Multiple Myeloma
Cancer Treatment
Multiple Myeloma
In Multiple myeloma, when the healthy plasma cells change and grow out of control, they not only lower the individual ability to fight infections but also crowd and suppress the growth of other normal cells in the bone marrow; the red blood cells, the white blood cells and platelets resulting in anaemic conditions and bleeding tendencies.
Symptoms of Multiple Myeloma :
People with multiple myeloma experience various symptoms and signs, while a few do not exhibit any symptoms wherein the cancer is asymptomatic.
- Anaemia is about having lower levels of red blood cells, which happens when myeloma plasma cells suppress or crowd out healthy red blood cells.
- Anaemia or other factors associated with myeloma, such as abnormal cytokine production, causes fatigue in people.
Bone pain is a common symptom. Myeloma cells grow in the bone marrow and cortical bone, causing local bone damage or generalized thinning of the bone called osteoporosis, making the bones brittle and more likely to break. It affects bones in multiple places, but the back or ribs are the most common sites of bone pain, and the condition worsens with body movements and during the night. If the spine is affected by cancer, the vertebrae (the individual bones that make up the spine) can collapse which is called a compression fracture. In advanced multiple myeloma, individuals might lose inches from their height due to compressed vertebrae over the course of their illness.
Frequent bouts of pain, numbness, and weakness occur when collapsed vertebrae press against the spinal cord or pinch a nerve coming out of the spine.
A vital aspect that we need to be mindful of, is that too much M protein may lead to kidney damage or failure. Kidney damage in its early stages does not often exhibit symptoms and can only be diagnosed through blood and urine tests. When the functioning of kidneys fails, it starts exhibiting multiple symptoms like itching, weakness, fatigue, shortness of breath, muscle cramps, nausea, appetite loss, sleeping trouble, changes in urination, anaemia, and swelling of the legs, feet, or ankles.
Hypercalcemia is a high level of calcium in the blood that occurs due to bone breakdown. It can cause drowsiness, constipation, and kidney damage.
Symptoms of weight loss, nausea, thirst, muscle weakness, and mental confusion are related to kidney failure, hypercalcemia, or other imbalances in blood chemicals.
Myeloma lowers immunity levels, which reduces the body’s capability to fight infections, resulting in fever and causing infection of the upper respiratory tract and lungs.
Hyperviscosity or thickened blood and low platelets cause blood clots, nosebleeds, bleeding gums, bruising and cloudy vision, are some of the symptoms of multiple myeloma.
It is important to note that, like regular plasma cells, myeloma cells can produce antibodies. But myeloma cells are incapable of producing healthy functioning antibodies instead they make monoclonal protein, monoclonal immunoglobulin or M protein. M protein can build up in the blood and urine, potentially damaging the kidneys and other organs and reducing immunity.
- Myeloma causes structural bone damage, which results in weakened bones and leads to painful fractures or bone breaks over time. Myeloma, usually called multiple myeloma due to the presence of more than one bone lesion in more than 90% of individuals.
- Solitary plasmacytoma is a mass, or tumour, of myeloma cells that involve only 1 site in the bone or, less commonly, in other organs
- Extramedullary plasmacytoma describes myeloma that originates outside the bone marrow in the lymph glands, sinuses, throat, liver, digestive tract, or under the skin.
Risk factors of Multiple Myeloma
- Age: Myeloma occurs most commonly in people over 60. The average age at diagnosis is 70, with a 2% possibility of occurrence in individuals under 40.
- Race: Myeloma occurs twice as frequently in black people than in white people. The reasons are unclear, although the disease is more common in the Middle East, North Africa, and the Mediterranean.
- Exposure to radiation or chemicals: People who have been exposed to radiation or asbestos, benzene, pesticides, and other chemicals used in rubber manufacturing may be at higher risk for developing myeloma. People often exposed to wood products, such as carpenters, furniture designers, and paper makers, are also at higher risk. There is also an increased incidence of myeloma among professional firefighters and those exposed to herbicides, including Agent Orange.
- Personal history: People with a history of a solitary plasmacytoma of the bone are at greater risk for developing multiple myeloma.
- Monoclonal gammopathy of undetermined significance (MGUS): An individual with a small amount of M protein in their blood has a 1% to 2% chance of developing myeloma, lymphoma, or other blood-related cancers called Waldenstrom’s macroglobulinemia annually.
Diagnosis of Multiple Myeloma
Based on the patient’s requirements, the consultant recommends any of the following diagnostic procedures to diagnose multiple myeloma cancer:
- The type of cancer suspected
- Your signs and symptoms
- Your age and general health
- The results of earlier medical tests
- Blood and urine tests: Myeloma cells usually secrete the monoclonal immunoglobulin antibody known as M protein, and its levels in the patient’s blood and urine help the doctor determine the extent of the disease and monitor the effectiveness of treatment. In some people, the myeloma cells secrete only part of the antibody called the light chain. The amount of M protein in the blood or urine is measured by serum protein electrophoresis (SPE or SPEP) or urine protein electrophoresis (UPE or UPEP).The serum-free light chain assay helps measure the amount of free light chains in the blood before the kidneys filter the blood, and the presence of light chains in the urine is called the Bence Jones protein.Blood analysis is performed to measure levels of serum albumin and serum beta-2 microglobulin (β2-M), calcium levels, and blood cells and also to measure the performance of kidneys.</p
- X-ray: X-rays are taken to evaluate the patient’s skeletal system and are typically the first procedure to examine the bones when myeloma is suspected or diagnosed.
- Magnetic resonance imaging (MRI): An MRI reveals if the normal bone marrow has been replaced by myeloma cells or plasmacytoma, especially in the skull, spine, and pelvis. The detailed images may also show compression fractures of the spine or a tumour pressing on nerve roots.
- Computed tomography (CT) scan: A CT scan creates a detailed, cross-sectional view that reveals any abnormalities or tumours in soft tissues. A computer then combines these pictures into a 3-dimensional image of the inside of the body.
- Computed tomography (CT) scan: A CT scan creates a detailed, cross-sectional view that reveals any abnormalities or tumours in soft tissues. A computer then combines these pictures into a 3-dimensional image of the inside of the body.
- Positron emission tomography (PET) or PET-CT scan: A PET-CT scan, a combination of a PET scan and a CT CT scan, is usually referred to as a PET scan by doctors and is taken to determine the abnormalities inside the body. A small amount of radioactive sugars is injected into the patient’s body and consumed by cells that use the most energy. Since cancer tends to consume more energy actively, it absorbs more of the radioactive substance. A scanner then detects this substance and produces images of the internal organs to help doctors determine the tumour’s location and spread.
- Bone marrow aspiration and biopsy: These two procedures are similar and often done simultaneously using a needle to examine the bone marrow and are crucial for making a myeloma diagnosis. Bone marrow has both solid and liquid components. A bone marrow aspiration helps collect the bone marrow fluid, whereas a bone marrow biopsy helps obtain a small mass of solid tissues.The pathologist then analyzes the collected samples. Cytogenetics and a special procedure called fluorescent in situ hybridization (FISH) help analyze the genes in myeloma. Cytogenetics is a type of genetic testing used to analyze the cell’s chromosomes. These tests determine the genetic makeup of the myeloma and its health risks. Bone marrow aspiration and biopsy are typically done in the pelvic bone located in the lower back by the hip.
Molecular testing of the tumour
- Cytogenetics the study of genetic changes in cells, and molecular studies may be performed on tissue samples removed during a biopsy to determine the aggressiveness of the cancer cells. In myeloma, the genes of plasma cells are routinely studied using the FISH test to identify health risks, which can be used as a guide in making customized treatment plans.
- Minimal residual disease (MRD): As treatments have become increasingly effective in treating myeloma, new approaches to measure its effectiveness have been developed, including MRD. The principle is that the harder it is to detect the disease, the better. If traces of the malignant cells (called MRD positive) exist after the treatment process, further treatments may be offered to suppress the disease further.
Stages of Multiple Myeloma
- Asymptomatic, which means the individual does not exhibit symptoms and signs of the disease. Patients without symptoms are generally watched closely without specific treatment, although therapies are sometimes offered to stop the disease from growing or spreading. This process is called active surveillance for smouldering myeloma.
- Symptomatic, which means the individual exhibits symptoms and signs of the disease or is about to develop symptoms and is in need of treatment.
International Staging System
- The International Staging System (ISS), now used more commonly to classify multiple myeloma, illustrates the factors critical for the best patient outcomes and is based on data collected from people worldwide with multiple myeloma. The system has 3 stages based on the measurement of serum albumin and the levels of serum β2-M.
- Efforts to further classify myeloma based on patterns of gene expression in myeloma cells are underway and are an ongoing area of research.
Stage I: β2-M <3.5 mg/L with a serum albumin of 3.5 g/dL or more
Stage II: Either of the following two criteria:
- β2-M between 3.5 mg/L and 5.5 mg/L
- Albumin <3.5 g/dL
Stage III: β2-M >5.5 mg/L
This system has recently been revised to include serum lactase dehydrogenase (LDH) and high-risk gene abnormalities defined by the FISH test and is called the Revised-ISS (or R-ISS). It is most commonly used to predict prognosis. Higher blood levels of LDH indicate a poorer prognosis. Abnormalities in chromosomes (as defined by the results of cytogenetic testing) of the cancer cells may also indicate the aggressiveness of the cancer and influence how the disease progresses.
Treatment for Multiple Myeloma
The treatment of multiple myeloma depends on the symptoms the patient exhibits symptoms and the patient’s overall health. In most cases, a team of doctors work with the patient to determine the best treatment strategy. The treatment objective is to eliminate myeloma cells, control tumour growth, control pain, and encourage patients to lead an active life. While there is no cure for multiple myeloma, the cancer can be managed successfully in majority of the cases for several years, enhancing survival prospects.
Treatment strategies vary based on symptomatic or asymptomatic myeloma and whether the individual is recently diagnosed with myeloma or is experiencing a disease recurrence.
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