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Multiple  myeloma
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  • 1. MULTIPLE MYELOMA
  • 2. Most common primary malignant tumor of bone. Multiple myeloma is a malignant clonal proliferation of plasma cells in the bone marrow with lytic bone leisions.
  • 3. TYPES Multiple myeloma (50%) Solitary myeloma (25%) Myelomatosis (15%) Plasma cell leukemia (1%) Extra skeletal - nasopharyngeal / oral cavity
  • 4. EPIDEMIOLOGY Age group : 50 – 60 yrs Sex : M:F- 3:1 Site : common in axial skeleton & flat bones than long bones. - spine , skull, pelvis , ribs , sternum, proximal femur
  • 5. CLINICAL FEATURES Bone pain is the most common symptom , which is relieved by rest. Persistent localised bone pain signifies pathological fracture. No swelling / deformity unless there is pathologic al # Compressive myelopathy due to vertebral collapse .
  • 6. CLINICAL HALLMARKS OF MM Weight loss , pallor, bleeding tendencies, fatigue Susceptibility to bacterial infections Hypercalcemia Renal failure Bone destructions lytic lesions) Presence monoclonal antibody
  • 7. INVESTIGATIONS Haemogram shows anaemia , leucopenia , thrombocytopenia ESR is very high Peripheral smear – NCNA with increased rouleaux formation. Leucoerythroblastic picture. Total protein increased with A:G reversal. S.Ca is increased, ALP normal.
  • 8. Electrophoresis on serum or urine shows ‘M’ band in the region of gamma globulin. Urine may show Bence Jones protein. Bone marrow – hypercellular with increased no. of plasma cells & myeloma cells. Mature & Immature plasma cells with eccenteric nuclei and ‘cart- wheel appearance’ of nuclear chromatin
  • 9. RADIOLOGICAL FINDINGS Multiple punched out lesions in skull & other flat bones.
  • 10. M M with pathological #
  • 11. Pathological wedge collapse of vertebra, commonly thoracic spine. Pedicles usually spared. Diffuse severe rarefaction of bones. Erosion of borders of ribs.
  • 12. CT & MRI Bone scan in solitarybone lesions helps to detect other sites of involvement. S. beta 2 microglogulin is the single most powerful predictor of survival.
  • 13. DIAGNOSTIC CRITERIA (DURIE & SALMON) Major criteria 1.BM plasmacytosis ( > or = 30% BM plasma cells) 2.Monoclonal globulin spike Ig G or Ig A 3.Light chain excretion in urine ; > or = 1g/24 hrs. 4.Biopsy proven plasmacytoma
  • 14. Minor criterias 1.BM plasmacytosis ; 10-30 % BM plasma cells 2.Monoclonal globulin spike gut < for major criteria. 3.Lytic bone lesions 4.Decrease in normal Ig level. Diagnosis - I major + 1 minor criteria 3 minor criteria that must include no. 1& no.2
  • 15. TREATMENT “Watchful waiting", where the progress of the disease is monitored . Chemotherapy • Melphalan, prednisone, thalidomide (MPT) • Bortezomib (Velcade), melphalan, prednisone (VMP) • Lenalidomide plus low-dose dexamethasone • Every 3-4 weeks for 6-12 cycles.
  • 16. Radiotherapy • Severe bone pain , pathological # , tumor lesions. Bone marrow transplantation Bisphosphonates (e.g. pamidronate or zoledronic acid) are routinely administered to prevent fractures and erythropoietin to treat anemia.
  • 17. Pathological # prevented by internal splinting of affected part. #s managed surgically by internal fixation . Treatment of other complications. In established cases survival is 2-3 yrs