Managing High-Risk Multiple Myeloma - Episode 1

A Case of High-Risk Multiple Myeloma

C. Ola Landgren, MD:This patient is a 74-year-old lady. She presents with renal failure. She has pain from her hip. She also presents with fatigue. And blood work is being done to clarify what’s going on, and the lab work shows that she has anemia. The hemoglobin is just barely over 10. Her creatinine is elevated, and also her estimated glomerular filtration rate is decreased—and these 2 are clearly linked with each other.

Further workup shows that she has high levels of kappa-free light chains in her blood, and that’s probably what’s contributing to the renal failure. She also has a monoclonal protein in her blood. Many patients present with both monoclonal proteins and light chains. In fact, 80% of patients who have plasma cell disorder would have a monoclonal protein, and the majority of them also do release light chains in combination.

Further workup of this patient shows, with imaging, that there is evidence of lytic lesions, and the lytic lesions are corresponding with the site where the pain is located, which is very typical. This is manifested in this case by lytic lesions in the leg, in the hip area where the pain is from. But there also is evidence of lytic lesions elsewhere. And it’s also very typical of patients who present with myeloma to have manifestations of bone disease throughout the skeleton.

Lastly, the patient is worked up with a biopsy of the bone marrow, which shows a pretty high plasma cell percentage. It’s estimated to be about 70% by immunohistochemistry. In a healthy person, the plasma cell percentage would be less than 5%, so here we have a much higher number. And it’s also confirmed with the immunohistochemistry and the corresponding immunophenotyping by flow cytometry that these plasma cells are light chain restricted. They are kappa light chain—restricted, which fits with the bloodwork showing the IgG kappa monoclonal protein and the overproduction of kappa light chain in the blood. So, all these pieces fit very well together.

As part of the workup of the bone marrow, FISH and cytogenetics have been conducted, and the reports say that the majority of the cells are expressing 17p deletions, which is known as one of the high-risk features. So, what we have here in front of us is a 74-year-old lady who presents with the classic symptoms of pain, fatigue, and also there is renal failure. And the workup confirms myeloma. I think it’s important, before we go further into the case, to also go over her background history. She has comorbidity. She has hypertension, and she also has a history of diabetes. Both of these conditions are being treated and out of control, but they will also impact management going forward, and we need to take this into account when talking about treatment and management.

Transcript edited for clarity.

  • A 74-year-old woman presented with anemia, proteinuria, renal insufficiency, and pain in her right hip
  • History: chronic HTN, aortic insufficiency, diabetes mellitus
  • ECOG performance status, 1
  • X-Ray of the pelvis showed numerous lytic lesions in the ilium and a large lesion in the right proximal femur
  • MRI confirmed a 9-mm lesion in the right femoral head and numerous bilateral T1 hypointense and T2 hyperintense lesions in both iliac region
  • Laboratory results:
    • Hb, 10.1 g/dL
    • Ca2+3.32 mmol/L
    • Creatinine, 1.9 mg/dL
    • Creatinine clearance, 30 mL/min
    • M-protein, 1.4 g/dL
    • B2M, 4.9 mcg/mL
    • SFLC, kappa, 150 mg/dL
  • Bone marrow biopsy, 70% plasma cells
  • Molecular testing, del17p