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Last updated:
02/06/2023
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NORD gratefully acknowledges Morie A. Gertz, MD, Hematology and Internal Medicine, Mayo Clinic, for assistance in the preparation of this report.
Multiple myeloma is a rare form of cancer characterized by excessive production (proliferation) and improper function of certain cells (plasma cells) found in the bone marrow. Plasma cells, which are a type of white blood cell, are produced in the bone marrow and normally reside there. Excessive plasma cells may eventually mass together to form a tumor or tumors in various sites of the body, especially the bone marrow. If only a single tumor is present, the term solitary plasmacytoma is used. When multiple tumors are present or the bone marrow has greater than 10% plasma cells, the term multiple myeloma is used.
Plasma cells are a key component of the immune system and secrete a substance known as immunoglobulin proteins (M-proteins), a type of antibody. Antibodies are special proteins that the body produces to combat invading microorganisms, toxins, or other foreign substances. Overproduction of plasma cells in affected individuals results in abnormally high levels of these proteins within the body, referred to as M proteins. Major symptoms of multiple myeloma may include bone pain, especially in the back and the ribs; low levels of circulating red blood cells (anemia) resulting in weakness, fatigue, and lack of color (pallor); and kidney (renal) abnormalities. Some affected individuals are more susceptible to bacterial infections such as pneumonia. The cause of multiple myeloma is unknown.
The specific symptoms, age of onset, and rate of progression of multiple myeloma varies from patient to patient. Some affected individuals will not exhibit any symptoms (asymptomatic or smoldering). Multiple myeloma may progress to cause life-threatening complications. It is important to note that affected individuals will not have all the symptoms listed below.
The most common symptom associated with multiple myeloma is bone pain, usually of the lower back or ribs. In most patients, movement worsens the pain, which may be mild, moderate or severe. Affected individuals are usually more susceptible to fractures than the general population and may experience repeated fractures of affected bones. The bones of the spine may become involved, potentially collapsing and resulting in spinal cord compression (rare). Compression of the spinal cord results in pain, weakness and numbness in the arms and legs.
Another possible sign of multiple myeloma is an elevated level of calcium in the blood, a condition called hypercalcemia. This occurs because damage to bones often results in the release of calcium into the bloodstream. Abnormally high levels of calcium may result in nausea, lack of appetite, fatigue, abdominal pain, muscle pain and weakness, excessive thirst and/or confusion.
Overproduction of plasma cells may also hinder the production and decrease the effectiveness of other cells of the body resulting in a variety of symptoms. Affected individuals may experience low levels of circulating red blood cells (anemia) resulting in weakness, fatigue, dizziness, shortness of breath and lack of color (pallor). Affected individuals may also experience low levels of cells that assist in clotting (platelets), a condition known as thrombocytopenia. Symptoms associated with thrombocytopenia include abnormal bleeding episodes that often result in purplish discoloration of the skin resulting from bleeding (hemorrhaging) of small blood vessels near the surface of the skin (purpura). Rarely, affected individuals may experience repeated nosebleeds (epistaxis).
Affected individuals may also have low levels of normal immunoglobulin (antibody) which weakens the immune system and results in a higher susceptibility than the general population to developing recurrent bacterial infections. The most common infection is pneumonia. In some patients, recurrent infections may be the first apparent symptom of multiple myeloma.
Individuals with multiple myeloma may also develop kidney abnormalities. In some patients, hypercalcemia may cause kidney damage. Abnormal proteins found in the blood or urine (M-proteins), which are produced by myeloma cells, may cause kidney damage (myeloma kidney). Kidney abnormalities may develop slowly or rapidly and may eventually progress to cause kidney (renal) failure.
Rarely, individuals with multiple myeloma may have an abnormally large liver (hepatomegaly) or spleen (splenomegaly). Rarely, multiple myeloma may occur in association with other disorders. The three most common disorders that may occur in association with multiple myeloma include hyperviscosity syndrome, cryoglobulinemia or amyloidosis.
Hyperviscosity syndrome is characterized by the blood becoming abnormally thick and sticky due to the abnormal accumulation of M-proteins in the blood. As a result, blood flow is slowed. Hyperviscosity syndrome may cause headaches, nose bleeding, fatigue, frequent bruising, gastrointestinal bleeding, and vision abnormalities such as disease of the retina (retinopathy).
Cryoglobulinemia is a rare disorder that occurs due to the accumulation of abnormal proteins (cryoglobulins) in the bloodstream. These proteins thicken or gel on exposure to cold. In some patients there are no symptoms and in others a variety of symptoms may develop. The most common symptoms are joint pain (arthralgia), pain and numbness in the fingers and toes in response to cold (Raynaud’s phenomenon), weakness, and purpura.
Amyloidosis is a rare disorder characterized by the abnormal accumulation of a fibrous protein (amyloidosis) in tissues of the body. The excessive accumulation of amyloid causes an affected organ to malfunction. (For more information on this disorder, see the Related Disorders section below.)
The exact cause of multiple myeloma is not known. Symptoms occur as a result of a process that is initiated by the abnormal multiplication of plasma cells in bone marrow. Scientists suspect there may be a variety of causes that may include environmental factors (e.g., the effects of exposure to radiation), genetic abnormalities, and/or additional factors that may play varying contributing roles. Exposure to dioxin has been associated with an increased risk of myeloma.
One factor of interest to researchers is that many myeloma cells have specific genetic abnormalities that impact prognosis. Also, the development of multiple myeloma is preceded in virtually all cases by a condition called monoclonal gammopathy of undetermined significance or MGUS (see Related Disorders section). The cause of MGUS is not known.
The specific symptoms of multiple myeloma result from excessive and unnecessary growth (neoplastic proliferation) of plasma cells.
Multiple myeloma is a rare cancer that is slightly more common in males than females. In 2019, over 32,000 individuals in the United States were diagnosed with this disease. It is believed that approximately 100,000 Americans currently have the disease.
According to reports in the medical literature, multiple myeloma accounts for approximately 1% of all malignancies in Caucasians and about 2% of all malignancies in individuals of African descent. It accounts for 10% of all hematological malignancies in the United States. The yearly incidence rate is estimated to be approximately 6.5 persons out of 100,000.
Multiple myeloma usually becomes apparent between the fourth and seventh decades of life, with a median age of 68 years at diagnosis. The occurrence of the disease before the age of 40 is rare.
A diagnosis of multiple myeloma is made based upon a thorough clinical evaluation, a detailed patient history, and a variety of specialized tests. Such tests may include removal and microscopic examination of small samples of bone marrow (biopsy or aspiration), blood tests to detect low levels of red and white blood cells, and various x-ray techniques including magnetic resonance imaging (MRI), computed tomography (CT) and positron emission tomography (PET) scanning that may reveal characteristic changes to bones. A test that sorts proteins in the blood or urine (electrophoresis) may be used to detect elevated levels of M-proteins. An immunoglobulin free light chain assay of blood is considered a standard of evaluation.
In 2018, the ClonoSEQ assay, a next generation sequencing-based test, was approved to measure the amount of cancer cells remaining in a person’s bone marrow in patients with multiple myeloma.
Treatment
The diagnosis and therapeutic management of multiple myeloma may require the coordinated efforts of a team of medical professionals, such as physicians who specialize in the diagnosis and treatment of cancer (medical oncologists), disorders of the blood and blood-forming tissues (hematologists), or the use of radiation to treat cancers (radiation oncologists); oncology nurses; orthopedic surgeons; dietitians; and/or other professionals.
Specific therapeutic procedures and interventions may vary, depending upon numerous factors, such as disease stage; tumor size; the presence or absence of certain symptoms; individual’s age and general health; and/or other elements. Decisions concerning the use of particular drug regimens and/or other treatments should be made by physicians and other members of the health care team in careful consultation with the patient based upon the specifics of his or her medical history; a thorough discussion of the potential benefits and risks, including possible side effects and long-term effects; patient preference; and other appropriate factors.
Some affected individuals may have a slow developing form of multiple myeloma that progresses over many years, often without symptoms (asymptomatic). Such individuals, and individuals with similar conditions like smoldering multiple myeloma and MGUS, may not require treatment. However, these individuals should be routinely monitored so that treatment can begin if symptoms appear.
The treatment of multiple myeloma usually involves chemotherapy to reduce the numbers of abnormal plasma cells, drugs to help fight infection (e.g., antibiotics), and medications to reduce pain (analgesic drugs). Additional treatment may include the use of high energy x-rays (radiation therapy) to destroy cancer cells and reduce bone masses that may develop. The use of new biologic drugs may also be recommended. If affected individuals experience involvement of the kidneys, fluids may need to be administered to avoid dehydration.
The following link provides information from the National Cancer Institute about medications that have been approved by the U.S. Food and Drug Administration (FDA) to treat multiple myeloma:
http://www.cancer.gov/cancertopics/druginfo/multiplemyeloma
Stem-cell transplantation along with high-dose chemotherapy is regularly used for the treatment of multiple myeloma. Stem cells, which reside in the bone marrow, function as “parent” cells, undergoing a series of divisions that result in the formation of all the different types of blood cells (e.g., red blood cell, platelets, etc.).
Other treatment is symptomatic and supportive.
Information on current clinical trials for multiple myeloma is posted on the Internet at www.clinicaltrials.gov. All studies receiving U.S. government funding, and some supported by private industry, are posted on this government website.
For information about clinical trials being conducted at the NIH Clinical Center in Bethesda, MD, contact the NIH Patient Recruitment Office:
Tollfree: (800) 411-1222
TTY: (800) 411-1010
Email: [email protected]
Some current clinical trials also are posted on the following page on the NORD website:
https://rarediseases.org/living-with-a-rare-disease/find-clinical-trials/
For information about clinical trials sponsored by private sources, contact:
www.centerwatch.com
For information about clinical trials conducted in Europe, contact:
https://www.clinicaltrialsregister.eu/
Recombinant erythropoietin may be used as a treatment for anemia in some individuals with multiple myeloma. Recombinant erythropoietin is an artificial (synthetic) version of a natural hormone that stimulates the growth of red blood cells. Zoledronic Acid infusions monthly to quarterly are considered standard to reduce the risks of skeletal events. Denosumab is also used to reduce the risk of skeletal events in myeloma.
There are multiple effective therapies for the management of multiple myeloma the specific regimen needs to be individualized based on patient factors. Many clinical trials offer the opportunity to participate in cutting edge therapies for this disorder. Contact for additional information about Multiple Myeloma:
Morie A. Gertz, MD
Hematology and Internal Medicine
Mayo Clinic
200 First Street S.W.
Rochester, MN 55905
507-284-2511
RareConnect offers a safe patient-hosted online community for patients and caregivers affected by this rare disease. For more information, visit www.rareconnect.org.
JOURNAL ARTICLES
Brigle K, Verina D, Faiman B. A Focus on newly diagnosed multiple myeloma. J Adv Pract Oncol. 2022;13(Suppl 4):7-14. doi:10.6004/jadpro.2022.13.5.10
El Hussein S, Medeiros LJ, Hu S, Lin P, Wang W. The many faces of plasma cell neoplasms: morphological and immunophenotypical variants of the great imitator. Pathology. 2022;54(1):32-42. doi:10.1016/j.pathol.2021.09.011
Hernández-Rivas JÁ, Ríos-Tamayo R, Encinas C, Alonso R, Lahuerta JJ. The changing landscape of relapsed and/or refractory multiple myeloma (MM): fundamentals and controversies. Biomark Res. 2022;10(1):1. Published 2022 Jan 9. doi:10.1186/s40364-021-00344-2
Kundu S, Jha SB, Rivera AP, et al. Multiple myeloma and renal failure: mechanisms, diagnosis, and management. Cureus. 2022;14(2):e22585. Published 2022 Feb 25. doi:10.7759/cureus.22585
Tacchetti P, Rocchi S, Barbato S, et al. Emerging and current treatment combinations for transplant-ineligible multiple myeloma patients. Expert Rev Hematol. 2021;14(12):1085-1098. doi:10.1080/17474086.2021.1983426
Gonsalves WI, Buadi FK, Ailawadhi S, et al. Utilization of hematopoietic stem cell transplantation for the treatment of multiple myeloma: a Mayo Stratification of Myeloma and Risk-Adapted Therapy (mSMART) consensus statement. Bone Marrow Transplant. 2019;54(3):353-367. doi:10.1038/s41409-018-0264-8.
Mikhael JR, Dingli D, Roy V, et al. Management of newly diagnosed symptomatic multiple myeloma: updated Mayo Stratification of Myeloma and Risk-Adapted Therapy (mSMART) consensus guidelines 2013 [published correction appears in Mayo Clin Proc. 2013 Jul;88(7):777. Stewart, Keith [corrected to Stewart, A Keith]]. Mayo Clin Proc. 2013;88(4):360-376. doi:10.1016/j.mayocp.2013.01.019
INTERNET
Multiple Myeloma. Mayo Foundation for Medical Education and Research. June 16, 2021. https://www.mayoclinic.org/diseases-conditions/multiple-myeloma/symptoms-causes/syc-20353378 Accessed Dec 1, 2022.
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