eMedicine Specialties > Hematology > Plasma Cell Disorders

Multiple Myeloma

Author: Sara J Grethlein, MD, Associate Dean for Graduate Medical Education, Associate Professor, Department of Internal Medicine, Division of Hematology and Oncology, State University of New York Upstate Medical University
Coauthor(s): Lilian M Thomas, MD, Fellow, Department of Hematology/Oncology, State University of New York Upstate Medical University
Contributor Information and Disclosures

Updated: Aug 12, 2009

Introduction

Background

Multiple myeloma is a debilitating malignancy that is part of a spectrum of diseases ranging from monoclonal gammopathy of unknown significance (MGUS) to plasma cell leukemia. First described in 1848, multiple myeloma is a disease characterized by a proliferation of malignant plasma cells and a subsequent overabundance of monoclonal paraprotein. An intriguing feature of multiple myeloma is that the antibody-forming cells (ie, plasma cells) are malignant and, therefore, may cause unusual manifestations.


Bone marrow aspirate demonstrating plasma cells o...

Bone marrow aspirate demonstrating plasma cells of multiple myeloma. Note the blue cytoplasm, eccentric nucleus, and perinuclear pale zone (or halo). All images and text are (c) 2002 by the American Society of Hematology. All rights reserved.

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Bone marrow aspirate demonstrating plasma cells o...

Bone marrow aspirate demonstrating plasma cells of multiple myeloma. Note the blue cytoplasm, eccentric nucleus, and perinuclear pale zone (or halo). All images and text are (c) 2002 by the American Society of Hematology. All rights reserved.


Bone marrow biopsy demonstrating sheets of malign...

Bone marrow biopsy demonstrating sheets of malignant plasma cells in multiple myeloma. All images and text are (c) 2002 by the American Society of Hematology. All rights reserved.

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Bone marrow biopsy demonstrating sheets of malign...

Bone marrow biopsy demonstrating sheets of malignant plasma cells in multiple myeloma. All images and text are (c) 2002 by the American Society of Hematology. All rights reserved.


The presentation of multiple myeloma can range from asymptomatic to severely symptomatic with complications requiring emergent treatment. Systemic ailments include bleeding, infection and renal failure; local catastrophes include pathologic fractures and spinal cord compression. Although patients benefit from treatment (ie, longer life, less pain, fewer complications), currently no cure exists. Recent advances in therapy have helped to lessen the occurrence and severity of adverse effects of multiple myeloma.

For excellent patient education resources, visit eMedicine's Blood and Lymphatic System Center. Also, see eMedicine's patient education article Myeloma.

Pathophysiology

Multiple myeloma can cause a wide variety of problems. The proliferation of plasma cells may interfere with the normal production of blood cells, resulting in leukopenia, anemia, and thrombocytopenia. The cells may cause soft-tissue masses (plasmacytomas) or lytic lesions in the skeleton. Feared complications of multiple myeloma are bone pain, hypercalcemia, renal failure, and spinal cord compression. The aberrant antibodies that are produced lead to impaired humoral immunity, and patients have a high prevalence of infection, especially with encapsulated organisms such as Pneumococcus. The overproduction of these antibodies may lead to hyperviscosity, amyloidosis, and renal failure.

Frequency

United States

The age-adjusted annual incidence of multiple myeloma is 4.3 cases per 100,000 white men, 3 cases per 100,000 white women, 9.6 cases per 100,000 black men, and 6.7 cases per 100,000 black women.

Mortality/Morbidity

  • Multiple myeloma affects the kidneys in several ways. The most common mechanisms of renal injury are direct tubular injury, amyloidosis, or involvement by plasmacytoma.1,2 Physicians manage the acute clinical condition with plasmapheresis to rapidly lower circulating abnormal proteins. Data about this approach are limited, but a small randomized study showed a survival advantage with the use of apheresis.2 Conventional therapy may take weeks to months to show a benefit. Renal impairment resulting from multiple myeloma is associated with a very poor prognosis. A recent case series demonstrated that patients with renal failure from myeloma may benefit from autologous stem cell transplants, and as many as one third may demonstrate improvement in their renal function with this approach.3
  • Spinal cord compression is one of the most severe adverse effects of multiple myeloma. Reports indicate that as many as 20% of patients develop spinal cord compression at some point during the course of their disease. Symptoms typically include back pain, weakness or paralysis in the legs, numbness, or dysesthesias in the lower extremities. However, depending on the level of involvement, patients may present with upper extremity symptoms. The mechanism of these symptoms may be the development of an epidural mass with compression, a compression fracture of a vertebral body destroyed by multiple myeloma, or, rarely, an extradural mass. The dysfunction may be reversible, depending on the duration of the cord compression; however, once established, the dysfunction is only rarely fully reversed.
  • A frequent complication of multiple myeloma is pathologic fractures. Bony involvement is typically lytic in nature. Physicians should orthopedically stabilize (ie, typically pin) and irradiate these lesions. Careful attention to a patient's bony symptoms, intermittent radiographic surveys, and the use of bisphosphonates may be useful to prevent fractures.4,5,6
  • Patients with multiple myeloma commonly develop hypercalcemia. The mechanisms include bony involvement and, possibly, humoral mechanisms. Treatment for myeloma-induced hypercalcemia is the same as that for other malignancy-associated hypercalcemia; however, the dismal outcome observed with hypercalcemia in solid tumors is not observed in multiple myeloma.

Race

Multiple myeloma accounts for 1.1% of the malignancies in white US residents and 2.1% of the malignancies in black residents.

Sex

The male-to-female ratio of multiple myeloma is 3:2.

Age

The median age of patients with multiple myeloma is 68 years for men and 70 years for women.

Clinical

History

Presenting symptoms of multiple myeloma include bone pain, pathologic fractures, weakness, anemia, infection (often pneumococcal), hypercalcemia, spinal cord compression, or renal failure. Increasingly, physicians are identifying asymptomatic patients through routine blood screening. Typically, a large gap between the total protein and the albumin levels observed on an automated chemistry panel suggests a problem (ie, protein minus albumin equals globulin).

  • Bone pain
    • This is the most common presenting symptom in multiple myeloma. Most case series report that 70% of patients have bone pain at presentation.
    • The lumbar spine is one of the most common sites of pain.
  • Pathologic fractures and bone lesions
    • Pathologic fractures are very common in multiple myeloma; 93% of patients have more than one site of bony involvement.
    • A severe bony event is a common presenting issue.
  • Spinal cord compression
    • This complication occurs in approximately 10-20% of patients with multiple myeloma at some time during the course of disease.
    • The symptoms that should alert physicians to consider spinal cord compression are back pain, weakness, numbness, or dysesthesias in the extremities.
    • It is common for spinal cord compressions in multiple myeloma to occur at multiple levels, so comprehensive evaluation of the spine is warranted.
    • Patients who are ambulatory at the start of therapy have the best likelihood of preserving function and avoiding paralysis.
  • Bleeding
    • Occasionally, a patient may come to medical attention for bleeding resulting from thrombocytopenia.
    • Rarely, monoclonal protein may absorb clotting factors and lead to bleeding.
  • Hypercalcemia
    • Confusion, somnolence, bone pain, constipation, nausea, and thirst are the presenting symptoms of hypercalcemia.
    • This complication may be present in as many as 30% of patients with multiple myeloma at presentation. In most solid malignancies, hypercalcemia carries an ominous prognosis, but in multiple myeloma, its occurrence does not adversely affect survival.
  • Infection
    • Abnormal humoral immunity and leukopenia may lead to infection.
    • Pneumococcal organisms are commonly involved, but shingles (ie, herpes zoster) and Haemophilus infections are also more common among patients with multiple myeloma.
  • Hyperviscosity
    • Epistaxis may be a presenting symptom of multiple myeloma with a high tumor volume. Occasionally, patients may have such a high volume of monoclonal protein that their blood viscosity increases, resulting in complications such as stroke, myocardial ischemia, or infarction.
    • Patients may report headaches and somnolence, and they may bruise easily and have hazy vision. Patients with multiple myeloma typically experience these symptoms when their serum viscosity is greater than 4 times that of normal serum.
  • Neurologic symptoms
    • Carpal tunnel syndrome is a common complication of myeloma.
    • Meningitis (especially that resulting from pneumococcal or meningococcal infection) is more common in patients with multiple myeloma.
    • Some peripheral neuropathies have been attributed to multiple myeloma.
  • Anemia
    • Anemia, which may be quite severe, is the most common cause of weakness in patients with multiple myeloma.

Physical

  • Pallor from anemia may be present.
  • Ecchymoses or purpura from thrombocytopenia may be evident.
  • Bony tenderness is not uncommon in multiple myeloma, resulting from focal lytic destructive bone lesions or pathologic fracture. Pain without tenderness is typical.
  • Neurologic findings may include a sensory level change (ie, loss of sensation below a dermatome corresponding to a spinal cord compression), weakness, or carpal tunnel syndrome.
  • Extramedullary plasmacytomas, which consist of soft-tissue masses of plasma cells, are not uncommon. Plasmacytomas have been described in almost every site in the body. Although the aerodigestive tract is the most common location, reports also describe orbital, ear canal, cutaneous, gastric, rectal, prostatic, and retroperitoneal lesions.
  • Amyloidosis may develop in some patients with multiple myeloma. The characteristic physical examination findings that suggest amyloidosis include the following:
    • The shoulder pad sign is defined by bilateral swelling of the shoulder joints secondary to amyloid deposition. Physicians describe the swelling as hard and rubbery. Amyloidosis may also be associated with carpal tunnel syndrome and subcutaneous nodules.
    • Macroglossia is a common finding in patients with amyloidosis (see Image 1 or below).
      Amyloidosis infiltrating the tongue in multiple m...

      Amyloidosis infiltrating the tongue in multiple myeloma. All images and text are (c) 2002 by the American Society of Hematology. All rights reserved.

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      Amyloidosis infiltrating the tongue in multiple m...

      Amyloidosis infiltrating the tongue in multiple myeloma. All images and text are (c) 2002 by the American Society of Hematology. All rights reserved.

    • Skin lesions that have been described as waxy papules or nodules may occur on the torso, ears, or lips.
    • Postprotoscopic peripalpebral purpura strongly suggests amyloidosis. Patients may develop raccoonlike dark circles around their eyes following any procedure that parallels a prolonged Valsalva maneuver. The capillary fragility associated with amyloidosis may account for this observation. In the past, this correlation was observed when patients underwent rectal biopsies to make the diagnosis.
  • The most widely accepted schema for the diagnosis of multiple myeloma uses particular combinations of laboratory, imaging, and procedure findings as diagnostic criteria. The findings are as follows:
    • I = Plasmacytoma on tissue biopsy
    • II = Bone marrow with greater than 30% plasma cells
    • III = Monoclonal globulin spike on serum protein electrophoresis, with an immunoglobulin (Ig) G peak of greater than 3.5 g/dL or an IgA peak of greater than 2 g/dL, or urine protein electrophoresis (in the presence of amyloidosis) result of greater than 1 g/24 h
    • a = Bone marrow with 10-30% plasma cells
    • b = Monoclonal globulin spike present but less than category III
    • c = Lytic bone lesions
    • d = Residual IgM level less than 50 mg/dL, IgA level less than 100 mg/dL, or IgG level less than 600 mg/dL
  • The following combinations of findings are used to make the diagnosis of multiple myeloma:
    • I plus b, c, or d
    • II plus b, c, or d
    • III plus a, c, or d
    • a plus b plus c
    • a plus b plus d

Causes

  • Genetic causes
    • A study by the Mayo clinic found multiple myeloma in 8 siblings from a group of 440 patients; these 8 siblings had different heavy chains but the same light chains.
    • Ongoing research is investigating whether human leukocyte antigen (HLA)-Cw5 or HLA-Cw2 may play a role in the pathogenesis of multiple myeloma.
  • Environmental or occupational causes: Case-controlled studies have suggested a significant risk of developing multiple myeloma in individuals with significant exposures in the agriculture, food, and petrochemical industries. Long-term (>20 y) exposure to hair dyes has been tied to an excessive risk of developing multiple myeloma.
  • MGUS: Approximately 19% of patients with MGUS develop multiple myeloma within 2-19 years.
  • Radiation
    • Radiation has been linked to the development of multiple myeloma.
    • In 109,000 survivors of the atomic bombing of Nagasaki during World War II, 29 died from multiple myeloma between 1950 and 1976; however, some more recent studies do not confirm that these survivors have an increased risk of developing multiple myeloma.
    • A recent study of workers at the Oak Ridge Diffusion Plant in eastern Tennessee showed only a weak correlation of risk of multiple myeloma to uranium exposure.7

More on Multiple Myeloma

Overview: Multiple Myeloma
Differential Diagnoses & Workup: Multiple Myeloma
Treatment & Medication: Multiple Myeloma
Follow-up: Multiple Myeloma
Multimedia: Multiple Myeloma
References
Further Reading
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References

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Further Reading

Additional resources on asthma are available at Medscape’s Multiple Myelome Resource Center and Medscape’s Multiple Myeloma Resource Center CME.

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Keywords

multiple myeloma, myeloma, bone marrow malignancy, bone marrow cancer, myeloma multiple, plasma cell myeloma, Kahler's disease, Kahler disease, plasma cell dyscrasia, plasma cell leukemia, leukopenia, anemia, thrombocytopenia, bone pain, hypercalcemia, spinal cord compression, hyperviscosity, amyloidosis, renal failure, monoclonal gammopathy of unknown significance, MGUS,

M and P chemotherapy, leukemia, plasma cell leukemia, VAD chemotherapy, plasmacytoma, renal impairment, compression fracture of vertebral body, shingles, herpes zoster, Haemophilus infections, epistaxis, stroke, myocardial ischemia, myocardial infarction, carpal tunnel syndrome, meningitis, peripheral neuropathies, ecchymoses, purpura, macroglossia

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Contributor Information and Disclosures

Author

Sara J Grethlein, MD, Associate Dean for Graduate Medical Education, Associate Professor, Department of Internal Medicine, Division of Hematology and Oncology, State University of New York Upstate Medical University
Sara J Grethlein, MD is a member of the following medical societies: American Society of Hematology
Disclosure: Nothing to disclose.

Coauthor(s)

Lilian M Thomas, MD, Fellow, Department of Hematology/Oncology, State University of New York Upstate Medical University
Lilian M Thomas, MD is a member of the following medical societies: American College of Physicians and American Society of Clinical Oncology
Disclosure: Nothing to disclose.

Medical Editor

Koyamangalath Krishnan, MD, FRCP, FACP, Paul Dishner Endowed Chair of Excellence in Medicine, Professor of Medicine and Chief of Hematology-Oncology, Program Director, Hematology-Oncology Fellowship, James H Quillen College of Medicine at East Tennessee State University
Koyamangalath Krishnan, MD, FRCP, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, American Society of Hematology, and Royal College of Physicians
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Troy H Guthrie, Jr, MD, Director of Cancer Institute, Baptist Medical Center
Troy H Guthrie, Jr, MD is a member of the following medical societies: American Federation for Medical Research, American Medical Association, American Society of Hematology, Florida Medical Association, Medical Association of Georgia, and Southern Medical Association
Disclosure: Nothing to disclose.

CME Editor

Rajalaxmi McKenna, MD, FACP, Southwest Medical Consultants, SC, Department of Medicine, Good Samaritan Hospital, Advocate Health Systems
Rajalaxmi McKenna, MD, FACP is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology, and International Society on Thrombosis and Haemostasis
Disclosure: Nothing to disclose.

Chief Editor

Emmanuel C Besa, MD, Professor, Department of Medicine, Division of Hematologic Malignancies, Kimmel Cancer Center, Thomas Jefferson University
Emmanuel C Besa, MD is a member of the following medical societies: American Association for Cancer Education, American College of Clinical Pharmacology, American Federation for Medical Research, American Society of Hematology, and New York Academy of Sciences
Disclosure: Nothing to disclose.

 
 
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