Multiple Myeloma

Overview of Multiple Myeloma in India

Multiple myeloma is a cancer that affects the bone marrow. In this disease, the white blood cells known as plasma cells multiply without control. While healthy white blood cells help create antibodies that fight harmful antigens in our bodies, in multiple myeloma, the excess white blood cells generate antibodies uncontrollably, which may destroy healthy cells in the bone marrow. The abnormal antibodies that are created will begin to aggregate in the body, causing damage to various organs. 

For example, the abnormal proteins made in the bone marrow can damage the kidney. At times, multiple myeloma will not progress aggressively and doctors sometimes encourage a wait and see approach before initiating treatment. During this waiting time, the cancer cells would be monitored closely and will be looking at how the myeloma is behaving. If myeloma were to not be treated when necessary, it has the potential to create many complications including infections, bone problems, kidney problems, and blood cell problems.

The state of the patient, the disease's stage, and the patient's reaction to treatment all influence the prognosis of multiple myeloma.  A combination of treatments can be administered to a patient with advanced multiple myeloma to improve the cancer's responsiveness to treatment.

What Is Multiple Myeloma?

Healthy bone marrow with healthy plasma cells, and bone marrow with multiple myeloma with abnormal plasma cells.

Multiple myeloma is a rare form of blood cancer that affects your plasma cells. Plasma cells are a type of white blood cell that make antibodies to help your body fight off infection. However, in multiple myeloma, plasma cells develop defects and grow in your bone marrow. Bone marrow is tissue inside the bones that make blood cells. The abnormal plasma cells produce abnormal proteins called M proteins.

The cancerous plasma cells can crowd out your normal bone marrow cells. This can result in an inability for your bone marrow to make healthy red blood cells. This will lead to a condition called anemia. The abnormal plasma cells can also damage your bones and kidneys.

Healthcare providers cannot cure multiple myeloma. However, they can help treat the symptoms and associated conditions that it can cause. Often they can slow down its progression which can allow you to live a longer life.

Multiple myeloma can result in diverse complications that may adversely affect a patient's quality of life and durability. Examples of complications are:

Infections: The disease's impact on the immune system makes patients with multiple myeloma more susceptible to various infections.

Bone problems: Multiple myeloma can cause multiple bone issues, including bone pain, osteoporosis, or weakened bones, and high risk of fracture. These complications happen because the disease disrupts normal bone remodelling, resulting in more fragile bones.

Kidney issues: When monoclonal proteins (or M proteins) accumulate in the kidneys, they can cause issue including kidney failure. This occurs when the extreme amounts of protein produced by the myeloma cells exceed the kidneys' ability to filter and remove them, resulting in damaged kidneys and impaired function. 

Anaemia: Multiple myeloma can also cause anaemia, where the body does not have enough healthy red blood cells to carry enough oxygen to the tissues. Anaemia can cause fatigue, weakness, pale skin, and shortness of breath.

High calcium: Bone break down releases calcium in the blood stream, causing high blood levels of calcium in the body (hypercalcaemia). High calcium can cause symptoms of excessive thirst, frequent urination, constipation, nauseous feelings, and mental confusion.

Types of Multiple Myeloma:

Multiple myeloma can be classified into different types, with distinctions based on disease characterization and specific genetic abnormalities. The types are as follows: 

Light chain myeloma: Also called light chain amyloidosis. Light chain myeloma is characterised by the production of light chain proteins that may build up in organs and cause damage. Detection and treatment early is important in preventing irreversible pathologic organ dysfunction. 

Non-secretory myeloma: This rare form of multiple myeloma is difficult to diagnose, as myeloma cells do not secrete measurable amounts of monoclonal immunoglobulin in the blood or urine. Diagnosis of this subtype depends on findings from a biopsy. 

Solitary plasmacytoma: Solitary plasmacytoma is a single tumour consisting of plasma cells. Solitary plasmacytoma may develop in bone (osseous) or outside of bone (extramedullary). Unlike multiple myeloma, solitary plasmacytoma is localised and has a potentially better prognosis with treatment options such as radiation therapy or surgery.

Extramedullary plasmacytoma: Extramedullary plasmacytoma is a solitary plasmacytoma that occurs outside the bone marrow, commonly in regions of the head and neck. This is an independent entity that has implications for treatment distinct from those of multiple myeloma.

Monoclonal gammopathy of undetermined significance (MGUS): MGUS is a precursor to multiple myeloma, defined by the presence of monoclonal immunoglobulin in the bloodstream in the absence of clinical evidence of multiple myeloma. MGUS itself is not considered a type of myeloma, however, it has a small risk of progressing to multiple myeloma.

Smouldering multiple myeloma (SMM): SMM can be defined as an asymptomatic form of multiple myeloma, in which patients have a higher level of monoclonal immunoglobulin in the blood than in MGUS and more likely an increased number of plasma cells in the bone marrow. SMM is characterized by a higher risk of progression to active multiple myeloma than MGUS.

Immunoglobulin D (IgD) myeloma: IgD myeloma is a rare form of myeloma that typically produces monoclonal immunoglobulin of the IgD type. It is not uncommon for IgD myeloma to present with a more advanced form of disease and have a more aggressive course than other subtypes of myeloma.

Immunoglobulin E (IgE) myeloma: IgE myeloma, a rare type of myeloma, produces IgE monoclonal immunoglobulin. Due to its rarity, the clinical features and prognosis of IgE myeloma are not well described or understood.

Procedure:

There are various treatments options for multiple myeloma. These treatment options include:

Chemotherapy

The chemotherapy drugs are used to kill or limit the growth of cancer cells. For multiple myeloma, doctors give different chemotherapy drugs at the same time to achieve a better response. Some of these chemotherapy drugs are:

• Bortezomib  
• Lenalidomide 
• Cyclophosphamide 

Target Drug Therapy

The target drugs are used to limit the nutrition of cancer cells by attacking their environment where the cancer cells grow. Some of these target drugs are:

• Bortezomib
• Carfilzomib
• Ixazomib

Immunotherapy

This approach uses the body's natural defense against the tumor cell sinden growth. Some common drugs used for multiple myeloma are:

• Daratumumab
• Elotuzumab
• Isatuximab

Stem Cell Transplantation

Healthy stem cells either collected from the patient or a donor are infused to replenish the bone marrow and facilitate the production of healthy blood cells. This approach is generally delivered after the cancer cells have been removed following other therapies.

Radiation Therapy

Radiation therapy use high-energy rays to destroy any remaining cancer cells. It can be given to ease bone pain or treat specific areas of bone destruction by multiple myeloma.

Supportive Care

Supportive care treatment is given when the cancer is in its final stages and the treatment is aimed at enhancing quality of life. This can include pain management, antibiotics for infections, medications to enhance bone strength, and blood transfusions.