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Multiple Myeloma PowerPoint Presentation

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Slide 1 - Multiple Myeloma Morning Report July 21, 2009 Lindsay Kruska
Slide 2 - Multiple Myeloma Neoplastic proliferation of single clone of plasma cells producing monclonal immunoglobulin Cause unknown Radiation and solvents ?associated 1% malignancy, 10% hematologic malignancy in US Incidence 4-5/100,000 Median age presentation 60-66y, rare <40y (2%)
Slide 3 - Presentation: Symptoms Suspected usually due to widely varied symptoms (>6mo in 40%) Bone pain (67%) Weakness and Fatigue (30%) Weight loss (24%) Asthenia (14%) Dyspnea (4%) Fever (<1%) Sx of cord compression Repeated infections (pneumonia, pyelonephritis)
Slide 4 - Presentation: Signs Physical Exam Pallor Organomegaly, palpable LN rare (<5%) Radiculopathy (cord compression) (5%) Peripheral neuropathy uncommon Labs Hypercalcemia (36%) Increased serum total protein Anemia (34%) Acute renal failure (34%) Low anion gap
Slide 5 - Work up CBC with diff, smear Anemia, rouleaux Chemistries Ca, Creatinine, Total protein SPEP with immunofixation (87% sensitive) UPEP (24h urine) (75% sensitive) Serum light chains Beta-2 microglobulin Bone marrow biopsy Bone survey, occasionally advanced imaging
Slide 6 - SPEP Electrophoresis Immunofixation
Slide 7 - Bone Marrow Biopsy Marrow plasmacytosis (>10%) CD138+, monoclonal Focal BM involvement 10% require multiple biopsies
Slide 8 - Bony involvement
Slide 9 - Diagnosis Presence of serum and/or urine monoclonal protein IgG (53%), IgA (25%), IgD (1%) Free light chains (20%) Clonal plasma cells or plasmacytoma End organ damage HyperCa, Renal failure, Anemia, Lytic Bone lesions
Slide 10 - Main Differential Diagosis: Elevated M protein MGUS (1%/year) Absence of symptoms M protein <3g/L <10% plasma cells in marrow No anemia, renal failure, hyperCa, lytic lesions Smoldering Multiple Myeloma (10%/year) Meets dx criteria for MM but no end organ Primary amyloidosis Metastatic cancer
Slide 11 - Differential Also Includes Other lymphoid neoplasms CLL B and T cell lymphomas Non lymphoid neoplasms Breast Ca CML Breast and colon cancer Cirrhosis Sarcoidosis Gaucher’s disease Pyoderma gangrenosum Autoimmune conditions Myasthenia gravis Rheumatoid arthritis Cold agglutinin disease Several rare skin DO
Slide 12 - Staging Durie-Salmon staging (Stages I-III, a/b), 1975 M protein Serum Calcium Radiographic Bone Involvement Hemoglobin Renal failure International Staging System (Stages I-III), 2005 Serum beta2 microglobulin Albumin
Slide 13 - Therapy Supportive care Hypercalcemia/bone involvement: usual therapies, analgesia, occ XRT Renal involvement: adequate hydration, ?plasmapheresis Low threshold for infectious complications Hyperviscosity: plasmapheresis Neurologic compromise: palliative radiation Anemia: transfusion Initation of specific therapy Chemotherapy Thalidomide Dexamethasone Melphalan/prednisone Bortezomib (proteasome inhibitor) HSCT
Slide 14 - Prognosis Usually fatal 10-20% mortality within first 2 months Mean survival 4-5y 5y survival 31%, 10y 10%, 15y 4% Delay in diagnosis associated with negative impact on disease course Lead time bias Improved survival with therapy including HSCT Major causes of death: progressive myeloma, renal failure, sepsis, therapy related acute leukemia or myelodisplasia; 25% die of age related illnesses
Slide 15 - References Fauci, et al. Harrison’s Internal Medicine. 17th edition. Abeloff, et al. Abeloff's Clinical Oncology, 4th ed. Up to Date. www.utdol.com
 

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