Multiple myeloma

Disease Description (Causes and Symptoms)

• Definition summary: Multiple myeloma is a blood cancer in which plasma cells in the bone marrow proliferate abnormally, overproduce monoclonal immunoglobulins (M-protein or light chains), and infiltrate the bone marrow.
• Causes/pathophysiology: Genetic predisposition, abnormalities in immune regulation, and exposure to radiation or chemicals may be associated with the disease. Symptoms develop through clonal proliferation of plasma cells → bone destruction (osteolysis), reduced bone marrow function, and accumulation of abnormal proteins (kidney damage, hyperviscosity, etc.).
• Main symptoms: Fatigue (anemia), bone pain/fractures (especially of the spine and ribs), frequent infections (reduced immune function), reduced kidney function (proteinuria, kidney failure), hypercalcemia (nausea, lethargy), bleeding tendency or bruising (thrombocytopenia), etc.
• Key diagnostic points: Blood tests (complete blood count, serum protein electrophoresis/immunofixation, free light chain testing), urine tests (Bence Jones/protein electrophoresis), bone marrow tests (bone marrow aspiration and biopsy, assessment of the plasma cell percentage), imaging tests (plain bone radiography, MRI/CT/FDG-PET), and risk assessment through cytogenetic testing and FISH.

Treatment Methods and Precautions

• Standard treatment (summary)
  • Initial treatment (newly diagnosed): Combine the following while considering the stage, the patient's condition, and concerning high-risk factors.
    • Standard induction therapy: Proteasome inhibitor (such as bortezomib) + immunomodulatory agent (such as lenalidomide) + steroid (dexamethasone) — e.g., VRd (bortezomib + lenalidomide + dexamethasone).
    • Select adjusted-dose treatment or single-agent therapy for older or refractory patients.
  • Autologous stem cell transplantation (ASCT): In eligible patients (generally those aged 65–75 years or younger, or those in good overall condition), performed after induction therapy together with high-dose myeloablative therapy to induce remission and prolong survival.
  • Maintenance therapy: Maintenance treatment with lenalidomide or similar agents after transplantation or in patients who did not undergo transplantation to prolong progression-free survival.
  • Relapsed/refractory disease: Various drugs and combination therapies are used, including carfilzomib, daratumumab (anti-CD38), pomalidomide, carfilzomib, and novel immunotherapies (antibody-drug conjugates, CAR-T, etc.).
  • Localized bone lesions: Radiation therapy (to relieve pain and improve compression symptoms), and orthopedic surgery (for pathological fractures or spinal cord compression).
• Symptomatic and supportive treatment
  • Bone protection: Bisphosphonates (such as zoledronate) or denosumab to suppress progression of bone lesions and reduce the risk of bone pain and fractures.
  • Infection prevention and treatment: Because the risk of infection is high, preventive vaccines (inactivated vaccines are recommended) and, when necessary, antibiotics or antiviral drugs.
  • Kidney protection: Correct dehydration, hypercalcemia, and electrolyte imbalance; dialysis if necessary.
  • Manage anemia with transfusions and hematopoietic growth factors, when necessary.
• Major side effects and precautions
  • Anticancer drug side effects: Bone marrow suppression (infection and bleeding), gastrointestinal symptoms, hair loss, nephrotoxicity (which varies by drug), and peripheral neuropathy (such as with bortezomib).
  • Immunomodulatory agents (such as lenalidomide): Increased risk of thrombosis → consider prevention of venous thromboembolism (anticoagulation).
  • Bisphosphonates/denosumab: Risk of osteonecrosis of the jaw → dental examination before treatment and caution with dental procedures.
  • Infection prevention: Vaccines (such as influenza and pneumococcal vaccines) are recommended, but live vaccines should be avoided.
  • Pregnancy/fertility: Some drugs (such as lenalidomide) carry a strong risk of causing birth defects → contraindicated during pregnancy; contraception is necessary.
• Complication monitoring: Continuous monitoring is needed for infection, fractures/spinal cord compression, kidney failure, hypercalcemia, bleeding tendency, and other complications.

Checklist Before an Outpatient Visit (Including Preparation Items and Example Questions)

• Items/documents to prepare
  • List of currently taken medications (including prescription drugs, over-the-counter drugs, and supplements)
  • Copies or summaries of previous test results (blood tests, urine tests, bone marrow tests, imaging tests, etc.)
  • Allergies and history of previous surgeries and hospitalizations
  • Symptom diary (location and intensity of bone pain, fever/frequency of infections, changes in urine volume, bleeding/bruising, degree of fatigue, etc.)
  • Recent weight changes, dietary and exercise habits, alcohol use, and smoking history
• Items to check before the outpatient visit (by the patient)
  • Whether there has recently been a fever or symptoms suggestive of infection
  • Any recent fracture or newly occurring severe pain (especially in the spine)
  • Changes in urine color (dark urine may indicate highly concentrated proteinuria)
  • Medication adherence and whether any side effects have been experienced

Examples of General Questions to Ask the Doctor

• "What are my stage and risk level (cytogenetics/FISH), and how do they affect my prognosis?"
• "What initial treatment do you recommend, and what are the expected goals (complete remission, partial response, etc.)?"
• "What are the major side effects of each treatment, and how are they managed?"
• "Am I a suitable candidate for autologous stem cell transplantation? What are the timing and procedures?"
• "What should I be especially careful about in daily life (infection prevention, exercise, diet, etc.)?"
• "Is participation in a clinical trial possible?"

Examples of Disease-Specific Questions

• "How are my M-protein level and free light chain (kappa/lambda) ratio changing, and how do you assess my response to treatment?"
• "Is treatment with a bisphosphonate (or denosumab) recommended? What dental preparations are needed to prevent osteonecrosis of the jaw?"
• "What prevention (aspirin, low-molecular-weight heparin, etc.) do you recommend to lower the risk of thrombosis?"
• "My kidney function is reduced (creatinine level/urine output). Is a different medication choice or dose adjustment necessary?"

In brief, multiple myeloma requires multidisciplinary management (hematology, medical oncology, radiation oncology, orthopedics, nephrology, etc.), and the key steps are diagnosis (blood, bone marrow, and imaging) → appropriate drug therapy and supportive care → long-term follow-up. Treatment choices and side-effect management vary according to each patient's individual risk level and overall condition.