Overview
The podcast features Dr. Edward Libby discussing the diagnosis and management of multiple myeloma, differentiating premalignant conditions, appropriate testing, treatment strategies, complications, and COVID-19 considerations for affected patients.
Typical Presentation and Initial Signs
- Anemia in adults, even if mild and progressive, should raise suspicion for multiple myeloma.
- Abnormal renal function is another early sign that warrants consideration of multiple myeloma.
- Persistent back pain in adults should prompt assessment for possible malignancy, especially multiple myeloma due to frequent skeletal involvement.
Distinguishing MGUS, Smoldering Myeloma, and Multiple Myeloma
- MGUS is a premalignant condition with <10% abnormal plasma cells in bone marrow and no end organ damage, progressing to myeloma at 1% per year.
- Smoldering multiple myeloma has ≥10% abnormal plasma cells, still without end organ damage, but carries a higher risk (10% per year) of progression.
- Multiple myeloma is characterized by ≥10% abnormal plasma cells and definitive end organ damage (anemia, hypercalcemia, renal dysfunction, or bone lesions).
Diagnostic Workup for Suspected Myeloma
- Order a complete blood count, metabolic panel (including calcium and renal function), serum protein electrophoresis, serum free light chain levels, and 24-hour urine protein electrophoresis.
- Imaging studies: targeted X-rays for bone pain, with hematology-oncology often coordinating full skeletal imaging.
- Serum free light chains are essential and can nearly replace 24-hour urine testing; missing this test risks underdiagnosing 15–20% of cases.
Referral to Hematology-Oncology
- Refer promptly when clinical suspicion arises or diagnostic workup suggests MGUS, smoldering, or overt myeloma.
- Early referral helps prevent severe complications like bone destruction and renal failure, which are often irreversible.
Treatment Paradigm for Multiple Myeloma
- Standard induction therapy is a triplet regimen: lenalidomide, bortezomib, and dexamethasone (RVD/VRD), typically for 4–6 months.
- Eligible patients then undergo autologous stem cell transplantation (using their own cells), which is better tolerated than allogeneic.
- Maintenance therapy (usually low-dose lenalidomide) follows transplantation for disease control with minimal impact on quality of life.
Complications of Disease and Therapy
- Disease complications: the “CRAB” features—hypercalcemia, renal dysfunction, anemia, and bone lesions/fractures.
- Therapy complications: bortezomib can cause neuropathy; prophylactic antivirals prevent shingles; lenalidomide increases risk of thrombosis, often mitigated by aspirin; and drug rashes are generally manageable.
COVID-19 Considerations in Myeloma Patients
- Assess degree of immunosuppression based on current therapy and disease control, not just diagnosis.
- Patients on maintenance therapy with minimal immunosuppressive agents generally have lower infection risk than those on combination or steroid-heavy regimens.
- Treatment and monitoring intensity should be individualized according to immunosuppression status.
Recommendations / Advice
- Include multiple myeloma in the differential diagnosis for adults with unexplained anemia, renal dysfunction, or persistent back pain.
- Ensure serum free light chain testing in the initial workup.
- Refer early to hematology-oncology to improve outcomes and prevent complications.
- Monitor for complications of both disease and therapy; provide prophylactic measures for infection and thrombosis where appropriate.
- Adjust COVID-19 management based on current treatment regimen and immunosuppression level.