Multiple myeloma is a malignant plasma cell disorder that commonly affects elderly individuals over 40 years of age. It involves the proliferation of plasma cells in the bone marrow, which causes osteoporosis and lytic bone lesions. Patients typically present with back pain from vertebral fractures or pathological rib fractures, along with weakness, weight loss, and renal failure in later stages. Diagnosis involves blood and urine tests showing abnormalities in calcium, globulin, and immunoglobulin levels along with bone marrow biopsy demonstrating plasma cell infiltration. Treatment focuses on pain management, chemotherapy including melphalan, and managing complications such as fractures and renal failure. Prognosis is poor with most patients surviving less than 3 years.

1. MULTIPLE MYELOMA
PRITHWIRAJ MAITI
FINAL YEAR MBBS
R.G.KAR MEDICAL COLLEGE
5.3.2014

2. Introduction
• It is the most common primary malignant
bone tumor.
• Age: It is seen primarily in elderly, in people of
>40 years.
• Male gender affected more than female.
• Bones affected: Flat bones (Pelvis, vertebrae,
skull, ribs).

3. Pathogenesis
• Multiple myeloma is a B cell lymphoproliferative disorder with plasma cell
predominant.
• There is extensive proliferation of marrow
cells.
• There is increased osteoclastic activity,
resulting in osteoporosis and discrete lytic
lesions.

4. Clinical features
• Multiple myeloma usually follows a chronic course.
• Initially the disease is silent, after which the patient
presents with pain on lumber and thoracic spine (back
pain), which is progressively increasing in severity.
• Sometimes patient presents with pathological fractures
of vertebra and ribs, where acute presentation (pain,
redness, swelling etc) is observed.
• Weakness (due to anemia).
• Loss of weight.
• Local bone tenderness.
• Neurological symptoms (from compression of spinal
cord/ nerve root) may also be seen.

5. Other associated features
• Hypercalcemia (due to osteoclastic activity):
Thirst,
Polyuria,
Abdominal pain.
• Acute/ chronic renal failure.
• Chronic nephritis.
• Recurrent infection.

6. Pathology
•
•
•
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Soft and crumbly in consistency.
Dark red in colour.
Usually located in medulla.
Cortex overlying the tumor is thin and broken.

7. Microscopy
• Closely packed round cells.
• Eccentric nucleus and nucleolus.
• Chromatin: “Spokes of wheel” appearance.

9. Radiology
• Multiple punched out lesion in skull and other
bones.
• Pathological wedge collapse in vertebrae
(Pedicle sign).
• Erosion of borders of ribs.

11. Relevant investigations
• Blood:
Severe anemia,
Very high ESR,
High total serum protein,
High serum calcium level,
Reversal of Albumin: Globulin ratio (normal
1.7:1),
Normal Alkaline Phosphatase level. (MCQ)

12. • Urine: Bence-Jones proteinuria (Ig light chain).
• Serum electrophoresis: M band. (γ-globulin).
• Sternal puncture: Myeloma cell.

14. Other investigations
• Bone biopsy (CT guided: from iliac crest).
• Bone scan.
• Open biopsy.

15. TREATMENT
•
•
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GENERAL MEASURES
Control of pain.
Supportive treatment: Fluid-electrolyte
balance.
Limb fracture: Plaster/ splint/ surgery.
Vertebral fracture: Bracing/ surgery.

16. RADIOTHERAPY
• It is applied only in cases of solitary
plasmacytoma.

17. •
•
•
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CHEMOTHERAPY
Melphalan is the drug of choice (MCQ).
Melphalan is an alkylating agent. It sticks to
one of the cancer cell's DNA strands and stops
replication.
It is often used concurrently with Vincristine/
Prednisolone/ Cyclophosphamide.
6-12 cycles of chemotherapy are given; the
duration between two cycles being 3-4 weeks.

18. Prognosis
• Multiple myeloma is a widespread disease and
fatal.
• Death occurs in the majority of patients within
3 years and in all patients within 5 years.

19. Complications of Multiple myeloma
• Pathological fractures.
• Spinal cord compression and neurological
complications.
• Anemia/ leucopenia/ thrombocytopenia.
• Severe infections.
• Renal failure.
• Amyloidosis.