Symptoms of Multiple Myeloma
How is Multiple Myeloma Diagnosed?
Does Everyone Diagnosed with Multiple Myeloma Require Treatment?
How is Multiple Myeloma Treated?

Multiple myeloma is a type of cancer that affects the bone marrow, the body's blood-forming system. In persons with mutliple myeloma, the plasma cells (a special type of white blood cell) become abnormal and multiply rapidly, crowding normal cells in the bone marrow. The abnormal, or malignant plasma cells interfere with the production of normal blood cells. The overgrowth of malignant cells in the bone marrow can also weaken the bones, especially in the back and ribs, and cause pain and bone fractures.

Normally, plasma cells produce proteins found in the bloodstream called immunoglobulins. These proteins fight bacteria and viruses that may cause infections. Malignant plasma cells found in multiple myeloma produce a large amount of abnormal immunoglobulins, which cannot effectively fight infection.  The amount of these immunoglobulins in the blood help to diagnose the disease, and also help determine how effective the treatment may be. 

Multiple myeloma is an uncommon type of cancer, affecting about three out of 100,000 persons a year. At this time, the cause is unknown. However, multiple myeloma can be controlled in most patients, sometimes for many years. In the past few years, new drug treatments have been developed that control multiple myeloma in more patients and result in longer survival.

Symptoms of Multiple Myeloma
A common symptom of multiple myeloma is back pain, especially in the lower back and ribs. This pain may be relieved by Tylenol, or similar mild pain relievers for a short time period. The pain is usually worse with movement, and may feel like muscle spasms or arthritis. Persons with multiple myeloma may also have spontaneous bone fractures, and feel weak and very tired from anemia. Persons who have been diagnosed with multiple myeloma may not have all these symptoms. Any new symptoms should be reported promptly to your nurse or doctor. 

Since multiple myeloma reduces the body's defense against disease, frequent infections may also occur, including pneumonia, urinary tract infections and shingles. As a patient responds to treatment, fatigue and anemia may lessen, fractures can heal, and pain may be controlled.

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How is Multiple Myeloma Diagnosed? 
A small sample of bone marrow or tumor tissue is taken from the patient, in a procedure known as an aspiration or biopsy.  The pathologist, a physician who diagnoses disease, views the sample under a microscope and looks for abnormal plasma cells in the marrow.

Most patients have the abnormal immunoglobulin G form of myeloma, also called the IgG form. Other types may also be seen, such as IgA or IgD.  These letters stand for the different immunoglobulins produced by myeloma cells. Some patients may also have another type of protein, called the Bence Jones protein, which is excreted in the urine. 

In some patients, plasma cells in the bone marrow are present in low numbers (10%), which produce a monoclonal protein in low levels (~<2.5g/dl), but no other features of myeloma are present. These patients have Monoclonal Gammopathy of Unknown Significance (MGUS). A small percentage of these patients, about 1% a year, will develop multiple myeloma or another malignancy, but the majority will not.  Close observation is the treatment of choice for these patients.

Along with a complete physical exam and review of their medical history, multiple myeloma patients may have the following tests done to diagnose the disease or follow its treatment:

Complete blood count (CBC): a test to measure the number of white blood cells, red blood cells and platelets.

Serum protein electropheresis: a test to find abnormal proteins in the urine.

Serum creatinine: a test to measure creatinine, which is normally found in the blood and urine. An increase may mean abnormal kidney function.

Blood urea nitrogen (BUN): a test to measure substances normally released from the kidney. An increase may mean abnormal kidney function.

Serum calcium: a test to measure calcium, which is normally found in blood. Serum calcium may be higher in multiple myeloma patients because of bone loss.

Beta2 microglobulin: a test to measure this protein in the blood. Beta2 microglobulin may be higher in patients with advanced multiple myeloma, but may also signal abnormal kidney function.

Bone X-rays: Skeletal Survey this test shows areas where the bones may be affected by multiple myeloma.

Bone marrow aspiration and biopsy:  in this test, a sample of bone marrow is removed with a long, thin needle and studied for the presence of abnormal plasma cells.

Magnetic resonance imaging (MRI): using a special machine (not X-rays), this procedure provides a picture of parts of your body, done if necessary.

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Does Everyone Diagnosed with Multiple Myeloma Require Treatment?
Patients with a low tumor mass who don't have bone lesions and are free of symptoms have Asymptomatic Multiple Myeloma.  Many of these patients will have disease that remains stable for years without treatment. Early treatment has not improved survival, and therefore, treatment for most patients should be deferred until signs of disease progression (significant anemia, a lytic bone lesion, or rising monoclonal serum protein) occur.

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How is Multiple Myeloma Treated?
Treatment generally depends on the stage of the disease, any previous treatments, and how well the patient has responded to previous treatment.

Patients may receive any one or a sequence of treatments. The purpose of the treatment is to slow or stop the growth of cancer cells. It can also prevent and relieve complications such as pain. Multiple myeloma is different from some other cancers because the cells cannot be removed by surgery. Since multiple myeloma involves the body's blood-forming systems, it is systemic (widespread) rather than localized (contained in one area). Treatment must reach all parts of the body to be effective.

Multiple myeloma is usually treated with chemotherapy-drugs given orally or intravenously to kill cancer cells. If you are treated at Parkside Oncology Center you may receive one or more of the following chemotherapy drugs:

• Dexamethasone  
• Thalidomide
• Cyclophosphamide (CTD or TD)
• Zometa alone or as dtZ
• Vincristine
• Doxorubicin
• Methylprednisolone (C-VAMP or VAD)
• Interferon
• Melphalan (with an autotransplant)
• New agents like Velcade

Patients who receive radiation therapy are seen by doctors with special training in that area. A machine delivers a specific dose of radiation to affected areas of the body. Radiation therapy destroys multiple myeloma cells, and can relieve pain in areas such as the spine. 

Some patients have a stem cell transplant after receiving very high doses of chemotherapy to the entire body, which destroys the bone marrow.  A stem cell transplant replaces the bone marrow after treatment.  The stem cells are collected at Guy’s Hospital. The patient comes in for a period of about 3 weeks for the transplant at Parkside Hospital.

When a patient begins to respond to treatment, many symptoms, including pain, may lessen. The extent of multiple myeloma varies among patients, and for this reason, treatments differ as well. Patients may also respond to the same treatment differently.                              

More detailed information on myeloma can be found at the following resources:

UKMF www.ukmf.org.uk

IMF www.myeloma.org.uk

MMRF www.mmrf.org

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