORATORY FINDINGS

Hypercalcemia is seen in 1/3 of cases. Serum creatinine levels are elevated in ~50% of patients. Anemia with hemoglobin is <12 mg/dL in 2/3 of patients. Elevated ESRs are >50 mm/hour in 2/3 of patients. Serum electrophoresis and immunoelectrophoresis usually reveal monoclonal gammopathy. Bence Jones proteinuria is noted. Hypergammaglobulinemia may manifest itself as rouleaux formation appreciable on a peripheral

IMAGING

Radiography:
Plain

film radiographs reveal multiple small, discrete, lytic lesions most commonly involving the axial skeleton (skull, spine, ribs). The surrounding bone does not show a sclerotic reaction, nor is there a periosteal reaction.

Because bone scans have a high incidence of false-negative results, they are not used routinely.
A

skeletal survey to evaluate for distant involvement often is a better study.

PATHOLOGICAL FINDING

Monoclonal plasma cells are found in bone marrow.

DIFFERENTIAL DIAGNOSIS

Metastatic bone disease Malignant lymphoma Fibrosarcoma

TREATMENT

The mainstay of treatment is chemotherapy. Surgical stabilization with irradiation is used for impending or complete pathologic fractures. External-beam irradiation is used for painful lesions that do not meet the criteria for pathologic fracture. Medical treatment:

Orthopaedic surgery consultation to consider surgical stabilization Selected patients are treated with bone marrow transplantation.

Diphosphonate therapy has become an integral component of medical therapy because these drugs effectively halt osteoclastic bone resorption.

Bone marrow transplantation commonly is offered.

ACTIVITY

Limited activity, according to the level of symptoms and the nature of the bony lesions

MEDICATION

NSAIDs or narcotic analgesics for pain control Chemotherapeutics (prednisone, alkylating agents)

SURGERY

Mostly internal fixation for stabilization of the long bones Decompression with spinal instrumentation may be necessary for patients with pathologic fractures and neurologic deficits.

PROGNOSIS

Prognosis is related to the stage of the disease, with an overall median survival of 1824 months (1).
Virtually

all patients eventually die of the disease.

Bone marrow transplantation currently is being tried in an attempt to cure selected patients

COMPLICATION

Pathologic fractures Spinal stenosis with compressive myelopathy Renal failure Amyloidosis (CTS)

FOLLOW UP

Monitor closely for impending pathologic fractures so that appropriate surgical intervention can occur before completion of pathologic fractures. Patients undergoing chemotherapy are monitored for changes in their serum protein levels to assess the response to treatment.