Mcphs Mmd Ii Multiple Myeloma

Front 1

Plasma cells develop from

Back 1

B lymphocytes

Front 2

The majority M-proteins secreted by malignant plasma cells are

Back 2

IgG (70%) & IgA (20%)

Front 3

Plasma cells secrete only light chain pieces in the urine or blood

Back 3

Bence Jones Proteins

Front 4

Malignant proliferation of plasma cells that secrete monoclonal protein (IgG > IgA) that invade and destroy bone tissue

Exact Etiology is unknown

Accounts for 10% of the hematologic malignancies, 1% of all malignancies

Annual incidence of 4 cases per 100,000

Mean age at diagnosis is 65 years-old

More common in African American that whites

More common in men than women

Back 4

Multiple Myeloma

Front 5

What are some incidences that can lead a person to be more prone to multiple myeloma?

Back 5

Exposure to radiation, Benzene, also higher prevalence in HIV and those with rheumatoid arthritis.

Front 6

What are the three classifications of multiple myeloma?

Back 6

Asymptomatic (Smoldering)
Symptomatic (Active)
Non-Secretory

Front 7

M-protein in serum >3.0g/dL
and/or
Bone marrow clonal plasma cells >10%
No Symptoms
No myeloma related organ or tissue impairment

Back 7

Asymptomatic (Smoldering)

Front 8

M-protein in serum and/or urine
Bone marrow clonal plasma cells or plasmacytoma
Myeloma related organ or tissue impairment
Calcium Elevation: serum calcium >11.5g/dL
Renal Insufficiency: serum creatinine >2mg/dL
Anemia: Hemoglobin <10g/dL or 2g < normal
Bone Damage: Lytic lesions, Osteoporosis or Osteopenia with compression fractures

Back 8

Symptomatic Myeloma (Active)

Front 9

No M-protein in serum and/or urine
Bone marrow clonal plasmacytosis > 10% or plasmacytoma
Myeloma related organ or tissue impairment

Back 9

Non-Secretory

Front 10

What is the pneumonic for symptomatic myeloma (active)?

Back 10

CRAB

Calcium Elevation: serum calcium >11.5g/dL
Renal Insufficiency: serum creatinine >2mg/dL
Anemia: Hemoglobin <10g/dL or 2g < normal
Bone Damage: Lytic lesions, Osteoporosis or Osteopenia with compression fractures

Front 11

What are common clinical findings in multiple myeloma?

Back 11

Common Clinical Findings: Bone Disease, Hyercalcemia, Anemia, Renal Insufficiency, Infections, Hyperviscosity Syndrome

Front 12

Someone presenting with this for the first time can be a sign of multiple myeloma?

Back 12

A blood clot due to hyperviscosity syndrome.

Front 13

What is the most common symptom with multiple myeloma?

Back 13

Bone pain

Front 14

What are the other bony manifestations that are associated with multiple myeloma?

Back 14

Osteoporosis, pathologic fractures, lytic bone lesions - caused by tumor expansion, excessive osteoclast formation and suppression of osteoblasts.

Front 15

These appear as punched otu areas and are characteristic of multiple myeloma?

Back 15

Lytic lesions. These show up in the axial skeleton: Skull, pelvis, spine, ribs, proximal long bone.

Front 16

Multiple myeloma increases the risk of what?

Back 16

Vertebral fractures/collapse which may lead to spinal cord compression.

Front 17

This is a clinical manifestation that occurs with multiple myeloma:

Caused by infiltration of plasma cells into bone marrow
Rouleau formation is common
Associated with fatigue, weakness, pallor

Back 17

Anemia - Associated with a normocytic normochromic anemia.

Front 18

This is a stacking of the RBC's, 3-12 RBC's stacking on each other.

Back 18

Rouleau formation

Front 19

This is a clinical manifestation that occurs with multiple myeloma:

Back 19

Continued infiltration of the bone marrow leads to suppression/failure
Decrease production & increased destruction of normal antibodies
High rate of S. pneumoniae and H. influenzae

Front 20

This is a clinical manifestation that occurs with multiple myeloma:

Nausea, constipation, fatigue

Back 20

Hypercalcemia

Front 21

Why are recurrent infections a clinical manifestation of multiple myeloma?

Back 21

Multiple myeloma causes abnormal antibody formation. Typically pneumonia presents in MM patients.

Front 22

This is a clinical manifestation associated with multiple myeloma.

Caused by deposition of light chains in the kidneys
May be exacerbated by probable NSAID use for bone pain and hypercalcemia

Back 22

Renal Insufficiency

Front 23

This is a clinical manifestation associated with multiple myeloma.

High levels of immunoglobulins increase blood viscosity
Fatigue, Headache, Blurry Vision, Confusion, Mucosal Bleeding

Back 23

Hyperviscosity Syndrome

Front 24

This can go back to normal after TX of multiple myeloma?

Back 24

Renal insufficiency, make sure to test BUN and Creatinine

Front 25

What diagnostic studies do you run with multiple myeloma?

Back 25

Serum laboratories, 24 hour urine collection, bone marrow biopsy, skeletal survey.

Front 26

Diagnostic study associated with multiple myeloma:

CBC with Differential
Chemistry: Calcium, BUN, Creatinine, Albumin, Uric Acid
C-Reactive Protein, ESR
LDH
Quantitative Immunoglobulins, Protein Electrophoresis & Immunoelectrophoresis,
Beta2-Microglobulin

Back 26

Serum laboratories

Front 27

In the serum laboratories what may be elevated directly linked to skeletal lesions?

Back 27

LDH

Front 28

Diagnostic study associated with multiple myeloma:

Total Protein, Protein Electrophoresis &Immunoelectrophoresis

Back 28

24 hour urine collection

Front 29

What tests are done in the serum laboratories to differentiate between IgG, IgA, IgM etc. ?

Back 29

Quantitative immunoglobulins, protein electrophoresis, and immunoelectrophoresis.

Front 30

What three things are associated with a bone marrow biopsy in multiple myeloma?

Back 30

1. Determine plasmacytosis

2. Plasma cell labeling index (PCLI)

3. Perform cytogenic studies on bone marrow.

Front 31

Indicates the proportion of plasma cell proliferating
Low percentage of proliferating cells usually indicates longer survival potential

Back 31

Plasma Cell Labeling Index (PCLI) - Bone marrow biopsy

Front 32

Deletion of chromosome 13 and translocations of chromosomes 4 & 14 as well as 14 and 16 are associated with poorer prognosis
Translocation between 11 and 14 may be associated with longer survival

Back 32

Perform Cytogenic Studies on Bone Marrow - Bone marrow biopsy

Front 33

X-rays or MRI for Lytic Lesions: Skull, Spine, Pelvis
PET scanning
Bone Density Testing for Osteoporosis

Back 33

Skeletal survey for multiple myeloma

Front 34

What are the two main things to look at in the Durie-Salmon Staging System?

Back 34

Whether or not the IgG and Bence Jones protein levels are elevated.

Front 35

Stage I
Hgb >10.5g/dL, Calcium ≤12mg/dL, nml skeletal survey or solitary plasmacytoma only, low M-protein: IgG <5g/dL or IgA <3g/dL, Bence Jones Protein <4g/24h

Stage II
Not stage 1 or stage III
A: No renal failure (Creatinine ≤2mg/dL)
B: Renal failure (Creatinine >2mg/dL)

Stage III
High M-protein: IgG >7g/dL or IgA >5g/dL, Bence Jones Protein >12g/24h

Back 35

Durie-Salmon Staging System

Front 36

Stage I
Beta2 Microglobulin <3.5mg/L
Serum Albumin ≥3.5g/dL

Stage II
Beta2 Microglobulin <3.5mg/L & Serum Albumin <3.5g/dL
or
Beta2 Microglobulin 3.5-5.5 mg/L irrespective of Albumin

Stage III
Beta2 Microglobulin >5.5mg/L

Back 36

International staging system for multiple myeloma

Front 37

Multiple myeloma treatment:

Stage I or Asymptomatic patients do not usually require immediate treatment

Back 37

Monitor every 3-6 months for progression

Treat anemia, osteoporosis, hypercalcemia, infections

Front 38

Multiple myeloma treatment:

Stage II and beyond or Active Multiple Myeloma

Back 38

Autologous Stem Cell Transplant + Chemotherapy

Chemotherapy only

Front 39

If multiple myeloma is stage three or higher what is the treatment?

Back 39

primarily palliative

Front 40

Chemotherapeutic Drugs with Stem Cell Transplant in multiple myeloma?

Back 40

Dexamethasone plus Thalidomide, Lenalidomide or Bortezomib or combination

Immunomodulatory Drug: Thalidomide, Lenalidomide

Proteosome Inhibitor: Bortezomib

Front 41

Immunomodulatory Drug: Thalidomide, Lenalidomide requires what?

Back 41

DVT prophylaxis

Front 42

Proteosome Inhibitor: Bortezomib has what as a major side effect?

Back 42

Peripheral neuropathy

Front 43

Chemotherapeutic drugs for patients who are not candidates for autologous stem cell transplant?

Back 43

Oral Melphalan and Prednisone in combination with either Thalidomide or Bortezomib

Front 44

What are additional treatments for multiple myeloma?

Back 44

Bone Pain/Osteoporosis
Analgesics and/or radiation therapy
Calcium and Vitamin D

Anemia
May respond with chemotherapy
Erythropoietin (EPO)
Plasmapheresis if hyperviscosity develops

Hypercalcemia
IV Bisphosphonates

Renal Impairment
Hydration, maintain urine output >2000ml/d

Front 45

What is the prognosis of multiple myeloma?

Back 45

The disease itself is incurable
Remission is possible
Relapse is inevitable
Patients usually die from complications: renal failure, infections, hemorrhage

Front 46

The drug oral melphalan is a chemotherapeutic agent used for patients who are not candidates for autologous stem cell transplant. What are patients on this drug at risk of?

Back 46

Leukemia

Front 47

When giving analgesics for bone paint in multiple myeloma what is best to avoid?

Back 47

NSAIDS, best to use tylenol.