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ORIGINAL ARTICLE |
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Year : 2014 | Volume
: 7
| Issue : 2 | Page : 185-188 |
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Clinical profile of the spectrum of multiple myeloma in a teaching hospital
Arundhati G Diwan1, Sushil A Gandhi2, Kavita Krishna1, Vineet P Shinde1
1 Department of Medicine, Bharati Vidyapeeth Medical College and Bharati Hospital, Pune, Maharashtra, India 2 Department of Medicine, Jehangir Hospital, Pune, Maharashtra, India
Date of Web Publication | 4-Feb-2014 |
Correspondence Address: Arundhati G Diwan Flat No. 16, "Laxmi Abhishek", Laxmi Park Colony, Navi Peth, Pune - 411 030, Maharashtra India
Source of Support: None, Conflict of Interest: None | Check |
DOI: 10.4103/0975-2870.126335
Aim: To analyze the clinical and laboratory features of multiple myeloma (MM). Settings and Design: A cross-sectional study of 20 newly diagnosed patients with MM over a period of 1 year in a tertiary health-care center. Materials and Methods: Based on Salmon-Durie criteria, newly diagnosed 20 patients of MM were selected for the study. Routine hematological and biochemical investigations, bone marrow examination, serum protein electrophoresis and urine for Bence Jones protein were done. Radiological investigations conducted to look for osteolytic lesions, extramedullary involvement and other pathologies. Results: Out of total 20 patients, 10 were males and 10 were females with sixth decade as the common age group at presentation. Common clinical symptoms were bone pains, localized body swelling, fever, generalized weakness and fatigue and motor weakness of lower limbs. Clinical examination revealed pallor in 80% patients, bony tenderness in 85% patients and 55% patients presented with infections. All patients had a presence of M band on serum protein electrophoresis, whereas 30% patients had urinary Bonce Jones protein positive. Among skeletal system spine and skull were the common sites of involvement 60% and 55%, respectively. Nearly, 85% patients had osteolytic lesions. Conclusions: Among 20 patients; various clinical presentations observed were infections, renal impairment, paraplegia and extramedullary plasmacytosis in addition to anemia and bony pains. Keywords: Lytic lesions, M band, multiple myeloma
How to cite this article: Diwan AG, Gandhi SA, Krishna K, Shinde VP. Clinical profile of the spectrum of multiple myeloma in a teaching hospital. Med J DY Patil Univ 2014;7:185-8 |
Introduction | | |
Multiple myeloma (MM) is a disorder caused by neoplastic proliferation of a clone of malignant plasma cells. The characteristic features include accumulation of monoclonal plasma cells in the bone marrow associated with monoclonal immunoglobulin (Ig) synthesis and osteolytic bone lesions. It comprises 13% of hematologic malignancies. MM is a disease of the elderly, with the peak age of 60-70 years at presentation. In spite of advances in treatment, MM remains to be a therapeutic challenge. Though most patients of MM are symptomatic at presentation needing prompt treatment, about 10-15% may remain asymptomatic in whom treatment may be delayed. Complications such as renal failure, infections, anemia, lytic bone lesions and amyloidosis lead to morbidity as well as mortality. [1] Though the disease is uniformly fatal; newer advances in treatment like autologous hematopoietic stem cell transplantation mini-transplants and advances in chemotherapy have improved the quality-of-life and increased survival. [2] Hence, this study was undertaken to evaluate the clinical profile of MM.
Materials and Methods | | |
This was a cross-sectional study conducted over a period of 1 year, in a teaching hospital. Institutional Ethical Committee's clearance was taken. Patients admitted in medical wards with features of bony pains, anemia, lytic bony lesions were included. Detailed history was taken and clinical examination was performed. Hematological investigations such as Hemoglobin (Hb), Total differential cell counts, erythrocyte sedimentation rate (ESR), platelet count, peripheral blood smear, bone marrow examination were done. Serum protein electrophoresis was done, using the cellulose acelate membrane and ponceau S stain to detect M band in all. Urine was examined for Bence Jones Proteinuria. Radiological investigations included skeletal survey; imaging studies like magnetic resonance imaging were performed, wherever indicated to look for osteolytic lesions, generalized osteoporosis, vertebral compressions, pathological fractures and spinal cord compression. Radiographs of local sites were taken if extramedullary involvement was present. Diagnosis of MM was based on Salmon-Durie criteria. [3],[4]
The Salmon-Durie Staging System
We had used Microsoft excel for data analysis and found the frequency for respective parameter.
Results | | |
- Out of total 20 patients, 10 were males, (50%) and 10 were females (50%). Sixth decade was the common age group at presentation in both males as well as age wise distribution is shown in [Table 1]. Mean age of the patients in our study population was 62 years. One patient was above 70 years of age.
Common clinical symptoms were bone pains (85%), localized body swelling (25%), fever (35%), generalized weakness and fatigue (55%) motor weakness of lower limbs in 2 patients (10%), whereas 1 patient had (5%) malena. Two patients had received multiple blood transfusions for anemia. Clinical examination revealed pallor in 16 patients (80%), bony tenderness in 85% (17 patients). Five cases had bony swelling (25%) [Figure 1], 11 patients presented with infection (55%), gum bleeding was observed in 2 patients (10%).
The mean duration of symptoms was 6.7 months with a range of 5-8 months. Hematological features were anemia in all (100%), median Hb concentration was 9.34 g/dL and elevated ESR was present in all (100%) cases. Rouleaux formation was observed in 7 patients (35%) at presentation white blood cells count was less than 6000 in 4 patients (20%) and platelet count was less than 1 lakh/mm 3 in 2 patients (10%) and greater than 4 lakh in 1 patient (5%). Serum creatinine of more than 1.9 mg/dL was seen in 6 patients (30%) at presentation. Hypercalcemia was observed in one patient (5%). All patients in study group (100%) had the presence of M band on serum protein electrophoresis and γ-region was the most frequent location of the monoclonal band. 6 patients (30%) had urinary Bonce Jones protein. Among skeletal involvement, 19 patients (85%) had osteolytic lesions, 8 patients (40%) had generalized osteoporosis, 7 patients (35%) had pathological fractures. Spine and skull were the common sites of involvement 60% and 55% respectively. One patient did not have skeletal involvement. Bone marrow examination revealed the presence of more than 50% plasma cells in 9 cases (45%), 7 patients (35%) had 10-30% plasma cells 4 patients (20%) had plasma cells in the range of 30-50% [Table 2].
According to Durie-Salmon staging, stage 2A was most common stage at presentation in 11 patients (55%) [Table 3].
As far as treatment was concerned the 20 cases, 19 received treatment for myeloma while one died at diagnosis. Of 19 patients, 3 cases (15%) received vincristine, doxorubicin and dexamethasone (VAD) regimen initially and thalidomide was added later. Of the rest 16 cases, four received dexamethasone and thalidomide and 12 were treated with thalidomide alone. In our study, we were unable to prognosticate the disease due to the poor follow-up and unavailability of B 2 microglobulin levels.
Discussion | | |
MM is a hematological malignancy usually presenting in the elderly, with a median age in India of 55-60 years. In the present study, five patients below 60 years of age, whereas one was 37 years of age and maximum number of cases were between 60 and 70 years, which is similar to other studies. [5] It has been mentioned that approximately 2% of cases of MM are younger than 40 years and it is still rare in patients younger than 30 years. Though MM is unusual in the young patients, it has been reported to be 0.3% at mayo clinic in patients younger than 30 years and 0.18% at National Cancer Institute and 1% frequency by Hewell and Alexanian. [6] In a study from PGIMER, Chandigarh, India, out of 150 myeloma cases reviewed over 10 years, 5 patients (3.3%) were less than 30 years of age. [7]
Our study showed equal affection of both genders, which may be due to the smaller number of cases studied. The most common symptoms observed were bony pains (85%), which are higher compared to other studies, which include backache, hip joint, shoulder neck pain. In some patients, (30%) pain was associated with bony swelling at various sites such as sternum, clavicle, skull and left foot. Generalized weakness and fatigue were other presenting symptoms (55%), which are comparable to other studies. [8] Of seven patients presenting with fever (35%), two had bacterial pneumonia and two had a urinary tract infection, Motor deficit in the form of paraperesis was seen in two patients. Hepatosplenomegaly and Lymphadenopathy were not observed in our study, whereas bony tenderness (85%) and pallor (80%) were frequently observed physical findings.
Normocytic anemia was observed in 17 cases (85%), four had Hb below 7 g/dL, which is comparable to other studies. [5],[8] The mechanisms of anemia in most is inadequate red blood cells production due to either erythropoietin deficiency from the accompanying renal failure or replacement of marrow by myeloma cells. In some patients, anemia is disproportionate to renal failure or marrow involvement and is thought to be related to cytokine mediated marrow suppression. The incidence of renal failure in our study was high (30%), in contrast to other studies. [8] Renal function impairment is a common phenomenon in MM; the major causes being myeloma kidney, hypercalcemia and dehydration.
In our study, all cases (100%) demonstrated monoclonal protein. On further categorization, myeloma was IgG type in all cases, while in Kyle study serum electrophoresis study revealed M band in 82% of patients. The band migrated in gamma range in 65.7%, in other ranges such as beta, alpha 2 and between gamma and beta it was equally distributed, i.e., 5.7% each. M band was not seen in 17.1% of patients. In our study, we did not found M band in other ranges. [8] Like Kyle et al. study two spikes (biclonal) were not found in any patients.
To conclude, our study highlights younger age of involvement, varied presentations such as bony swellings, paraplegia, acute renal failure and infections. Majority of our patients had anemia and skeletal involvement. Non-specific symptoms like generalized weakness and fatigue can be presenting symptoms of MM unexplained anemia, renal failure, bone pains specially backache should give the physician a high index of suspicion for MM.
References | | |
1. | UK myeloma forum. British Committee for Standards in Haematology. Diagnosis and management of multiple myeloma. Br J Haematol 2001;115:522-40. |
2. | Gupta D, Hideshima T, Anderson KC. Novel biologically based therapeutic strategies in myeloma. Rev Clin Exp Hematol 2002;6:301-24. |
3. | Shah PM. Plasma cell dyscrasias. In Munjal Y P (ed) API Text Book of Medicine. 7 th ed.The Association of Physicians of India. New Delhi Jaypee Brothers Medical Publishers 2003; 961-3. |
4. | Musnshi NC, Longo DL, Anderson KC. Plasma cell disorders. In Fauci A S, Braunwald E, Casper D L, Hauser S L, Longo D L, Jameson J L (eds), Harrison's International Medicine. 17 th ed. New York, NY: McGraw Hill; 2008;703-5. |
5. | Mohanty PK, Patel DK, Nanda R, Panda RS. Multiple myeloma: Review of 21 cases with special reference to associated illnesses in a referral center in Western Orissa. Indian Pract 2004;57:285-9. |
6. | Hewell GM, Alexanian R. Multiple myeloma in young persons. Ann Intern Med 1976;84:441-3. |
7. | Kapoor R, Bansal M. Clinical spectrum and prognosis of multiple myeloma in patients younger than 30 years, Case report. JK Science 2006;8:225-8. |
8. | Kyle RA, Gertz MA, Witzig TE, Lust JA, Lacy MQ, Dispenzieri A, et al. Review of 1027 patients with newly diagnosed multiple myeloma. Mayo Clin Proc 2003;78:21-33. |
[Figure 1]
[Table 1], [Table 2], [Table 3]
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