Multiple+Myeloma

​ The incidence appears to be stable. While some reports have suggested an increase in incidence over time, this more likely reflects the enhanced availability and use of medical facilities, especially by older persons. Our database from Olmsted County, Minnesota has documented a stable incidence from the 1940s to the early 21st century. MM occurs in all races and all geographic locations. The incidence varies by ethnicity; the incidence in blacks is almost twice that in whites and the incidence in various Asian populations is lower than that seen in Caucasian and Black populations. MM is also slightly more frequent in men than in women (approximately 1.4:1). MM is a disease of older adults. The median age at diagnosis is 66 years; only 10 and 2 percent of patients are younger than 50 and 40 years, respectively. A small but unknown fraction of cases are familial. The risk of developing MM is approximately 3.7 fold higher for persons with a first degree relative with MM. MM has been reported in clusters of two or more first-degree relatives, identical twins, and in four members spanning three generations in one family, with an incidence of approximately 3 familial cases per 1000 patients with myeloma. In one report of 15 families with MM clustering, 10 occurred in siblings. The same IgG kappa monoclonal pattern was present in all cases in seven families. 8 || · bone pain · bleeding · infections · fatigability ·  Anemia, with thrombocytopenia and /or granulocytpoenia appearing in approximately one third of the patients. · Plasma cells are found primarily in the tissues and organs of the lymphorecticular system, especially in the bone marrow, lymph nodes, liver, and upper respiratory and gastrointestinal tract mucosa. ⁵ || __Patients with paraimmunoglobulinopathy and must have at least one of the following also:__ Marrow plasmacytosis > 5% Tissue biopsy which demonstrates replacement and distortion of normal tissue with plasma cells >500 plasma cell per mm 3 in the blood. Osteolytic lesions that have other causes ruled out. __Patients without paraimmunoglobulinopathy have to have radiographic evidence of osteolytic lesions OR palpable tumors and at least one or more of the following:__ Marrow plasmacytosis > 20% in the absence of any other causes Tissue biopsy which demonstrates replacement and distortion of normal tissue with plasma cells Radiographic skeletal survey should be performed Beta 2 -microglobulin serum level. 2 || Grade 0 Normal radiograph Grade 1 Extensive osteoporosis or osteopenia Grade 2 Osteolysis Grade 3 Pathologic fracture⁷ || This system is based on 4 factors: This system uses these factors to divide myeloma into 3 stages. Stage I indicates the smallest amount of tumor, and stage III indicates the largest amount of tumor: __Stage I__: A relatively small number of myeloma cells are found. All of the following features must be present: **Stage II: ** A moderate number of myeloma cells are present. Features are between stage I and stage III. This system divides cases of myeloma into 3 stages based only on the serum beta-2 microglobulin and serum albumin levels. Stage I: Serum beta-2 microglobulin is less than 3.5 (mg/L) and the albumin level is 3.5 (g/dL) or higher . Stage II**:** Neither stage I or III, meaning that either: OR Stage III**:** Serum beta-2 microglobulin is greater than 5.5 ⁶ || The most easily measurable predictive parameter ate the serum B-microglubulin and serum albumin levels (<=3 g/dL). ¹² || Palliative treatments include radiation and chemotherapy. __Chemotherapy__ Usually treated with melphalan, frequently in combination with prednisone. __Radiation Therapy__ Is used in the following circumstances: (a) as primary treatment in localized disease, (b) as palliative treatment for disseminated disease when chemotherapy was not successful, (c) for prevention of pathologic fractures in weight bearing bones, and (d) relief of spinal cord or nerve root compression. Radiation therapy is used to treat lytic disease to prevent fracture, spinal disease to combat cord compression, and bony pain palliation. Treatment fields for bony lesions should encompass the entire bone of possible. Skin tattoos should be used especially for the spine to assist in the setup and planning of future treatments as needed. Fields treating areas with abundant bone marrow (e.g. pelvis) should be kept as small as possible to maximize bone marrow function for future chemotherapy treatments. For patients receiving treatment to weight bearing bones, orthopedic support should be used. Radiation can be delivered before or after bone fixation. If treating local areas of spread for palliation, the dose should be 15-20 Gy. The exact dose should be determined by pain relief needed and patient's condition. Hemibody radiation is good for patients with diffuse disease needing palliation, and works for 80%-90% of patients within 2 days. The dose should be 7.5 - 8.5 Gy. ¹² || TD 5/5 for Multiple Myeloma Treatment Sites 9 || Figure 1 Treatment of Distal Extremity 10
 * Epidemiology: || Multiple myeloma (MM) accounts for approximately 1 percent of all cancers and slightly more than 10 percent of hematologic malignancies in the United States (US). The annual incidence in the US is approximately 4 to 5 per 100,000. A similar incidence has been reported in the South Thames area of the United Kingdom.
 * Etiology: || The cause is unknown but multiple myeloma is a proliferation and accumulation of cells that secrete immunoglobulin. These cells are derived from B cell lymphocytes. 1 ||
 * Signs & Symptoms: || Common complaints of patients with multiple myeloma include
 * Diagnostic Procedures: || The diagnostic criteria were developed by the Chronic Leukemia-Myeloma Task Force:
 * Histology: || Monoclonal immunoglobulin secreting cells that are derived from B cell lymphocytes. 3 ||
 * Lymph Node Drainage: || A search of the literature does not demonstrate lymph node drainage playing a role in this disease. ||
 * Metastatic Spread: || Plasma cells circulate through the blood and lymph systems, multiple myeloma can appear in a localized area or may be disseminated anywhere in the body. Therefore, because of its nature, multiple myeloma does not metastasize to any specific organ⁴ ||
 * Grading: || <span style="color: #ff00ff; font-family: 'Times New Roman','serif'; font-size: 90%;">Radiographic Grading of the Bones in Patients with Multiple Myeloma
 * Staging: || <span style="color: #ff00ff; font-family: 'Times New Roman','serif';">Multiple myeloma may be staged using the Durie-Salmon system. Although some doctors use this system, its value is becoming limited because of newer diagnostic methods. Recently, a new staging system called the //International Staging System for Multiple Myeloma// has been developed. It relies mainly on levels of albumin and beta-2-microglobulin in the blood. Other factors that may be important are kidney function, platelet count and the patient's age.
 * <span style="color: #003366; font-family: 'Times New Roman','serif';">The Durie-Salmon staging system **
 * <span style="color: #ff00ff; font-family: 'Times New Roman','serif';">The amount of abnormal monoclonal immunoglobulin in the blood or urine: Large amounts of monoclonal immunoglobulin indicate that many malignant plasma cells are present and are producing that abnormal protein.
 * <span style="color: #ff00ff; font-family: 'Times New Roman','serif';">The amount of calcium in the blood: High blood calcium levels are also related to advanced bone damage. Because bone normally contains lots of calcium, bone destruction releases calcium into the blood.
 * <span style="color: #ff00ff; font-family: 'Times New Roman','serif';">The severity of bone damage based on x-rays: Multiple areas of bone damage seen on x-rays indicate an advanced stage of multiple myeloma.
 * <span style="color: #ff00ff; font-family: 'Times New Roman','serif';">The amount of hemoglobin in the blood: Hemoglobin is the substance in red blood cells that carries oxygen. Low hemoglobin levels indicate that the myeloma cells occupy much of the bone marrow and that not enough space is left for the normal marrow cells that produce red blood cells.
 * <span style="color: #ff00ff; font-family: 'Times New Roman','serif';">hemoglobin level only slightly below normal (above 10 g/dL)
 * <span style="color: #ff00ff; font-family: 'Times New Roman','serif';">bone x-rays appear normal or show only 1 area of bone damage
 * <span style="color: #ff00ff; font-family: 'Times New Roman','serif';">normal blood calcium levels (less than 12 mg/dL)
 * <span style="color: #ff00ff; font-family: 'Times New Roman','serif';">relatively small amount of monoclonal immunoglobulin in blood or urine
 * <span style="color: #ff00ff; font-family: 'Times New Roman','serif';">Stage III: ** <span style="color: #ff00ff; font-family: 'Times New Roman','serif';">A large number of myeloma cells are found. One or more of the following features must be present:
 * low hemoglobin level (below 8.5 g/dL)
 * high blood calcium level (above 12 mg/dL)
 * three or more areas of bone destroyed by the cancer
 * large amount of monoclonal immunoglobulin in blood or urine
 * <span style="color: #003366; font-family: 'Times New Roman','serif';">The International Staging System **
 * <span style="color: #ff00ff; font-family: 'Times New Roman','serif';">the beta-2 microglobulin level is between 3.5 and 5.5 (with any albumin level,
 * the albumin is below 3.5 while the beta-2 microglobulin is less than 3.5
 * Radiation Side Effects: || Combination therapy may result in fever, neutropenia, mucositis, nausea, vomiting, and diarrhea. In addition to erythema in the radiatin field. Rare late effects include firbrosis, contractures, and growth arrest. Doses of 6000 cGy have been known to produce osteosarcoma in previously treated areas. Leukemia is also a possible, rare late effect. ¹¹ ||
 * Prognosis: || Prognostic factors associated with shortened survival or reduced remission include old age, severe anemia, hypercalcemia, blood urea nitrogen > 40 mg/dL, elevated M protein, hypoalbuminemia, and high tumor cell burden.
 * Treatments: || No effective curative treatment is established.
 * TD5/5: || [[image:TD5-5_Plasma_&_Multiple.JPG width="393" height="134"]]

Figure 2 Simulation Field of the Forearm 10

1. Sorenson SM, Gentili A, Masih S, et. al. //Multiple myeloma//. Available at: [|//http://emedicine.medscape.com/article/391742-overview//]//.// Accessed February 15, 2010. 2. Chao KS, Perez CA., Brady LW. //Radiation Oncology - Management Decisions//. 2nd ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2002:601-602. 3. Sorenson SM, Gentili A, Masih S, et. al. //Multiple myeloma//. Available at: [|//http://emedicine.medscape.com/article/391742-overview//]//.// Accessed February 15, 2010. <span style="color: #f41fe0; font-family: 'Arial','sans-serif'; font-size: 10pt;">4. Lenhard,E. Raymond. Jr.,MD., Osteen, T. Robert, Gansler,Ted,.MD. The American Cancer Society's Clinical Oncology. 1st edition. Atlanta,GA. 2001.pg 518-522 <span style="color: fuchsia; font-family: 'Arial','sans-serif'; font-size: 10pt;">5. <span style="color: green; font-family: 'Arial','sans-serif'; font-size: 10pt;"> [|www.cancer.net/Cancer+Types/MultipleMyeloma.com] <span style="color: fuchsia; font-family: 'Arial','sans-serif'; font-size: 10pt;">Accessed Febuary 14, 2010 6. [|www.cancer.org/MultipleMyeloma]. Accessed Febuary 14, 2010 7. http:/www.aafp.org/afp/990401/ap/1885.html. <span style="color: #ff00ff; font-family: 'Times New Roman','serif';">Accessed Feb 19, 2010 8. [] Accessed February 18, 2010 9. Wikibooks en.wikibooks.org TD5/5 adapted from Emami 1991 10. Faiz M. Khan. //Treatment Planning in Radiation Oncology//. 2nd ed. Philadelphia, PA Lippincott Williams & Wilkins. 2007  11. Washington CM, Leaver D. // Principles and Practice of Radiation Therapy //. 2nd ed. St. Louis, MO: Mosby. 2004 12. Chao KS, Perez CA., Brady LW. //Radiation Oncology - Management Decisions//. 2nd ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2002
 * __References__**