Updated: 8/4/2019

Multiple Myeloma

Topic
Review Topic
0
0
Questions
9
0
0
Evidence
7
0
0
Videos
2
https://upload.medbullets.com/topic/120464/images/left_humerus_with_myeloma.jpg
https://upload.medbullets.com/topic/120464/images/rouleaux.jpg
https://upload.medbullets.com/topic/120464/images/plasmacytoma_ultramini1.jpg
Snapshot
  • A 65-year-old man presents to his primary care physician with generalized fatigue and lower back bone pain. He reports an unexpected 20-pound weight loss over the course of 3 months. Physical examination is notable for conjunctival pallor and tenderness upon palpation of the lower spine. Laboratory studies are notable for a normocytic, normochromic anemia, hypercalcemia, and renal insufficiency. Urine studies is notable for Bence Jones proteins.
Introduction
  • Overview
    • neoplastic proliferation of plasma cells within the bone marrow 
      • leads to the production of monoclonal immunoglobulin (Ig)
        • mostly IgG (52%) and IgA (21%)
      • results in skeletal destruction
  • Epidemiology
    • demographics
      • older adults
        • median age is 66 years of age
    • risk factors
      • monoclonal gammopathy of undetermined significance (MGUS)
  • Pathophysiology
    • clonal malignant plasma cell proliferation
  • Associated conditions
    • Fanconi syndrome
    • renal tubular acidosis type 2
    • ↑ susceptibility to infection 
    • primary amyloidosis
Presentation
  • Symptoms
    • fatigue
      • secondary to anemia
    • bone pain 
      • especially in the back and chest
    • radiculopathy
      • especially in the thoracic or lumbosacral area
      • it's the most common neurological complication of multiple myeloma
      • secondary to
        • paravertebral plasmacytoma
        • bone collapse
    • peripheral neuropathy
      • rare and usually secondary to amyloidosis
    • sequelae associated with hypercalcemia
      • e.g., constipation, abdominal pain, muscle pain, and frequent urination
Imaging
  • Radiography
    • indication
      • can be used as an initial imaging study when evaluating bone pain
        • it is the least sensitive method for detecting skeletal lesions
    • findings
      • lytic bone lesions  
  • Whole body low-dose CT scan
    • indication
      • used in most cases to have a baseline assessment of how much the bone is involved
  • MRI whole body (or spine and pelvis)
    • indication
      • when CT scan does not demonstrate bone lesions but there is a high suspicion of multiple myeloma
        • most sensitive in evaluating bone involvement
      • when there is concern for cord compression
  • PET scan
    • indication
      • suspected extramedullary disease
        • most sensitive in evaluating extramedullary involvement
Studies
  • Serum labs
    • normocytic, normochromic anemia
      • secondary to
        • bone marrow replacement
        • renal damage
        • hemodilution with large M protein
    • elevated serum creatinine
      • secondary to
        • light chain cast nephropathy (myeloma kidney)
          • Bence Jones protein in urinalysis
        • hypercalcemia
    • hypercalcemia 
    • protein electrophoresis of the serum (SPEP)
      • monoclonal immunoglobulin spike (M protein)
    • peripheral blood smear
      • rouleaux formation of red blood cells  
        • "stack of coins" appearance
  • Invasive studies
    • bone marrow aspiration  
      • ≥ 10% clonal plasma cells 
      • multiple plasma cells with a "clock-face" chromatin pattern 
  • Imaging 
    • punched-out lytic bone lesions on radiograph
Differential
  • MGUS 
    • differentiating factors
      • < 10% clonal plasma cells
      • absence of lytic lesions
      • serum M protein is low
  • Waldenstrom macroglobulinemia  
    • differentiating factors
      • IgM gammopathy
      • absence of hypercalcemia, renal involvement, anemia, and bone lytic lesions
Treatment
  • Medical
    • chemotherapy
      • indication
        • treatment of choice
          • optimal treatment has not been established yet
Complications
  • May lead to
    • renal insufficiency
    • ↑ susceptibility to infection 
    • anemia
    • primary amyloidosis (AL)
 

Please rate topic.

Average 5.0 of 5 Ratings

Thank you for rating! Please vote below and help us build the most advanced adaptive learning platform in medicine

The complexity of this topic is appropriate for?
How important is this topic for board examinations?
How important is this topic for clinical practice?
Questions (9)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
Calculator

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

You have 100% on this question.
Just skip this one for now.

(M2.ON.4691) A 68-year-old male presents to his primary care physician with complaints of fatigue and pain in his upper arms and lower back for the past 2 months. Physical examination reveals pallor, hepatosplenomegaly, and focal bony tenderness to palpation over the lumbar vertebrae, bilateral humeri, and skull. Laboratory evaluation reveals hemoglobin 9.8 g/dL, serum calcium of 9.4 mg/dL, serum creatinine of 1.4 mg/dL, albumin of 3.7 g/dL, and rouleaux formation on peripheral blood smear. Serum protein electrophoresis reveals an elevated spike of a monoclonal IgG protein, with an M-protein serum concentration of 50 g/L. Which of the following radiographs would most likely be associated with this patient's condition? Review Topic

QID: 107650
FIGURES:
1

Figure A

5%

(1/19)

2

FIgure B

11%

(2/19)

3

Figure C

5%

(1/19)

4

Figure D

11%

(2/19)

5

Figure E

63%

(12/19)

M2

Select Answer to see Preferred Response

SUBMIT RESPONSE 5

You have 100% on this question.
Just skip this one for now.

(M2.ON.6) A 68-year-old man presents with a 6-month history of worsening fatigue and weight loss. He is especially concerned about a recent episode in which he noticed a blurring of his vision and headache; he also notes that his “memory is not as good as it used to be,” which his wife confirms. Physical exam is notable only for pallor and general weakness. Laboratory studies reveal anemia as well as an elevated erythrocyte sedimentation rate. Serum protein electrophoresis (SPEP) reveals a sharp, narrow spike of monoclonal IgM; serum IgM concentration is 6.3 g/dL. What is the most likely diagnosis in this case? Review Topic

QID: 104646
1

IgM monoclonal gammopathy of undetermined significance (MGUS)

0%

(0/15)

2

Multiple myeloma

27%

(4/15)

3

Waldenstrom’s macroglobulinemia

67%

(10/15)

4

Non-Hodgkin’s lymphoma

0%

(0/15)

5

Chronic lymphocytic leukemia

0%

(0/15)

M2

Select Answer to see Preferred Response

SUBMIT RESPONSE 3

You have 100% on this question.
Just skip this one for now.

(M2.ON.20) A 57-year-old woman with a history of hypertension presents to her physician with severe mid-back pain. She reports that the pain is sharp and began when she was reaching to retrieve a plate from a cabinet in her kitchen. She denies any major trauma to the back or any history of lifting heavy objects. On exam, she has spinal tenderness over the site, which is not warm or erythematous. On laboratory evaluation, she is found to have a creatinine of 5.6 mg/dL and a calcium of 16 mg/dL. Which of the following bone marrow biopsy findings is most likely to be found in this patient? Review Topic

QID: 104660
FIGURES:
1

Figure A

81%

(13/16)

2

Figure B

0%

(0/16)

3

Figure C

6%

(1/16)

4

Figure D

6%

(1/16)

5

Figure E

0%

(0/16)

M2

Select Answer to see Preferred Response

SUBMIT RESPONSE 1
ARTICLES (7)
VIDEOS & PODCASTS (2)
Topic COMMENTS (12)
Private Note