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Myeloma
Last updated 5th December 2023
Introduction
- Myeloma is a cancer of bone marrow plasma cells that secrete abnormal antibodies (paraprotein and/or free light chains (FLC). This may result in multiple signs and symptoms, including anaemia, non-specific pain originating in the bones, fatigue, infections, and kidney damage.
- Although these signs and symptoms may seem unconnected, it is important to remember that myeloma usually presents with vague symptoms that are progressive.
- Early diagnosis is key to preventing end organ damage and improving survival
When to Suspect Myeloma
- Any of the following blood test abnormalities:
- Raised Calcium
- Unexplained Renal impairment
- Anaemia
- Symptom or finding:
- Bone pain – usually presents as unexplained pain, generalised or localised
- Back pain – persistent or severe/atypical
- Generally unwell – fatigue, weight loss, suspicion of underlying cancer
- Recurrent infections with low immunoglobulins
- Pathological or fragility fractures, e.g. of the vertebra
- Important factors to consider:
- Symptoms and findings persist without explanation or despite initial interventions.
- ·Red flags for myeloma investigation include unexplained symptoms and more than one symptom.
- The CRAB (Calcium, Renal, Anaemia, Bone) criteria for myeloma.
What Tests to Request
- Serum protein electrophoresis for paraprotein
- Serum free light chain (sFLC) assay if no paraprotein and found to have hypogammaglobulinemia (after d/w haematologists)
- Urine Bence Jones protein (BJP) – can be done in house, and quicker turn around than sFLCSerum immunoglobulins (IgG, IgA an
- Full blood count
- Corrected serum calcium
- Serum creatinine
What to Do Next
- Any paraprotein/abnormal sFLC ratio with significant symptoms indicative of an urgent problem (e.g. spinal cord compression, acute kidney injury) – Recommend immediate referral to Clinical Haematology
- Moderate concentration of paraprotein (IgG>15g/L, IgA or IgM>10g/L) or Identification of an IgD or IgE paraprotein (regardless of concentration) or Significant abnormal sFLC ratio <0.1 or >7 or Identification of BJP – Recommend discussion with urgent referral to Clinical Haematology (2-week rule)
- Minor concentration of paraprotein (IgG <15g/l, IgA or IgM <10g/l) without relevant symptoms or Minor abnormal sFLC ratio (>0.1 and <7.0 but outside normal range) – Recommend recheck serum and urine in 2–3 months to confirm pattern and assess any progression. Patients whose paraprotein concentration increases (25% and >5g/L) or develop symptoms will need an urgent referral. Discuss with your Clinical Haematology Department if results not clear or concerns.
- No serum paraprotein, Normal sFLC ratio (0.26–1.65), No BJP, Normal immunoglobulin level – Myeloma very unlikely but symptoms may still need to be investigated with other clinical specialties
Myeloma Treatment
- Treatment consists of a combination of drugs; typically, this will be chemotherapy, steroids and treatments such as proteasome inhibitors and/or immunomodulatory drugs.
- Younger, fitter patients are usually offered an autologous stem cell transplant after initial chemotherapy.
- Older, frailer patients with multiple comorbidities may be more suitable for palliative care only.
Other Conditions Associated with Monoclonal Proteins
- Monoclonal gammopathy of undetermined significance (MGUS)
- MGUS with renal impairment (MGRS)
- MGUS with clinical consequences (MGCS) – such as AL amyloidosis
- Low grade lymphoma
All require follow-up or review
Links
Content by Ranjit Thomas & Chris Isles