Multiple myeloma

Early Normalization of Free Light Chains Predicts Better Outcomes in Patients with Multiple Myeloma

Background: The half-life of free light chain is short and can be used as an early marker for tumor response in patients with multiple myeloma [MM]. This prospective study is aimed at evaluating whether early light chain response can predict response to treatment in patients with MM.

Materials and Methods: Thirty six patients with a diagnosis of MM and with an abnormal to normal light chain ratio of > 10 were included in this study.

Results: The median age at presentation was 56 years. Fourteen patients had lambda light chain disease, whereas 22 patients had kappa light chain disease. Twenty-four patients [66.6%] had reduction of abnormal to normal light chain ratio to < 10 after 2 cycles, of whom 15 [62.5%] achieved a CR or VGPR after 6 cycles. Among 12 patients who did not have reduction of abnormal to normal light chain ratio to < 10, only 1 patient achieved CR while 11 patients [91.6%] achieved a PR or less[Fishers exact p=0.004]. Median follow-up was 13 months. Median progression-free survival for the entire cohort was 15 months. One-year Progression-Free Survival was 77% vs 57.1%, [p= 0.008], respectively for patients with early normalization and those who did not show early normalization.

Conclusion: Early light chain response after 2 cycles of chemotherapy is a good predictor for treatment response in patients with MM treated with bortezomib based chemotherapy. Treatment intensification based on early light chain response merits further evaluation in a prospective trial

Hematopoietic neoplasias in horses: myeloproliferative and lymphoproliferative disorders

Leukemia, i.e., the neoplasia of one or more cell lines of the bone marrow, although less common than in other species, it is also reported in horses. Leukemia can be classified according to the affected cells (myeloproliferative or lymphoproliferative disorders), evolution of clinical signs (acute or chronic) and the presence or lack of abnormal cells in peripheral blood (leukemic, subleukemic and aleukemic leukemia). The main myeloproliferative disorders in horses are malignant histiocytosis and myeloid leukemia, the latter being classified as monocytic and myelomonocytic, granulocytic, primary erythrocytosis or polycythemia vera and megakaryocytic leukemia. The most common lymphoproliferative disorders in horses are lymphoid leukemia, plasma cell or multiple myeloma and lymphoma. Lymphoma is the most common hematopoietic neoplasia in horses and usually involves lymphoid organs, without leukemia, although bone marrow may be affected after metastasis. Lymphoma could be classified according to the organs involved and four main clinical categories have been established: generalized-multicentric, alimentary-gastrointestinal, mediastinal-thymic-thoracic and cutaneous. The clinical signs, hematological and clinical pathological findings, results of bone marrow aspirates, involvement of other organs, prognosis and treatment, if applicable, are presented for each type of neoplasia. This paper aims to provide a guide for equine practitioners when approaching to clinical cases with suspicion of hematopoietic neoplasia.

Bone marrow histology and serum beta 2 microglobulin in multiple myeloma--a new prognostic strategy

Bone marrow biopsies of 720 patients with multiple myeloma (MM) were investigated from 1968-1989. Histologic variables were correlated with clinical parameters and survivals to determine prognostic factors. In 207 of these patients initial levels of serum beta 2 microglobulin (SB2M) were also measured for prognostic evaluation. Four tumour growth patterns were distinguished: interstitial (56%), interstitial/sheets (13%), nodular (15%) and packed marrow (16%) with median survivals of 46, 31, 22 and 16 months. When grouped according to the tumour cell mass in the biopsy, four histologic stages were recognized. Cellular characteristics were used to classify MM into 6 histologic types which were subsequently combined into 3 grades of malignancy: low, intermediate and high, analogous to the malignant lymphomas. With respect to tumour products, only SB2M proved to be a valuable prognostic indicator for staging and follow-up. Complications of MM such as anaemia, azotaemia, osteolytic lesions, hypercalcaemia and hypoalbuminaemia all predicted a poor prognosis, highly significant in the test statistics. We propose a new prognostic approach in MM, comprising 1) parameters defining the tumour itself, 2) the tumour products (SB2M) and 3) the tumour complications. This prognostic strategy combines information both on stage and malignancy of MM and enables definition of smouldering and of aggressive variants of MM at an early stage.

Gastrointestinal plasmacytoma that caused anemia in a patient with multiple myeloma

BACKGROUND

A 70-year-old white male diagnosed with IgA lambda multiple myeloma, who had been treated with two cycles of melphalan and prednisone, was evaluated for persistent anemia. He had required more than 15 U of packed red blood cells within a 2-month period for his anemia, despite recombinant erythropoietin treatment, and his hemoglobin level was persistently below 9 g/dl.

INVESTIGATIONS

Physical examination and laboratory tests, which included a red blood cell mean corpuscular volume, platelet counts, coagulation studies, a peripheral blood smear, lactate dehydrogenase level, haptoglobin and bilirubin level, vitamin B12 and folate level, serum iron studies, bone marrow biopsy and immunophenotyping. Additionally, Congo red staining of the subcutaneous fat aspirate and a bone marrow biopsy were carried out, as well as esophagogastroduodenoscopy with gastric and duodenal biopsies.

DIAGNOSIS

Gastrointestinal plasmacytoma.

MANAGEMENT

Control of underlying disease (multiple myeloma) with 2 cycles of treatment with melphalan and prednisone followed by high-dose pulse dexamethasone chemotherapy as outlined by the oncologist. PPI therapy was continued and NSAIDs were avoided. The patient died because of infectious complications with subsequent multi-organ failure while awaiting work up for autologous stem cell transplantation.

Comparison of vincristine, carmustine, melphalan, cyclophosphamide, prednisone (VBMCP) and interferon-alpha with melphalan and prednisone (MP) and interferon-alpha (IFN-alpha) in patients with good-prognosis multiple myeloma: a prospective randomized study. Greek Myeloma Study Group

OBJECTIVES

The purpose of the study was to evaluate, in a selected group of myeloma patients with favorable prognosis, the effect, on response and survival, of polychymotherapy compared with melphalan prednisone, plus interferon in both arms.

METHODS

Eighty-nine previously untreated patients with multiple myeloma and prognostic factors indicating a good prognosis were randomized to either oral melphalan plus prednisone (MP) in combination with recombinant interferon-alpha (rIFN-alpha) or combination chemotherapy with vincristine, carmustine, melphalan, cyclophosphamide, and prednisone (VBMCP) alternating with rIFN-alpha. The two treatment groups were comparable in terms of pretreatment characteristics.

RESULTS

The overall response rate was 67.4% (2.3% complete remission, 65.1% partial response) in the MP/IFN-alpha group and 69.1% (14.3% complete remission, 54.8% partial response) in the VBMCP/IFN-alpha group (p=0.59). There were no differences also in response duration and overall survival between the two treatment groups. The median response duration was 39.1 months in the MP/IFN-alpha group and was not reached in the VBMCP/IFN-alpha group (p = 0.6). Overall survival was long in both treatment groups. The estimated 5-yr survival was 66% and 62% in the MP/IFN-alpha and VBMCP/IFN-alpha group, respectively (p=0.8). Toxicity was modest and treatments were well tolerated. Neutropenia (WHO grade 3 or 4) was higher, but not statistically significant, in the VBMCP/IFN-alpha group.

CONCLUSIONS

The results of the study show that in myeloma patients with good prognosis, combination chemotherapy alternating with interferon-alpha has no advantage over conventional MP plus interferon-alpha, in regard to response rate, response duration, and overall survival of patients.

Unusual cause of chest pain in a 60-year-old woman

Chest pain is a common emergency department complaint. Many patients presenting with this complaint are discharged with the nonspecific diagnosis of musculoskeletal chest pain. That was the diagnosis given to the patient in this case at the time of her initial presentation to the ED, a diagnosis that was correct but incomplete. This case illustrates the importance of taking a complete history, including a thorough review of systems in every patient, even when the diagnosis seems obvious.

Current drug therapy for multiple myeloma

Recent years have witnessed tremendous advances in the molecular pathogenesis and management of multiple myeloma. Standard chemotherapy (melphalan and prednisone; MP) has been the mainstay of treatment of multiple myeloma for about 3 decades. However, it is no longer considered the 'gold standard', particularly for those patients who will subsequently undergo intensive chemotherapy with autologous or allogeneic peripheral blood stem cell (PBSC) or bone marrow transplantation (BMT), or for patients with refractory myeloma. A variety of induction combination chemotherapy regimens have been developed, some of which have demonstrated an improved response rate and duration and a superior 5-year survival rate when compared with standard chemotherapy. The early use of high dose chemotherapy with autologous PBSC support or BMT has significantly increased the complete remission rate, and has prolonged event-free sur vival and overall survival. Allogeneic bone marrow or PBSC transplantation may be a good option for selected patients with poor prognostic features. The role of interferon-alpha in multiple myeloma is still inconclusive despite many years of clinical evaluation. The clinical application of chemosensitising agents that can inhibit P-glycoprotein (P-gp) expression and function, and particularly the development of more potent P-gp modulators such as valspodar (PSC 833) and elacridar (GF120918) has made it possible to reverse multidrug resistance in some refractory patients and to enhance the efficacy of chemotherapeutic agents. Immunotherapeutic approaches to purging of autologous bone marrow or PBSC, or as adjuvant therapy for minimal residual disease, show great promise. Finally, a number of new therapies specifically designed to treat many of the complications of multiple myeloma are improving clinical outcomes and quality of life for these patients.

Hematopoietic Cell Transplantation for Multiple Myeloma

BACKGROUND: Multiple myeloma (MM) is a malignant plasma cell disorder with a median survival of three years. Despite the development of numerous conventional chemotherapy regimens and interferons, there has been little progress in improving the survival of patients with MM. Very high-dose chemoradiotherapy and autologous or allogeneic hematopoietic stem cell transplantation (HSCT) can result in high complete remission rates, even in patients with advanced disease. METHODS: A prospective, randomized study has shown that autologous HSCT results in superior response rates, progression-free survival, and disease-free survival compared with conventional chemotherapy. This is the first real advance in the treatment of this disease in 30 years. Unfortunately, few, if any, patients with MM who receive autologous HSCT are cured. RESULTS: Allogeneic HSCT can be curative for a fraction of patients with MM. However, very high transplant-related morbidity and mortality limit the application of allografts to younger patients with compatible donors. CONCLUSIONS: Challenges for the future include the development of less intensive or more disease-specific chemotherapy regimens that preserve the antitumor activity but are less toxic, improvement in the control of graft-vs-host disease in the case of allografts and, for autologous graft recipients, the development of vaccines and cytotoxic lymphocytes to augment a graft vs myeloma effect.

Management of Myeloma: Current and Future Approaches

BACKGROUND: The treatment of multiple myeloma, relatively stagnant for many years, appears to be entering a promising era for improvement. This paper reviews treatment interventions available for patients with multiple myeloma to indicate a standard approach and to evaluate the spectrum of current standard therapy. METHODS: The author reviews published literature on the treatment of multiple myeloma. Both journal articles and papers presented at national and international meetings are utilized. RESULTS: Intensive combination chemotherapy offers relatively modest improvement over standard melphalan plus prednisone, but the use of interferon for maintenance therapy lengthens response duration and possibly survival. High-dose chemotherapy with stem-cell transplantation is a relatively safe and effective treatment modality for patients under 70 years of age at first relapse. Studies in progress will determine its role in first response consolidation. Use of hematopoietic growth factors, prophylactic antibiotics, and bisphosphonate treatment of lytic bone disease has diminished disease morbidity. CONCLUSIONS: While cure of multiple myeloma remains elusive and 10-year survival is still uncommon, newer treatment approaches offer better control of disease manifestations and perhaps a real opportunity to prolong functional life. Future treatments that will address minimal residual disease may improve long-term survival.

Allogeneic stem cell transplantation for multiple myeloma

High-dose chemotherapy (with or without total body irradiation) followed by allogenic marrow transplantation is curative for some patients with advanced multiple myeloma. A relatively high transplant-related mortality, however, limits the wider application of this approach. The challenge for future studies will be to develop less toxic preparative regimens, more efficient ways to prevent infection and graft-versus-host disease, and methods to enhance the graft-versus-leukemia effect of allografts.

Complete remission induction with combined VBMCP chemotherapy and interferon (rIFN alpha 2b) in patients with multiple myeloma

The purpose of this study was to evaluate a new regimen for the treatment of multiple myeloma based on alternating 3-week cycles of chemotherapy and interferon (rIFN alpha 2). In this prospective phase II clinical trial the Eastern Cooperative Oncology Group evaluated a regimen consisting of 2 cycles of VBMCP (Vincristine 1.2 mg/M(2) IV d1, BCNU 20 mg/M(2) IV d1, Melphalan 8 mg/M(2) PO dl-4, Cyclophosphamide 400 mg/M2 IV d1, Prednisone 40 mg/M(2) PO d1-7) followed by alternating 3-week cycles of VBMCP and rIFN alpha2 5 Mu/M(2) SC 3x/week. Treatment was administered for 2 years. Fifty-eight patients with previously untreated multiple myeloma were entered. Objective response (OR) required 50% decrease in M-protein with correction of severe anemia and no progression of skeletal disease. Complete remission (CR) was defined by disappearance of M-protein and normalization of the bone marrow morphology. Life table analysis was utilized to express survival and response duration. Fifty-four patients were evaluable. Objective response was seen in 80% of patients including CR in 30% (16 patients). The median response duration is 35 months, 46 months for patients with CR. The median survival is 42 months for all patients. Five year survival is 42%. Although 78% of patients had neutrophil nadirs <1000 x 10(9)/L, the incidence of severe infection was only 9%. These data demonstrate that VBMCP + interferon is an effective new regimen combining chemotherapy with a biological response modifier for the treatment of multiple myeloma. The incidence of CR is high, and the response and survival durations appear to be 1 year longer than usually seen with standard chemotherapy. A current ECOG randomized trial compares VBMCP + interferon with VBMCP alone.

Sequential phenotyping of myeloma patients on chemotherapy: persistence of activated T-cells and natural killer cells

To better detail the status of functional T cell subsets and natural killer cells in multiple myeloma, we undertook a detailed immunophenotypic study of circulating mononuclear cells in myeloma. We studied myeloma patients entered on a large prospective, randomized ECOG chemotherapy trial EST 9486 for patients with newly diagnosed multiple myeloma. All patients were studied prior to entry and then two months after initiation of therapy (e.g. post two cycles of Vincristine, BCNU, melphalan, cyclophosphamide and prednisone (VBMCP)). The chemotherapy protocol was a three-arm protocol utilizing either VBMCP, VBMCP alternating with interferon, or VBMCP with intermittent high dose cyclophosphamide. The major findings in this analysis include significant reductions in the white blood cell count, total lymphocytes, T cell (CD3+), T helper (CD4+), and T suppressor (CD8+) cells, after 2 cycles of VBMCP. However, there was a relative sparing of Natural killer (CD16+) and activated T cell (CD2+, HLADR+) reduction in these same patients. In summary, only two cycles of combination chemotherapy resulted in significant reductions in white blood cell and lymphocyte counts in multiple myeloma patients. All cell types appear to have been reduced by chemotherapy except for activated T cells and natural killer cells. The impact of selective modulation of functional T cells subsets during therapy for patients with multiple myeloma is an important parameter which needs to be addressed in the overall approach to these patients.

Standard treatment of multiple myeloma

OBJECTIVE

To review the available standard treatment regimens for multiple myeloma.

DESIGN

Studies from the literature were summarized, and the efficacy of various chemotherapeutic regimens for induction, maintenance, and relapse therapy was assessed.

RESULTS

For many years, standard therapy for multiple myeloma has been intermittent cycles of melphalan+prednisone (MP). Although administration is easy and clinical responses are frequently good, treatment failure usually occurs in less than 2 years, and the 5-year survival is low. The combination regimens of vincristine sulfate, 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU), melphalan, cyclophosphamide, and prednisone (VBMCP) and two that feature 3-week cycles of melphalan and cyclophosphamide alternating with BCNU and Adriamycin (doxorubicin hydrochloride), either with (VMCP/VBAP) or without (ABCM) vincristine and prednisone, reportedly yield more frequent and durable responses and a higher 5-year survival than MP. Although a meta-analysis of 18 published trials found no overall difference in efficacy between MP and combination chemotherapy, the end point analyzed was only 2-year survival, and the studies were possibly too heterogeneous to afford valid comparisons. Currently, the high response rates, improved duration of disease control, and generally good toxicity profile of VBMCP, ABCM, and VMCP/VBAP make them the preferred primary treatment in patients who can tolerate more intensive therapy than MP. Elderly patients who are bedridden may have difficulty with VBMCP and related regimens and should receive MP instead. Promising results have been obtained with alternating cycles of VBMCP and recombinant interferon-alpha. As maintenance therapy, interferon has delayed relapse, whereas MP has consistently been ineffective. In patients with relapses after unmaintained responses to VBMCP, reinduction therapy with the same regimen can yield a 1-year response.

CONCLUSION

Although the issue is still unresolved, data suggest that combination chemotherapies are superior to MP for treating multiple myeloma.

AgNORs and myeloma prognosis

The argyrophilic nucleolar organizer regions (AgNORs) were analysed in bone marrow biopsies from 80 patients with multiple myeloma (MM) at presentation. The mean AgNOR number per MM cell (AgNOR counts) and their distribution within the nucleus (configuration) were assessed. AgNOR counts were significantly associated with several recognized prognostic factors: Durie and Salmon clinical staging system (p = 0.02), percentage of plasma cells (PCs) in aspirates (p = 0.01) and in bone marrow biopsies (p = 0.0000), pattern of bone marrow involvement (p = 0.0003), calcaemia (p = 0.0005) and creatininaemia (p = 0.0003). AgNOR counts were also associated with the degree of PC differentiation (p = 0.0000). A single central cluster of 2-3 large-sized AgNORs (configuration A) was evident in most G1 MM; one cluster of 4-5 medium-sized dots or two clusters of 2-4 dots (configuration B) were seen in most G2 MM; many small-sized, scattered dots were present in G3 MM (configuration C). AgNOR counts and configuration were related to the prognosis: in the univariate analysis, the 5 year survival rate was 7% for cases with > 4.5 AgNORs/cell and 46% for cases with < or = 4.5 AgNORs/cell (p = 0.01), 53% for configuration A, 12% for configuration B and 0% for configuration C (p = 0.0000). AgNOR counts (p = 0.02) and configuration (p = 0.000) were independent prognostic variables in the multivariate analysis. The AgNOR counts were significantly higher in "fulminant myeloma" than in less aggressive cases (p = 0.002). The plasma cell labelling index (LI%), evaluated in 44 MM patients, showed significant correlation with prognosis: the 5 year survival rate was 51% for LI% < or = 1 and 17% for LI% > 1 (p = 0.02). More than 70% of patients with low LI% had low AgNOR counts and more than 70% of patients with high LI% had high AgNOR counts (p = 0.007). AgNOR counts and configuration reflect the myeloma cell mass, the degree of differentiation and the kinetics of the myeloma cells. They offer an exact evaluation of the tumour characteristics and can be useful additional parameters for MM prognosis.

Light chain deposition disease (nodular glomerulopathy, kappa light chain deposition disease): a case report

A typical case of kappa light chain deposition disease is detailed. Clinical and pathological findings are described. The discussion focuses on the diagnostic challenges encountered in the diagnosis of monoclonal light chain-related renal diseases. Experimental models have played a relevant role in clarifying and elucidating fundamental questions of diagnostic significance.

Coincidental polycythemia vera and multiple myeloma: case report and review

Polycythemia vera (PCV) and multiple myeloma are both clonal disorders of hematopoietic stem cells. The simultaneous occurrence of these diseases in an individual patient is rare. A case of synchronous PCV and smoldering myeloma is presented and the literature is reviewed. The issues of clinical importance in this unusual case include the mechanisms of anemia in multiple myeloma, the difficulty in using anemia as a parameter on which to base the initiation of therapy for myeloma, and the risks of treatment-induced leukemia and myelodysplasia.

Plasma cell myeloma in the horse. A case report and literature review

Plasma cell myelomas in horses have been reported infrequently. Data from 10 cases, 9 from the literature and 1 new case, are used to characterize the disease in the horse. Hot-blooded horses (7/10), specifically Quarter Horses (4/10), were most often affected. Median age at diagnosis was 11 years (range, 3 mo-22 yr) and both male (5) and female horses (5) were represented equally. Clinical findings included weight loss (6/8), anorexia (4/8), fever (4/8), limb edema (4/8), pneumonia (3/8), rear leg paresis/ataxia (3/8), epistaxis (3/8), palpable lymphadenopathy (2/8), and bone pain (2/8). Anemia (8/8) was present routinely, and in three horses, RBCs were macrocytic. Leukopenia (2/8), thrombocytopenia (2/8), and circulating plasma cells (3/8) were variable findings. Except for abnormal protein concentrations and hyponatremia (3), abnormal results from serum biochemical analysis including hypocholesterolemia (1), hypercalcemia (1), and azotemia (1) were reported infrequently. Hyperproteinemia (8/9), hypoalbuminemia (7/9), and hyperglobulinemia (8/9) were characteristic but not invariable findings. Monoclonal proteins (7/7) were detected in the alpha 2, beta, or gamma region by serum electrophoresis. The paraprotein's heavy chain, determined in four horses, was a subclass of IgG. Three horses had decreased concentrations of normal immunoglobulins. Variable proteinuria (trace to 4+) was detected by routine urinalysis in four of six horses. Bence Jones proteinuria was detected in one of five horses (heat precipitation) and monoclonal proteins were detected in two of three electrophoresed urine samples. Three of the horses had lytic bone lesions detected radiographically. Bone marrow aspirates were diagnostic in two of five horses.(ABSTRACT TRUNCATED AT 250 WORDS)

Radiation therapy for the palliation of multiple myeloma

PURPOSE

This reviews the experience at the University of Arizona in an effort to define the minimum effective radiation dose for durable pain relief in the majority of patients with symptomatic multiple myeloma.

METHODS AND MATERIALS

The records of 101 patients with multiple myeloma irradiated for palliation at the University of Arizona between 1975 and 1990 were reviewed. Three hundred sixteen sites were treated. Ten sites were asymptomatic, including six hemibody fields with advanced disease unresponsive to chemotherapy and four local fields with impending pathological fractures. Three hundred six evaluable symptomatic sites remained. The most common symptom was bone pain. Other symptoms included neurological impairment and a palpable mass.

RESULTS

Total tumor dose ranged from 3.0 to 60 Gy, with a mean of 25 Gy. Symptom relief was obtained in 297 of 306 evaluable symptomatic sites (97%). Complete relief of symptoms was obtained in 26% and partial relief in 71%. Symptom relief was obtained in 92% of sites receiving a total dose less than 10 Gy (n = 13) and 98% of sites receiving 10 Gy or more (n = 293). No dose-response could be demonstrated. The likelihood of symptom relief was not influenced by the location of the lesion or the use of concurrent chemotherapy. Of the 297 responding sites, 6% (n = 19) relapsed after a median symptom-free interval of 16 months. Neither the probability of relapse nor the time to relapse was related to the radiation dose. Retreatment of relapsing sites provided effective palliation in all cases.

CONCLUSION

Radiation therapy is effective in palliating local symptoms in multiple myeloma. A total dose of 10 Gy should provide durable symptom relief in the majority of patients.

Hyperammonaemic encephalopathy as the presenting feature of IgD multiple myeloma

We observed a case of hyperammonaemic encephalopathy in a patient without liver dysfunction which revealed meningeal involvement of IgD multiple myeloma. We have reviewed briefly the hyperammonaemic syndrome and we believe that this diagnosis has to be considered in differential diagnosis of encephalopathies in patients with multiple myeloma.

Surgery for multiple myeloma of the spine. A retrospective analysis of 12 patients

We report on 12 surgically treated patients with myeloma of the spine. Pain relief was obtained in all the patients. Paraparesis was present in 5 patients. All 12 patients subsequently became ambulatory. The average postoperative survival was 2.3 years. Eight patients, all without symptoms from the treated lesion, survived for more than 1 year. Our experience suggests that surgical treatment of multiple myeloma of the spine may be rewarding.

Argyrophilic nucleolar organizer region counts in multiple myeloma: a histopathological study on bone marrow trephine biopsies

Argyrophilic nucleolar organizer region (Ag-NOR) analysis was performed on bone marrow biopsies from 90 patients with multiple myeloma (MM) at presentation. The pattern of AgNOR expression and its relationship to histological features were evaluated. The mean AgNOR number per plasma cell was directly correlated with the degree of MM differentiation (3.18 for G1, 4.36 for G2, 6.13 for G3; P less than 0.0001), with the percentage of bone marrow plasma cells (BMPC%) (3.06 for BMPC% less than or equal to 20, 4.28 for BMPC% 21-50, 5.14 for BMPC% greater than 50; P less than 0.0001), with the pattern of medullary involvement (3.63 for interstitial, 4.44 for nodular, 5.17 for diffuse involvement; P less than 0.001) and with medullary fibrosis (5.23 for cases with fibrosis, 4.29 for cases without fibrosis; P less than 0.05). The plasma cells of G1 MM showed 2-3 large AgNORs, tightly grouped in a central nuclear cluster; those of G2 MM showed a central nuclear cluster composed of 4-5 medium-size dots and/or two clusters of 2-3 dots; the G3 MM plasma cells showed many small dots scattered in the nucleolus or dispersed in the nucleus. Our results indicate the diagnostic value of AgNOR analysis in MM and suggest the use of this method for identifying clones of atypical plasma cells with different proliferative activity in bone marrow biopsies. It allows simultaneous evaluation of the morphology and kinetics of MM cells in routinely fixed, decalcified, paraffin-embedded material.

Histologic, biochemical, and clinical parameters for monitoring multiple myeloma

In a retrospective and prospective follow-up study from 1968 to 1989, bone marrow biopsy specimens, serum beta-2-microglobulin (SB2M) levels, and the clinical features of 251 patients with multiple myeloma (MM) and 28 patients with monoclonal gammopathy of undetermined significance (MGUS) were investigated. The main histologic variables (tumor cell type, tumor growth, tumor load, and fibrosis), SB2M level, serum thymidine kinase (STK) level, and various clinical parameters were analyzed to determine factors of value in monitoring the clinical phases of activity in MM. Our recently proposed prognostic strategy combining bone marrow histologic type, SB2M level, and signs of organ failure was tested for its ability to (1) diagnose the early and smoldering variants; (2) facilitate decisions on the time of initiation, the type and duration of initial induction therapy in the pretreatment phases (active and rapidly progressive phases); and (3) characterize variations in tumor regression and tumor-host interactions during chemotherapy (early treatment, plateau, relapse, transition, and refractory phases). The results indicate that this clinicopathologic monitoring combines information both on stage and aggressivity of MM and thus facilitates therapeutic decisions in the various clinical phases of MM.

Multiple myeloma: A review of 92 cases at King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

A review of 92 cases of multiple myeloma (66 males and 26 females) seen at the King Faisal Specialist Hospital and Research Centre from October 1975 through December 1987 revealed the age for affected patients ranged from 23 to 90 years (mean, 56 years). Six percent of the patients were less than 40 years old at the time of diagnosis. Bone pain was the most common presenting symptom in our patients (80%), most frequently involving the back. Anemia was the initial finding in 74%, followed by plasmacytoma (22.8%), hypecalcemia (19.6%), and renal insufficiency (18.5%). Skeletal survey abnormalities were seen in 92.4% of the cases, with osteolytic lesions as the predominant finding. Serum protein electrophoresis showed a monoclonal paraprotein in 78% of the cases, of which 55.5% were the IgG class. Free light chains were detected in the urine of 20 patients. The median survival time for all patients was 68 months. Twenty patients died of renal failure and/or infection. The combination of melphalan and prednison was used for treatment in 37 patients, while 31 patients received the M2 protocol and 19 patients received different therapy such as VCEP (vindesine, cyclophosphamide, VP 16 and prednisone), MPV (melphalan, prednisone, and vincristine) or high-dose melphalan. Five patients either refused treatment or died before treatment could be started.

Pneumocystis carinii pneumonia complicating multiple myeloma

Pneumocystis carinii pneumonia complicated the course of two patients with multiple myeloma. The diagnosis was established in both cases by bronchoalveolar lavage, which demonstrated the typical pneumocysts. Clinical and roentgenographic improvement in both patients was observed following a course of trimethoprim-sulfamethoxazole. One patient had lymphocyte subsets performed with a CD4/CD8 ratio of 0.8; both patients were HIV antibody-negative by ELISA. Both patients tolerated prophylactic TMP-SMX given concurrently with the subsequent chemotherapy for myeloma. We suggest that the immune defect seen in multiple myeloma may have placed these patients at risk for opportunistic infections such as P carinii pneumonia; however, as opposed to patients with AIDS, our patients tolerated therapy with TMP-SMZ quite well.

Dental implants placed in a patient with multiple myeloma: report of case

A 69-year-old male, under active treatment for multiple myeloma, fractured his left maxillary second premolar palatal abutment tooth and requested treatment because his upper partial denture no longer fit. Several other teeth were deemed hopeless, and construction of a maxillary complete denture presented problems. There are general contraindications regarding dental implant surgery in the terminally ill patient; however, in this case, the patient wished to maximize his quality of life and opted to undergo implant surgery. With close management, the treatment was successful.

Immunoregulatory cell dysfunction in chronic B-cell leukemias

Chronic B-cell malignancies are routinely characterized as B-cell clonal diseases that have signs and symptoms primarily related to the continuing expansion of these cells. This review discusses chronic lymphocytic leukemia, multiple myeloma and hairy cell leukemia from the perspective of secondary abnormalities in non-malignant cells. Thus, our main purpose is to elaborate on the alterations/abnormalities of the immunoregulatory (IR) cells in these diseases and focus on the qualitative and quantitative aspects of T-cells, natural killer (NK) cells and monocytes. The relevance of the IR-cell changes to the basic disease process and their complications are emphasized.

A case of occipitocervical fusion in myeloma

Posterior fusion (from occiput to C4) with an iliac graft on the right side and methyl methacrylate on the left side was performed in a 49-year-old woman with an osteolytic destruction of the second vertebral body caused by multiple myeloma. Thirty months after the fusion, the patient remains free from pain, although there is progression of the osteolytic lesion, now extending to the third vertebral body.

Clonal derivatives of a human B-lymphoblastoid cell line producing prolactin?A cytogenetic characterization

The IM-9-P cell line is a variant of the human B-lymphoblastoid cell line IM-9 which ectopically secretes prolactin (hPRL). The heterogeneous line IM-9-P and three sublines of clonal origin, two of them positive and one negative for PRL gene expression, were subjected to cytogenetic analysis and compared with the reference line IM-9 which showed a normal female diploid karyotype. G-banding revealed several rearrangements in the chromosomes. Nine altered chromosomes including one stable marker chromosome were common to all analysed karyotypes of IM-9-P cells and their clones. A second marker chromosome 'mar2' occurred only in the karyotypes of the hPRL producing clones, but not in the non-producing clone. None of the visible alterations involve chromosome 6 which carries the PRL gene in humans.

Detection and typing of paraproteins: comparison of different methods in a routine diagnostic laboratory

In this paper we review four methods: Protein electrophoresis (PE), immunoelectrophoresis (IEP), immunofixation electrophoresis (IFE) and a nephelometric kappa:lambda ratio method for the ability, first, to detect, and second, to isotype paraproteins in urine and serum. IFE was the most sensitive assay both in the detection of paraproteins and the most accurate in their typing. The nephelometric kappa:lambda ratio was associated with false-positive and false-negative results and cannot be considered suitable for routine diagnostic use. Although IFE was the most sensitive assay it was not without problems. Dilution of the serum to produce a concentration suitable for IFE is critical, and the assay is demanding in operator skill and time. The extra paraproteins identified by IFE are generally of low concentration and with the exception of certain well-defined clinical situations are probably not of great importance in patient management. In the case of diseases where the demonstration of a small amount of paraprotein is important, such as amyloidosis, then IFE should be performed in case other techniques fail to demonstrate a paraprotein. Otherwise, IFE is best reserved for paraproteins detected by PE which cannot be typed by IEP. A schema for the management of paraprotein identification for use in a routine diagnostic laboratory is presented.

Multiple myeloma in Korea--clinical analysis and treatment results in 61 cases

A clinical analysis was made of 61 cases of multiple myeloma diagnosed between January 1976 and June 1984 at Seoul National University Hospital using the criteria of the Southwest Oncology Group.

The following observations were made. 1) The major clinical problems at Initial presentation were bone pain(52%), anemia(20 %), renal impairment(11%), and infection(10%). 2) Clinical stages at presentation were stage I, 11%; stage II, 8%; and stage III, 81% of patients. Three(5%) of the patients in stage II and 18(31%) in stage III showed renal impairment with a serum creatinine ≥2.0 mg/dl. 3) Combination chemotherapy produced a response rate of 29% with melphalan and prednisone, and 40% with M2 protocol(among 14 and 20 evaluable patients respectively). Both regimens showed statistically significant survival difference between responders and non-responders(p <0.01). 4) The median survival of all patients was 13 months. 5)Age, calcium level, creatinine level, and performance status were important prognostic factors on survival.

Bone metastasis. Prognosis, diagnosis and treatment

Carcinoma of the breast, lung or prostate cause the majority of all bone metastases. Prolonged survival is common in patients with breast or prostate tumours. Different types of treatment may significantly increase the quality of life. Single-dose or fractionated radiation therapy may be effective, and 70 to 90 per cent of patients obtain partial or complete relief from pain. Surgery followed by irradiation is indicated in most patients with pathologic femur fractures. Immediate surgical treatment, either alone or combined with radiation therapy, may prevent paraparesis in patients with incipient cord compression. For neoplasms sensitive to systemic therapy such treatment should often be added to local treatment.

Renal function in the elimination of oral melphalan in patients with multiple myeloma

Pharmacokinetic studies in 11 patients with multiple myeloma were undertaken on the first and last days of one course of chemotherapy. The drug was administered PO in single doses of 6-14 mg daily. Melphalan concentrations were determined by high-performance liquid chromatography. The interpatient variability of pharmacokinetic parameters noted by other authors was observed. Regression analysis showed a significant positive correlation between the elimination rate constant for melphalan and renal function (P = 0.003). The form of the line which describes the overall elimination rate constant for melphalan is given by the equation: Kel = 5.67 X 10(-3) + [4.90 X 10(-5) X GFR]. There was also a significant negative correlation between renal function and the area under the plasma melphalan concentration/time curve (P = 0.006). In vitro stability studies of melphalan in plasma at 37 degrees C and pharmacokinetic data suggest that hydrolysis and renal clearance are the major mechanisms of melphalan elimination. This work shows quantitatively the relationship between renal function and drug elimination and how the data may be used in predicting melphalan half-life from creatinine clearance.