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Multiple myeloma is a very complex disease. Getting an accurate diagnosis is often not easy, and the treatment proposed can vary widely. Patients often seek help from family doctors, orthopedists, surgeons, traumatologists, rheumatologists, internists, nephrologists, to finally reach hematologists, where a diagnosis is often made after many months of delay. This situation can cause a feeling of confusion in the patient, especially if the disease is detected after a long time.
Multiple myeloma (plasmacytoma) accounts for about 1% of all cancers and about 10-15% of hematological cancers. Observations from recent years indicate that the incidence of multiple myeloma is definitely increasing, and we also find patients more and more often among people under 55 years of age. Patients with symptomatic form of multiple myeloma are usually in the second or third stage of disease advancement.
Multiple myeloma – symptoms
In laboratory tests in patients with myeloma, we find elevated levels of total protein in the serum as well as elevated levels of calcium and lowered hemoglobin levels. Patients complain of weakness, fatigue, bone pain, peripheral edema, more frequent infections, constipation and cardiac arrhythmias may appear. If bone damage is not a problem, symptoms may be minor and the disease may go undiagnosed. Fatigue, prolonged recovery times, and pain in the lumbar region are common and can be caused by many factors. The diagnosis may be accidental, e.g. on the occasion of increased protein concentration in the blood or urine, or elevated, most often three-digit ESR during periodic tests.
Multiple myeloma is a disseminated hematological neoplasm formed from plasma cells. Plasmocytes are normal bone marrow cells (about 5%) that produce antibodies. In sick people, the number of neoplastic myeloma cells in the bone marrow exceeds 10%. During the course of the disease, changes in the bone marrow are disseminated. The course of the disease varies greatly from person to person due to differences in: the extent of the changes in the bone marrow, the location of the changes (e.g. bones in the spine, pelvis, upper or lower limbs), and the activity of myeloma cells.
We do not know of any single factor that caused the disease. However, it is known that: multiple myeloma is extremely rare in children, adolescents and young adults. In adults, the incidence of multiple myeloma increases with age.
Multiple myeloma – causes
The highest incidence occurs in the sixth and seventh decades of life. The disease may be the result of: reduced effectiveness of the immune system, accumulation of environmental factors, age-related changes in the body (e.g. hormonal). Multiple myeloma is more common among men. As above, the reasons for this remain unexplained, possibly due to hormonal differences and to environmental exposure at work. It seems that some of the occupations, as well as exposure to chemical agents (e.g. dioxins, solvents, cleaning agents) and radiation, may be the cause of multiple myeloma in predisposed individuals. The enormous variety of environmental factors and genetics makes it impossible to accurately establish in this respect. Although there is a higher incidence of multiple myeloma in some families (3-5%), it is unlikely to happen. Currently, no genetic tests are available to detect such predisposition. Infections, especially viral ones, were considered a potential cause of the disease. Some studies have linked the disease to HIV, hepatitis, herpes (HHV-8), EBV, and emerging viruses such as mutant cytomegalovirus (CMV). The importance of these infections, however, is still under research. Multiple myeloma is most likely caused by several different factors in a person.
If multiple myeloma is suspected, a series of tests should be performed to establish the final diagnosis, determine the activity and stage of the disease:
1. Bone marrow biopsy – special tests are also performed to determine the prognosis of the disease (cytogenetic, immunological, amyloid detection), as a single test it allows to determine the percentage of cancer cells in the bone marrow. In the first stage of disease advancement and when plasmacytoma is diagnosed, direct tumor biopsy is performed. On the basis of cytogenetic tests (chromosomal analysis) the presence of good and poor prognosis parameters can be ascertained.
2. Blood tests: blood count, biochemical tests, blood protein tests allow the assessment of the severity of anemia, the assessment of the number of leukocytes and the assessment of the number of platelets.
3. It is extremely important to test urine to assess kidney function. Serum is tested for creatinine, urea, uric acid and calcium levels, and for lactate dehydrogenase (LDH) activity, and for the presence, type and amount of monoclonal protein in the urine.
4. Bone examinations: radiological (X-ray), magnetic resonance imaging (NMR), computed tomography (CT) allow the assessment of the presence, advancement and location of bone defects. X-ray still remains the “gold standard” in looking for bone damage. A complete skeleton examination is necessary to demonstrate osteoporosis, osteopenia, lytic lesions and fractures.
Multiple Myeloma – Treatment
Although at present multiple myeloma remains an incurable disease, there are many treatments. Often, for many years after cancer diagnosis, patients can lead a normal life. The constant progress and development of medicine contributes to the improvement of the prognosis in this disease. Knowing and understanding the principles of multiple myeloma therapy helps reduce anxiety and learn to live with the disease. The decision to start treatment is very important once the disease has been diagnosed. It is extremely important to perform basic examinations earlier, to determine the stage of the disease and prognosis. Treatment is recommended in patients with a symptomatic form of the disease. The intensity of therapy depends on the patient’s symptoms. If one of the proposed treatments has failed, it does not mean that the other will not be more effective and will not lead to remission of the disease – this is very important and it should be remembered!
Currently, the gold standard is dexamethasone therapy with thalidomide and cyclophosphamide in younger patients. A method known for many years and often used is chemotherapy: melphalan, prednisone, thalidomide. Oral form of therapy leads to disease remission in about 60-70% of patients. Of course, chemotherapy has side effects: it can damage stem cells, which reduces the chances of a bone marrow transplant later. Improvement is slow, over many months.
There are methods available to alleviate the physical and emotional impact of the disease on a person’s life after cancer diagnosis. Applying these approaches early is as important as treating the underlying disease. Anemia-related fatigue and weakness can be relieved by blood transfusions (concentrated red blood cells) in severe anemia, erythropoietin preparations in milder anemia. Combating bone pain is extremely important in itself, as well as for maintaining physical activity that strengthens the bones and improves the mood and general condition of the patient.
Fever and / or symptoms of infection are treated with appropriate antibiotic therapy – antibiotics should be selected and used with caution, and it is extremely important to control the symptoms of infections quickly. It is recommended that the patient be in possession of an antibiotic that can be used quickly in an emergency. In severe cases, blood cultures and other microbiological tests are necessary for an accurate diagnosis of the infection. Administration of G-CSF growth factors if an increase in the number of leukocytes is indicated, and intravenous administration of immunoglobulins in case of severe infections.
In addition to managing specific symptoms, many other supportive treatments are important. You should check with your doctor if there are any restrictions on physical activity (such as bone damage) that you should maintain. Usually, you can choose the optimal exercises for a given patient, e.g. walking, swimming, stretching and strengthening treatments, yoga. There is no specific diet for people with multiple myeloma. Research on this important issue is currently underway. In general, general recommendations for healthy eating should be followed, as well as recommendations resulting from the coexistence of other diseases (e.g. cardiovascular). Maintaining a good mental state is extremely important throughout the treatment process. Know exactly what your plan is and what might happen. Regular sleep is extremely important for the smooth functioning of the immune system. Adapting everyday life and reducing the stress related to work, family and social situation to a minimum. Treatment of multiple myeloma is paramount, at least until good remission and a stable situation are achieved, i.e. the disease plateaued.
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