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Updated: Oct 31 2021

Multiple Myeloma

  • Introduction
    • Multiple myeloma is cancer of monoclonal plasma cells
      • produces large amounts of IgG (55%) or IgA (25%)
      • high levels of IL-6 may be present
    • Epidemiology
      • most common primary tumor arising within bone in the elderly
    • If asymptomatic
      • called monoclonal gammopathy of undetermined significance (MGUS)
      • increased gamma globulin on serum electrophoresis but no symptoms of multiple myeloma are present
    • Pathophysiology
      • initial event - abnormal response of B lymphocyte to antigenic stimulation results in monoclonal proliferation of plasma cells -> MGUS
      • additional mutations causes progression from MGUS to multiple myeloma
      • since the plasma cell population in multiple myeloma are clones, they produce the same antibody, resulting in the monoclonal M spike on serum protein electrophoresis
        • though total serum antibody levels increase, these antibodies do not provide protection against pathogens because there is a lack of antibody antigenic diversity
  • Presentation
    • Symptoms
      • bone pain
      • sequelae associated with hypercalcemia
      • sequelae associated with renal failure
  • Evaluation
    • Serum protein electrophoresis
      • monoclonal immunoglobulin spike (M protein)
    • Urinalysis
      • Ig light chains (Bence Jones protein)
    • Peripheral blood smear
      • Russell bodies
        • Ig containing inclusion bodies seen in plasma cells
      • RBC rouleaux formation
        • Igs coat RBC and neutralize the ionic charge than normally repels RBCs
    • Bone marrow aspiration
      • proliferation of large monoclonal plasma cells
        • "fried-egg" appearance
    • Serology
      • hypercalcemia
        • result of bone degradation due to cytokine production that activates RANK receptor on osteoclasts
        • associated with decreased phosphate, increased PTH-rp and decreased vitamin D levels
      • prolonged bleeding time
    • Imaging
      • punched-out lytic bone lesions on x-ray
  • Prognosis, Prevention, and Complications
    • May lead to
      • renal insufficiency
      • ↑ susceptibility to infection
      • anemia
      • primary amyloidosis (AL)
    • Poor prognosis
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