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Multiple Myeloma

Overview

Multiple myeloma is also called Kahler’s disease or bone marrow cancer. It is a type of blood cancer that is formed in plasma cells. A plasma cell is a type of white blood cell in the bone marrow. White blood cells are part of the body’s immune system and help combat infections by forming antibodies. These antibodies sense the abnormal activity in the body and recognize them and kill the infections. In multiple myeloma, there is an uncontrolled accumulation of these plasma cells in the bone marrow due to abnormal multiplication that overcrowds and interferes with the normal functioning of healthy blood cells. In multiple myeloma, the plasma cells abnormally produce too many immunoglobulins in bones and blood. The cause of multiple myeloma is unknown. The benign state of multiple myeloma is called monoclonal gammopathy of undetermined significance (MGUS). It is marked by the presence of M protein (a protein produced by defective plasma cells) in blood.

Causes

The precise cause of multiple myeloma is yet to be established; however, a combination of genetic and environmental factors is thought to play a role in developing multiple myeloma. Radiation exposure, herbicides, chemicals exposure, chronic inflammation all can provide an underlying base for multiple myeloma.

Risk Factors

Some factors that increase the risk of getting multiple myeloma include:

  • Increasing age (Most people diagnosed in the mid-60s)
  • Ethnicity (More common in a black race)
  • Gender(Increase risk in men than women)
  • Family history(If disease present in a first-degree relative)
  • The presence of monoclonal gammopathy of undetermined significance (MGUS) Increases the risk.
  • Obesity
  • Previous exposure to radiotherapy
  • Previous exposure to chemicals in factories like rubber production, Firefighting, herbicides, or woodworking.
  • Serious viral infections

Epidemiology

Multiple myeloma is uncommon cancer, but now it has increased to about 126% globally, and deaths due to multiple myeloma have increased up to 94%. In the United States, 10% of all blood cancers are due to multiple myeloma. Every year, the frequency of new cases is 8.2 cases per 100000 in white men. The most common age at which the diagnosis is made is 69 years. Australia, Asia, North America, and Western Europe have the highest prevalence of multiple myeloma.

Signs And Symptoms

The signs and symptoms of multiple myelomas are variable in the early phases of the disease. There could be no clinical feature at all. Some notable signs and symptoms are described below:

  • Chest or spine pain is usually the first symptom.
  • Weight loss.
  • Constipation.
  • Nausea.
  • Bone pain.
  • Recurrent infections Due to low immunity.
  • Reduced appetite.
  • Brain fogging
  • Confusion.
  • Fatigue.
  • Numbness in legs.
  • Polydipsia (Too much thirst)
  • Back pain (Commonly lower back pain)
  • Hypercalcemia
  • Anemia
  • Kidney damage.
  • Stomach issues.
  • Fractures
  • Frequent bruising.
  • Nerve damage
  • Bowel or bladder incontinence.

Diagnosis

It is found accidentally during regular blood tests or when exploring the cause related to signs and symptoms. Some tests include.

1. Blood test

  • Complete blood count.
  • Blood urea nitrogen and creatine.
  • High protein but low albumin named globulin gap.
  • Serum calcium level (hypercalcemia)
  • Serum uric acid (hyperuricemia)
  • M protein produced by myeloma cells In blood.
  • Anemia (low blood cell count)

2. Urine test

The urine sample shows the presence of Bence Jones protein (M-protein)

3. Imaging

  • X-ray (shows bone damage)
  • CT scan
  • MRI
  • Pet scan

4. Bone marrow examination

  • Bone marrow aspiration and biopsy.
  • Fluorescence in-situ hybridization (FISH) test detects gene mutation in Myeloma cells.

Differential Diagnosis

Some diseases may exactly mimic multiple myeloma, but It can be differentiated via

thorough investigations.

  • Osteogenesis imperfecta
  • Homocystinuria
  • Asymptomatic plasma cell myeloma.
  • Plasma cell leukemia
  • Osteoporosis
  • Plasmacytoma
  • Osteomalacia
  • Scurvy

Treatment

The treatment of multiple myeloma depends on the risk if it is high, intermediate, or standard based on the abnormal gene in the tumor. If there are no symptoms, the doctor does not start the treatment. Rather make management plan improving quality of life and suggesting effective healthy nutrition. Medications are prescribed for high-risk cases depending on the individual's age and grading of cancer and depending on how aggressive the cancer is. During treatment, a healthy diet, exercise, rest, and hydration can help overcome side effects, and also the management of disease becomes easier. Some medications used in the treatment of multiple myeloma are:

 

1)   Chemo drugs used to treat multiple myeloma are vincristine (oncovin), liposomal. Doxorubicin(Doxil), cyclophosphamide(Cytoxan), bendamustine.

2)   Corticosteroids are prescribed with chemo drugs to prevent adverse effects.

3)   Immunomodulatory drugs perform two basic tasks. One is keeping myeloma cells deprived of new vessels so it doesn’t grow and the other function of this drug is to make the immune system strong naturally. This class of drugs include thalidomide(Thalomid), pomalidomide(pomalyst), lenalidomide(Revlimid).

4)  Immunotherapy monoclonal antibodies help the immune system detect and destroy myeloma cells permanently. This class of drugs includes daratumumab, elotuzumab, siltuximab. Among these, any of the drugs can be started in asymptomatic patients.

5) Protease inhibitors: Myeloma cells produce excess proteins, so protease inhibitor drugs inhibit the consumption of proteins by other cells, allowing cancer cells to starve and die eventually. This class of drugs includes bortezomib, ixazomib, carfilzomib.

6) Histone deacetylase inhibitors (HDAC): It deactivates abnormal genes and is prescribed after immunomodulatory drugs and bortezomib.

7) Nuclear export inhibitor (selinexor) destroys tumor cells.

8) Interferon therapy for remission cases.

Prognosis

The course and outcome of multiple myeloma are highly variable. Most deaths occur due to fatal infections, as people with multiple myeloma are prone to getting infections due to a weakened immune system. Some other complications include;

  • Blood issues like anemia leading to heart problems
  • Problems with the clotting system
  • Impaired renal filtration system due to kidney damage
  • Bone weakness causing frequent fractures.

Lifestyle Modifications

Some of the things to be taken care of while coping with multiple myeloma are:

  • Adopt a healthy lifestyle.
  • Take a well nutritious diet mainly containing iron, vitamin D, calcium to cope with the complications of the disease.
  • Some form of light exercise should be done.
  • Take care of Vaccination status to prevent infections like cold, flu, pneumonia.
  • Consult the doctor for medications to increase bone density, preventing fractures and bone loss.
  • Discuss anemia with your doctor, who may prescribe supplements that increase blood count.

Our clinical experts continually monitor the health and medical content posted on CURA4U, and we update our blogs and articles when new information becomes available. Last reviewed by Dr.Saad Zia on May 07, 2023.

 

References

https://jamanetwork.com/journals/jama/article-abstract/2788522

https://www.nhs.uk/conditions/multiple-myeloma/#:~:text=Multiple%20myeloma%2C%20also%20known%20as,%2C%20skull%2C%20pelvis%20and%20ribs.

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