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02.15 Multiple Myeloma

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Overview

Multiple Myeloma- cancer of the plasma cells aka malignant plasma cells

Nursing Points

General

  1. Pathophysiology
    1. Differentiation- (one possible path) Bone Marrow Stem Cells -> WBCs -> B Lymphocytes -> Plasma Cells
      1. WBCs- fight infection, fuel immunity, arise from stem cells in the Bone Marrow
      2. B Lymphocyte (antibody driven immunity) -> Plasma Cell
      3. Plasma Cells- secrete antibodies (proteins that kill invaders) in response to antigens (unique molecules on invaders)
        1. Malignant Plasma Cells (Multiple Myeloma) secrete abnormal antibodies called monoclonal antibodies or M proteins that do not fight infection
    2. Monoclonal Gammopathy of Undetermined Significance (MGUS) vs Smoldering Multiple Myeloma (SMM) vs Multiple Myeloma (MM)
      1. MGUS- low levels of M proteins and therefore abnormal plasma cells, no damage
      2. SMM- intermediate levels of M proteins and abnormal plasma cells, no damage
      3. MM- active disease with damage
      4. 20% of pts with MGUS develop MM, risk is 1% per year

 

Assessment

  1. Signs/Symptoms
    1. Decreased Immunity/ Increased Infections- fewer functioning antibodies to fight
    2. Anemia/Pancytopenia- malignant cells crowd bone marrow decreasing functional/normal cells
    3. Bone Pain/Lytic Lesions (damaged spots), 2-fold-
      1. Crowd out normal bone cells
      2. Secrete osteoclast activators
    4. Impaired Kidney Function- M proteins build up and cause damage
    5. Neuro, 2-fold
      1. Bone destruction leading to spinal cord damage
      2. M proteins are toxic to nerves (PN)
    6. Hypercalcemia- multifactorial but mostly from bone destruction
  2. Diagnosis
    1. Blood Tests & Bone marrow biopsy and aspiration–> look for abnormal cells and M proteins, altered CBCDs (CBC with differential)
    2. Urine- can detect M proteins and kidney damage (glomerular damage causes leakage of large cells due to big sieve holes)
    3. Imaging- looking for bony abnormalities and lytic lesions
    4. CRAB Criteria- C- Hypercalcemia, R- Renal Insufficiency, A- Anemia, B- Bone Disease
  3. Risk Factors
    1. Older Age- 65+
    2. Male- slightly more than women
    3. Black- 2x more than whites
    4. Obesity- the only modifiable risk factor
    5. Family history- can sometimes run in families

Therapeutic Management

  1. Treatments
    1. MGUS and SMM- watch and wait, no treatment
    2. Targeted treatments- target specific abnormalities on malignant cells
    3. Biological or immunomodulating treatments- use the body’s immune system
    4. Chemotherapy- kills all rapidly dividing cells
    5. Radiation treatment- damages all rapidly dividing cells so that they die
    6. Corticosteroids- boost immune system, can directly act against abnormal plasma cells
      1. Watch for bone and renal damage with long term steroids
    7. Bone marrow transplant (BMT)- kill all Bone Marrow and replace with new cells
    8. Symptomatic treatment
      1. Bisphosphonates to preventbone loss
      2. Bone marrow stimulators
      3. Blood transfusions for pancytopenia

Nursing Concepts

 

  1. Cellular Regulation
  2. Immunity
  3. Lab Values

Patient Education

  1. Nursing Care and Pt Ed- SAFETY!!
    1. Protect from infections
    2. Protect from mechanical bone damage (falls)
    3. Protect from foot/hand/limb damage- Peripheral Neuropathy similar to diabetes or paralysis
    4. Additional nursing care for side effects of treatments

 

Reference Links

Study Tools

Video Transcript

Today we’re going to be talking about Multiple Myeloma. It’s a LOT of information so bear with me! The nursing concepts are Anatomy & Physiology, Cellular Regulation, Immunity, and Lab Values. Since Multiple Myeloma is a disease of plasma cells which are a type of white blood cell and it involves antibody immunity, we’ll do a quick overview of these first. If we remember all the way back to A&P, all blood cells are made in the bone marrow and start as stem cells. Those stem cells then form into the different types of blood cells which is called differentiation. This is just one possible pathway for a stem cell to take that makes a plasma cell. First the stem cell becomes a white blood cell which fight infection and boost immunity. The white blood cell then becomes a B lymphocyte which is involved in antibody driven immunity- we’ll talk about antibodies in a minute. Finally, the B lymphocyte becomes a plasma cell which secrete those antibodies. Now that we know how the cells involved are made, we can look at how antibody driven immunity works. Antigens are molecules on invaders such as bacteria or viruses that identify them. Think of them like nametag. Antibodies secreted by the plasma cells are specific proteins that recognize those antigens and flag them for destruction. Think of them like an eviction notice. Each antigen and antibody pair are for the most part a matching set since the antibody is made for that specific antigen. They are like a lock and key. Ok so now that we remember all that, we can understand Multiple Myeloma. Multiple Myeloma is cancer of the plasma cells or malignant plasma cells. The diseased plasma cells secrete abnormal antibodies called Monoclonal antibodies or M Proteins (write these out). Since M proteins are not normal and don’t fit any locks, they do not fight infection. They also start a complicated cascade process to activate osteoclasts which are the bone breaker down cells weakening the bones. Finally, remember cancer cells of any type have lost apoptosis or natural cell death and grow out of control. In Multiple Myeloma, they overgrow and overcrowd in 2 ways- in the bloodstream crowding out normal blood cells of all kinds and in the bone marrow itself pushing out it into the bones. Think of your pants after a big meal. The inside becomes too big for the outside, so it gets tight and painful. The signs and symptoms are all related to the abnormal antibodies and the overgrowth. Since the antibodies don’t work to kill anything and they’ve pushed out normal functioning white blood cells, we don’t have the protection or immunity against infections. As the bad plasma cells crowd out normal blood cells in the bloodstream, we get low blood cells of all kinds or pancytopenia. When either the bones break down or the bad bone marrow pushes out into the bones (or both!), they create pockets of weak bone called lytic lesions which are more likely to break. These are all painful processes. As those bones break down and weaken, they release all their calcium into the blood causing hypercalcemia. If spinal bones are weakened or break, they can cause spinal cord damage. Also M proteins are toxic to nerves. Both of these can cause neurological issues ranging from peripheral neuropathy with tingling and numbness all the way up to paralysis. With all these extra cells and waste products of cell destruction, the kidneys get damaged. Think of the kidneys like a strainer with lots of little holes to filter the blood. If too much goes through the strainer, it damages the holes making them bigger and healthy stuff falls out. Testing is mostly looking for the M proteins or abnormal plasma cells. They can be in the peripheral blood, bone marrow or urine. Blood and urine can also show us kidney function. We can look for bone abnormalities and lytic lesions with imaging such as XRays, MRIs and CT Scans. To be diagnosed with active Multiple Myeloma, you must meet the CRAB criteria which means you have some sort of damage. CRAB stands for: hyperCalcemia, Renal, Anemia, Bone disease. You have to have one of those. Nursing care and patient education is all about protection. Protection from infections with handwashing, face masks, social distancing… sound familiar? Protection from mechanical bone damage like falls and bumps Protecting the extremities from damage when the nerves can’t tell us they’re being hurt. Just like diabetic peripheral neuropathy. Precautions like wearing shoes and gloves and checking water and floor temperatures prevent damage. Also, we need to remember to treat any side effects from treatment with things like antiemetics, cell stimulators to make healthy cells, transfusions and appetite stimulants. What are the risk factors for Multiple Myeloma? Older age- less than 1% are people under 35 and the majority are over 65 Men are slightly more likely to get it than women African Americans are almost twice as likely to get it than other races There is a genetic component so if we have a close family member with it, we are slightly more likely to get it. The only modifiable risk factor is obesity, but we aren’t sure of the connection. Treatments are all about decreasing the number of abnormal plasma cells. Remember all cancer cells of any kind are rapidly dividing and growing out of control. Chemotherapy- kills all rapidly dividing cells including cancer cells Radiation- damages all rapidly dividing cells so that they die Targeted treatments- target specific abnormalities on malignant cells to kill them Biological or immunomodulating treatments- use the body’s immune system to attack the cancer cells Bone Marrow Transplant- kills all bone marrow and replaces it with new cells And Corticosteroids- boost immune system and can directly act against abnormal plasma cells. Don’t forget long term steroids can cause bone damage and bone marrow suppression so that’s a fine line. Patients can sometimes have abnormal plasma cells (and therefore M proteins) in low levels that have not caused damage… YET… There are 2 different precursors to Multiple Myeloma like this. Think of these like pre-labor. The contractions are there, but they aren’t causing any cervical change yet. The first is Monoclonal Gammopathy of Undetermined Significance or MGUS This is low levels of abnormal plasma cells 1% of people with MGUS go on to develop cancer The other is Smoldering Multiple Myeloma This is a medium level of abnormal cells Think of this like a smoldering fire, its hot and red but doesn’t have flames yet. Finally, once or if the abnormal cells reach high enough levels to cause damage on the CRAB criteria, then its active Multiple Myeloma. Hippocrates said “Cure sometimes, treat often, comfort always.” This was a lot of information so thanks for hanging in with me! I hope this helps and Multiple Myeloma isn’t so confusing anymore! Go out and be your best self today! And as always, Happy Nursing!

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