Multiple myeloma

Myeloma is a cancer of plasma cells found in the bone marrow. Multiple myeloma is one of several types of blood and marrow cancer that UCHealth specialists can treat with proven procedures and advanced technology.

Five-year multiple myeloma cancer survival rates

Chart comparing all stages Multiple myeloma Cancer UCHealth 54.3% survival rate to Colorado state average of 51.0%

Number of Patients Diagnosed – UCHealth 232 – State of Colorado – 1,257
Number of Patients Surviving – UCHealth 125 – State of Colorado – 641
*n<30, 5 Year Survival – (Date of diagnosis 1/1/2010–12/31/2014)

Overview

Your bone marrow produces many types of cells, including plasma cells, that in turn produce antibodies to help your immune system fight infections.

Myeloma occurs when healthy plasma cells become abnormal plasma cells and grow out of control. This suppresses the growth of normal plasma cells, red blood cells, white blood cells and platelets in the marrow. Myeloma also causes structural bone damage, which can lead to fractures or breaks over time.

Myeloma is usually called multiple myeloma because 90% of patients have multiple bone lesions when diagnosed or over the course of the illness. We do not fully understand what causes myeloma, and there are no known ways to prevent it.

Other plasma cell disorders

There are other plasma cell disorders that also have abnormal plasma cells but do not meet the criteria to be called active multiple myeloma. These include:

Extramedullary plasmacytoma is myeloma that started outside the bone marrow in the lymph glands, sinuses, throat, liver, digestive tract or under the skin.

Light chain amyloidosis, AL or primary amyloidosis. A disorder of abnormal plasma cell growth, but with lower amounts of abnormal plasma cells in the bone marrow compared to multiple myeloma. Antibodies are made up of joined protein chains, two short light chains and two longer heavy chains. In light chain amyloidosis, abnormal plasma cells make too many light chains which are shorter and weigh less than the heavy chains. The light chains build up in tissues as an abnormal protein known as amyloid, which can enlarge certain organs and adversely affect their performance.

Man stretching on track

Monoclonal gammopathy of undetermined significance (MGUS). Like regular plasma cells, myeloma cells can produce antibodies, but they are not healthy, functioning antibodies. Instead, they make monoclonal protein (M protein), which is a non-functional antibody. By definition, this is the only abnormality seen; MGUS has no other impact on organ function, but does have a risk of progressing to multiple myeloma of approximately 1% / year. Usually, patients with MGUS only require periodic monitoring in the clinic without treatment.

Smoldering multiple myeloma (SMM). An early or asymptomatic myeloma that isn’t causing problems with internal organs or bones. Many people with SMM do not need treatment right away, but because it can become active in months to years, we watch them closely for signs of myeloma.

Solitary plasmacytoma is a mass of myeloma cells that involves only one site in the bone, or other organs such as in the upper respiratory tract, including the nose and throat or gastrointestinal systems. Solitary plasmacytomas are usually treated with radiation alone, but monitoring is required afterwards due to a risk of recurrence and developing multiple myeloma.

Waldenstrom macroglobulinemia (WM). The cancer cells in people with WM combine features of both multiple myeloma and non-Hodgkin lymphoma (NHL). WM can present as enlargement of the spleen, liver, or lymph nodes. The WM cells characteristically produce an IgM-type M-protein which can be followed for response to therapy.

Symptoms and risk factors

Symptoms

Multiple myeloma typically results in these signs and symptoms:

  • Anemia. A low level of red blood cells.
  • Fatigue.
  • Bone pain and fractures. The back or ribs are the most common sites, but any bone can be affected. In advanced multiple myeloma, a patient may lose inches in height from compressed vertebrae over time.
  • Hypercalcemia. A high level of calcium in the blood that can arise as a result of bone breakdown. It can cause drowsiness, constipation, and kidney damage.
  • Fever and infections. A result of the suppressed immune system.
  • Kidney failure. The M-protein builds up in the blood and can clog the outflow of the kidneys. M-protein can produce a frothy or foamy appearance of the urine.

Causes and risk factors

We do not fully understand the cause of myeloma. The changes in plasma cells are acquired, not inherited, but research shows a slight increase in the incidence of disease in parents or siblings of people with multiple myeloma. There are weak associations between exposure to radiation, pesticides, and processed wood used in carpentry and development of myeloma.

These risks may increase the chances of developing myeloma:

  • Age. Age is the greatest risk factor for MM. Myeloma occurs most commonly in people over 60, and the average age at diagnosis is 70.
  • Race. Myeloma occurs twice as frequently in black people than in white people.
  • Exposure to radiation or chemicals. Asbestos, benzene, pesticides, and chemicals used in rubber manufacturing and wood products may cause myeloma. Firefighters and those exposed to herbicides have a higher rate of myeloma.
  • Personal history of MGUS.
  • Gender. More common in men.

Diagnosis and staging

Diagnosis

We use these tests to properly diagnose multiple myeloma:

  • Blood and urine tests. Myeloma cells often secrete an antibody called monoclonal immunoglobulin, or M protein. We measure the M protein levels in your blood and urine to determine the extent of the disease and to monitor treatment. Sometimes we measure a fragment of the M-protein called serum free light chain if the MM cells do not make intact immunoglobulin. Light chains in the urine is also called Bence Jones Protein.
  • X-ray. Typically a first step in evaluating your bones. The radiologist is looking for areas of bone loss, called “lytic lesions” that indicate MM involvement.
  • Magnetic resonance imaging (MRI). Can show if normal bone marrow has been replaced by myeloma cells or by a plasmacytoma (plasma cell tumor), especially in the skull, spine, and pelvis.
  • Computed tomography scan (CT or CAT). Creates a detailed, cross-sectional view that shows any abnormalities or tumors in soft tissues.

  • Positron emission tomography scan (PET or PET-CT). A way to create pictures of organs and tissues inside your body based on their metabolism. Cancer cells have more metabolic activity that stand out on the PET-CT scan wherever they may be in the body.
  • Bone marrow aspiration and biopsy. Often done at the same time to examine the bone marrow. A bone marrow aspiration uses a needle to remove a sample of the liquid marrow. A bone marrow biopsy uses a needle to remove a small amount of solid marrow tissue using a needle.
  • Fat pad aspirate. If amyloidosis is suspected, then we may take a sample of the collection of fat using a fine superficial needle around a person’s abdomen to be biopsied.
  • Molecular testing of the tumor. Results of these tests can help determine your treatment options.

Staging

UCHealth uses the Revised International Staging System (RISS) to classify multiple myeloma, which is based on patients from around the world. It defines the factors that influence patient survival.

The system has three stages based on four factors:

  • The amount of albumin in the blood.
  • The amount of beta-2-microglobulin in the blood.
  • The amount of a chemical called lactate dehydrogenase in the blood.
  • The specific DNA abnormalities (cytogenetics) of the cancer.

Stage I. Serum beta-2 microglobulin is less than 3.5 (mg/L), albumin level is 3.5 (g/dL) or greater, cytogenetics are considered not high risk, and LDH levels are normal.
Stage II. Not stage I or stage III.
Stage III. Serum beta-2 microglobulin is 5.5 (mg/L) or greater, cytogenetics are considered high-risk, and/or LDH levels are high

Recent efforts have been made to further classify myeloma based on patterns of gene expression in myeloma cells.

Treatment and recovery

Your personalized treatment plan for multiple myeloma will be determined by our multidisciplinary team working with you to decide the best approaches. This includes both treatment to control the disease as well as supportive therapy to improve your quality of life.

A typical plan includes drug therapy, such as targeted therapy and/or chemotherapy, with or without steroids. You may also need stem cell transplantation or other types of treatments, such as radiation therapy and surgery.

Possible treatments include:

Chemotherapy. Drugs that destroy cancer cells, usually by stopping the cancer cells’ ability to grow and divide. We often use more than one drug at a time for maximum results.

Targeted therapy or novel therapy. Drugs that target the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. In recent years, targeted therapy has proven to be increasingly successful at controlling myeloma and improving a prognosis.

Immunotherapy or biologic therapy. Uses materials made either by the body or in a laboratory to improve, target, or restore immune system function.

Other drug therapy. We may give anti-inflammatory steroids alone or at the same time as targeted therapy or chemotherapy.

Bone modifying drugs. We treat most of our multiple myeloma patients with bone modifying drugs that help strengthen the bone and reduce bone pain and the risk of fractures. Drugs in this class include bisphosphonates.

Bone marrow transplantation or stem cell transplantation. A medical procedure in which bone marrow that contains cancer is replaced by highly specialized cells, called hematopoietic stem cells, that develop into healthy red blood cells, white blood cells, and platelets in the bone marrow. Most stem cell transplants in multiple myeloma utilize the patient’s own (autologous) cells, rather than from a donor (allogeneic), resulting in elimination of graft vs host disease risk.

Radiation therapy. High-energy X-rays or other particles that destroy cancer cells.

Surgery. We might use surgery to treat bone disease, especially if there are fractures, and recent plasmacytomas, especially if they occur outside the bone.

Questions and answers (FAQs)

The 5-year median survival rate depends on the stage:

Stage I: has not been reached.
Stage II: 83 months
Stage III: 43 months.

Source: National Cancer Institute

Myeloma is not considered to be a curable malignancy, since relapses can still occur after many years of remission. However, myeloma can be controlled for long periods of time, akin to hypertension or diabetes.