Oncology & Palliative Care
A 70 year old man is brought to the Emergency Department by his concerned daughter. She tells you that he is normally fit and well but has become acutely confused over the last 2 days. The only past medical history of any note she can recall is that he has been complaining of lower back pain and been taking regular paracetamol and ibuprofen.
His blood results are as follows:
- Haemoglobin: 109 g/L
- White cell count: 8.8 x 109/L
- Platelets: 143 x 109/L
- MCV: 105 fL
- Neutrophils: 6.2 x 109/L
- Urea: 18 mmol/L
- Creatinine: 228 mmol/L
- Total serum protein: 88 g/L
- Albumin: 34 g/L
- Calcium: 3.0 mmol/L
What is the most likely diagnosis?
Answer:
Myeloma would be most likely, given the hallmark findings of bone pain, macrocytic anaemia, renal failure, raised serum protein and hypercalcaemia.Multiple Myeloma
Haematology / Oncology & Palliative Care
Last Updated: 6th September 2022
Multiple myeloma is a progressive malignant disease of the plasma cells that normally produce immunoglobulin. The condition is characterised by a proliferation of abnormal monoclonal immunoglobulins (M proteins) in the blood, referred to as paraproteinaemia.
Clinical features
Suspect multiple myeloma in adults, particularly over 60 years of age, with:
- Unexplained bone pain, often in the lower back or thoracic area
- Fatigue
- Symptoms of hypercalcaemia (such as bone pain, abdominal pain, depression, confusion, muscle weakness, constipation, thirst, and polyuria)
- Weight loss
- Hyperviscosity symptoms (such as headache, visual disturbance, cognitive impairment, mucosal bleeding, and breathlessness)
- Symptoms of spinal cord compression (such as sensory loss, paresthesia, limb weakness, walking difficulty, sphincter disturbance, and spinal deformity)
- Fever
On examination, there may be:
- Hepatomegaly
- Splenomegaly
- Lymphadenopathy
Complications
Multiple myeloma may also present with other complications such as:
- Pathological bone fractures due to skeletal damage by osteolysis from proliferation of abnormal plasma cells in the bone marrow
- Spinal cord compression due to direct compression of the spinal cord by tumour tissue, or to vertebral collapse due to erosion of the vertebrae
- Renal damage primarily due to obstruction of renal tubules by excess light chains
- Impaired resistance to infection due to abnormal immunoglobulin production and leukopenia; recurrent infection with pneumococcal and haemophilus organisms is common, as is exacerbation of Herpes zoster infection
- Anaemia due to disordered blood synthesis
- Bleeding disorders secondary to impaired platelet production
- Hyperviscosity of the blood, due to raised circulatory levels of high density protein; this can cause impaired cerebral blood flow, stroke, heart failure, epistaxis, Raynaud's phenomenon, carpal tunnel syndrome
- Death, largely due to infection, disease progression, and renal damage
Investigations
Initial investigations:
- Full blood count
- Normochromic normocytic anaemia
- Neutropaenia
- Thrombocytopaenia
- ESR or plasma viscosity
- Elevated ESR
- Raised plasma viscosity
- Urea and electrolytes
- Renal impairment
- Calcium, albumin and uric acid
- Hypercalcaemia
- Raised uric acid
- Raised total protein concentration
- Myeloma screen
- Serum protein electrophoresis (to confirm presence of paraprotein)
- Serum-free light chain assay (to confirm presence of paraprotein)
- Urine protein electrophoresis (to look for Bence Jones protein)
- Peripheral blood film
- Rouleaux formation (suggests underlying paraproteinaemia)
- X-rays of symptomatic areas for people with bone pain
- Pathological fractures
Specialist investigations:
Investigations carried out in secondary care to confirm the diagnosis of multiple myeloma may include:
- Immunofixation of serum and urine, to confirm the presence of a paraprotein.
- Bone marrow aspirate and trephine biopsy, with plasma cell phenotyping, to confirm the presence of monoclonal plasma cells in the bone marrow.
- Magnetic resonance imaging (MRI) to determine the extent of myeloma bone disease or investigate possible spinal cord compression.
Further tests to estimate tumour burden and prognosis include:
- Fluorescence in situ hybridisation analysis of bone marrow aspirate.
- Serum beta-2 microglobulin concentration.
- Next generation DNA sequencing (if locally available).
Management
People with confirmed multiple myeloma should be treated in secondary care by a haematologist and a multidisciplinary team that may include oncologists, psychological support services, physiotherapists, occupational therapists, dietitians, adult social care, dental services, and critical and palliative care physicians.
Treatments for multiple myeloma in secondary care depend on the person's age, disease stage, prognosis, and comorbidities, and may include:
- Bisphosphonates to reduce bone disease and pain such as zolendronic acid, disodium pamidronate, or sodium clodronate.
- Treatments for anaemia such as darbepoetin, epoetin alpha, epoetin beta, or blood transfusion.
- Chemotherapeutic drugs such as cyclophosphamide, doxirubicin, carfilozmib, bortezomib, and melphalan.
- Corticosteroids such as dexamethasone and prednisolone.
- Immunomodulatory drugs such as thalidomide, lenalidomide, and pomalidomide.
- High-dose drug therapy and stem cell transplant.
- Deep vein thrombosis prophylaxis (for people taking immunomodulatory drugs) such as aspirin, low molecular weight heparins, and vitamin K antagonists.
Report A Problem
Is there something wrong with this question? Let us know and we’ll fix it as soon as possible.
Loading Form...
- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
