Multiple Myeloma

1. Multiple Myeloma
Mohammad Saraireh
School of Nursing
The Hashemite University
2021/2022
Instructor: DR.Anas AL-sharawneh

2. Introduction:
 Multiple myeloma (MM) is a B-cell malignancy neoplasm of
plasma cells that accumulate in bone marrow, leading to bone
destruction and marrow failure.
 MM accounts for about 1.8% of all cancers and 18% of
hematologic malignancies
 MM is most frequently diagnosed among people aged 65 to 74
years, with the median age being 69 years.
 The American Cancer Society has estimated 32,270 new MM
cases in the United States in 2020, with an estimated 12,830 deaths

3. Introduction:

4. Introduction:

5. Introduction:
 MM has three hallmarks that distinguish this
disease:
 1- the presence of a serum or urine monoclonal
immunoglobulin
 2- monoclonal plasmacytosis,
 3- and bony lytic lesions
 Normal immunoglobulins are called "polyclonal
protein."

6. Incidence and Prevalence :

7. Risk factors
 Age (65 Y)
 Genetics risk factors
 Overweight and obesity
 Radiation exposure
 Race (Twice common in Black
people)

8. Pathophysiology
 Plasma cells are a type of white blood cell that bone
marrow produces. They fight off infection within the
body by producing antibodies. Normally, the bone
marrow has a small number of plasma cells; however,
when there are cancerous cells in the bone marrow as a
result of multiple myeloma, the cancerous cells produce
abnormal plasma cells. These are called myeloma cells.
 An antibody is a protein produced by the plasma cells in
response to an antigen. Antibodies circulate in the blood
and are present in certain secretions (tears, saliva, and
more)

9. Pathophysiology
 An abnormal antibody called “M protein” (monoclonal protein) is
produced by the malignant plasma cells. The hallmark characteristic
of having high levels of M protein in the blood, noted in people with
multiple myeloma, can cause:
 Tumors
 Kidney damage
 Bone destruction
 Impaired immune function

10. Pathophysiology
 Normal plasma cells secrete immunoglobulins (antibodies) to fight
infections. Immunoglobulins are proteins that attach to substances
entering the body that the body recognizes as foreign. Normal
immunoglobulins are called "polyclonal protein." Myeloma cells,
which are cancerous plasma cells, secrete monoclonal protein.
Monoclonal protein is an abnormal immunoglobulin that cannot
properly fight infection.
 Healthy plasma cells or myeloma cells can produce
immunoglobulins. These immunoglobulins made up of two heavy
chains and two light chains that are bound together.

11. Pathophysiology

12. Screening
 In the absence of known causative
agents, identified tumor markers, or
definitive diagnostic tests, the ability to
apply prevention and early detection
strategies to MM remains unapplicable
.

13. CLINICAL MANIFESTATIONS
 Frequent infections due to a weakened immune system (a
person with myeloma is referred to as being
immunocompromised)
 Bone pain (often in the back, ribs, and hips)  Pathological
fractures
 Hypercalcemia may be observed in 20% to 30% of patients
 Renal Impairment
 Weakness due to anemia (two-thirds of patients with MM have
anemia at presentation)

15. Diagnosis
 The diagnosis of multiple myeloma is suspected by
finding an elevated amount of M antibodies in the
blood and urine.
 A bone marrow biopsy and a bone marrow aspirate
are performed to confirm the diagnosis.
 Bone Marrow Evaluation: The percentage of clonal bone marrow
plasma cells (≥10%) is a major criterion for the diagnosis of MM. The
percentage of plasma cells in bone marrow is estimated by unilateral
bone marrow aspiration and biopsy. Immunohistochemistry and/or
flow cytometry can be used to confirm presence of monoclonal
plasma cells, and to more accurately quantify plasma cell
involvement

16. Diagnosis Specific tests
Test Purpose
Bone marrow aspirate/biopsy Measure percentage of plasma cells
Serum protein electrophoresis
(SPEP)
Check for the presence of serum M-
protein
Quantitative Immunoglobulins Identify specific elevated
immunoglobulin level
Urine immunofixation
electrophoresis (UIFE)
Identify specific monoclonal light-
chain immunoglobulin
Skeletal survey Check for osteolytic lesions
Serum chemistry hypercalcemia, renal dysfunction
Complete blood count anemia, thrombocytopenia

17. STAGING

18. THERAPEUTIC APPROACHES AND
 MM remains incurable and fatal. But
 In the past 20 years, few diseases have seen as
great progress in their treatment as multiple
myeloma.
 Treatment of multiple myeloma (MM) has
advanced dramatically in the past two decades
which led to similar prolong of overall survival.

19. THERAPEUTIC APPROACHES AND
 Traditional chemotherapy drugs such
as(melphalan, cyclophosphamide, or
bendamustine) which work to kill cancer cells
 Anti-inflammatory drugs which work to reduce
inflammation by stopping white blood cells from
traveling to areas where myeloma cells are causing
damage
 Proteasome inhibitors such as bortezomib,
carfilzomib, or ixazomib, which work to kill myeloma
cells
 Immunomodulatory drugs such as lenalidomide,
thalidomide, or pomalidomide, which possess

20. THERAPEUTIC APPROACHES AND
 Monoclonal antibodies, including daratumumab or
elotuzumab, treat multiple myeloma by targeting
antigens on the surface of myeloma cells, called
CD38. (Monoclonal antibodies are often used for
people with myeloma who do not respond to initial
treatment, those who do not qualify for stem cell
therapy, or those who have symptoms that recur
after a period of remission from the disease.)
 Stem cell transplant, which helps replenish the
bone marrow normal cells after high dose
chemotherapy

21. THERAPEUTIC APPROACHES
 Autologous HCT
 In 1996, results of the first randomized trial were reported; this trial
demonstrated that autologous HCT is associated with statistically
significantly higher response rates and increased OS and event-free
survival (EFS) when compared with the response of similar patients
treated with conventional therapy
 Stem cell toxins, such as nitrosoureas or alkylating agents
compromise stem cell reserve. Regimens with these agents (notably
melphalan) should be avoided in patients who are potential candidates for
HCT until stem cells are collected

22. THERAPEUTIC APPROACHES
 In patients with MM and monoclonal gammopathies, renal disease
usually results from the production of monoclonal immunoglobulin or
light/heavy
 chains by a clonal proliferation of plasma cells or B cells. Renal
disease is
 seen in 20-50% of patients with MM and has been observed to
negatively
 affect outcomes

23. Complications
• Bone fractures
• Hypercalcemia
• Anemia
• Decreased platelet production
• Compromised immune system (resulting in
various types of infections)
• Myeloma kidney (monoclonal antibodies collect
in the kidneys, which can interfere with kidney
function)
• Kidney stones (from an increase in uric acid
caused by the growth of cancerous cells)
• Kidney failure
• Amyloidosis (the build-up of proteins called
amyloid in the kidneys, liver, and other organs)

24. Coping with Multiple Myeloma