2. Paraproteinemic hemoblastoses – clonal malignancies in which the substratum is plasma cells on the stage of differentiation when they are already able to produce Ig-s or their fragments, but Ig-s or their fragments are pathological monoclonal (m-proteins).

3. Immunoglobulines Gamma-globuline fraction 5 classes: IgM, IgG, IgA, IgE, IgD 2 heavy chains 5 classes of heavy chains: γ, α, μ, δ, ε The structure of heavy chains determines the class of Ig (IgM, IgG, IgA, IgE, IgD) 2 light chains 2 types: κ, λ Determine the type of molecule (IgM-κ, IgM-λ, IgG- κ, IgG-λ, IgA-κ, IgA-λ, IgE-κ, IgE-λ, IgD-κ, IgD-λ)

4. Multiple myeloma (MM) is a malignant disorder of plasma cells characterized by: 1. a monoclonal paraprotein in serum and/or urine; 2. bone changes leading to pain and pathological fractures (either diffuse osteoporosis or lytic bone lesions ) 3. excess plasma cells in the bone marrow.

5. Incidence - MM accounts for approximately 1% of all malignant diseases and 10% of hematologic malignancies. - The annual incidence of myeloma is three to four per 100,000. - The median age at diagnosis for myeloma patients is approximately 69 years for men and 71 years for women; less than 5% of patients are younger than 40 years. Although myeloma can occur in people younger than 30 years, the diagnosis should be considered only after careful evaluation of all data and when other causes of monoclonal gammopathy or lytic lesions, such as a non-Hodgkin lymphoma or metastatic malignancy, have been ruled out.

6. Aetiology and pathogenesis The aetiology is unknown.  Exposure to ionizing radiation is the most convincing risk factor for MM. MM occurred after a long latent period in atomic bomb survivors exposed to high-dose radiation.  Exposure to various metals have been linked to myeloma. A significant risk of myeloma has been found among smelter, metallurgy, and sheet metal workers.  Benzene has been suggested as a possible etiologic agent of MM because its metabolites are known bone marrow toxins.  Familial occurrence of myeloma is well established. The cell of origin is probably a postgerminal centre B-lymphoid cell. The cells all secrete the same immunoglobulin (Ig) or Ig component, e.g. part of a heavy chain attached to a light chain or light chain (k or l) alone. Rarely (<1%) the cells are non-secretory.

7. B-cell development occurs initially in the bone marrow and subsequently in lymphoid tissues. Terminal B-cell differentiation takes place in the bone marrow. In the bone marrow, hematopoietic progenitor cells differentiate into the earliest identifiable cell type committed to the B lineage, the pro-B cell. This cell undergoes rearrangement of its immunoglobulin (Ig) heavy chain genes and is called a pre-B cell. Subsequent rearrangement of the light chain enables the cell to express surface IgM and the cell becomes an immature B lymphocyte. These cells leave the bone marrow and, on entering the peripheral blood, start to express surface IgD and are called virgin B cells. They are arrested in the G 0 phase of the cell cycle. These virgin B cells enter the lymphoid tissue, where they are exposed to antigen- presenting cells, become activated, and differentiate into short-lived low-affinity plasma cells or memory B cells. These memory B cells travel from the extrafollicular area of the lymph node to the primary follicles, where they are confronted with an antigen, presented by follicular dendritic cells, resulting in the development of a secondary response. At this stage, primary follicles change into secondary follicles containing germinal centers. Through activation by an antigen, memory B cells differentiate into centroblasts, resulting in Ig isotype switching and somatic mutations in the variable region of the Ig with the generation of high-affinity antibodies. Centroblasts then progress to the centrocyte stage and reexpress surface Ig. The centrocytes with high-affinity antibodies differentiate into either memory B cells or plasmablasts, which subsequently move to the bone marrow and ter minally differentiate to plasma cells. These bone marrow plasma cells produce most of serum Igs and have a lifespan of approximately 1 month. Cell of origin for myeloma most likely is either a memory B cell or a plasmablast.

8. During migration of the B cell through the germinal center, multiple DNA breaks occur at the level of the gene coding for the heavy chains of the Ig (14q32). In addition, while and after the antigen-primed B cell leaves the germinal center, additional DNA breaks occur when the Ig isotype switches from IgM to either IgA or IgG. These DNA breaks lead to genetic instability and an increased chance of chromosome translocations involving 14q32.

10. When myeloma cells adhere to the bone marrow stroma, stromal cells produce cytokines and inflammatory proteins such as interleukin (IL)-6, IL-1, tumor necrosis factor (TNF), and some others. In addition, myeloma cells secrete osteoclast-activating factors (OAFs), which induces osteoclast differentiation and maturation

11. Cytokines Stroma: IL-6 is a growth factor for myeloma, blocks apoptosis Support for the role of IL-6 in the survival and growth of myeloma cells has been provided by the clinical application of anti–IL-6 monoclonal antibodies and IL-6 receptor antagonists. Adhesion proteins: myeloma cells stay in the bone marrow Myeloma-cells: IL-1β, tumor necrosis factor, some others: activate osteclasts osteodecstruction

12. Pathogenetic stages Chronic One clone of malignant cells Low proliferative activity Myelodepressin, intoxication are not severe Tumor doesn’t‘ leave bone marrow Terminal Subclones of malignant cells appear High proliferative activity Metastases in other organs Severe myelodepression, intoxication Leycemisation Oncogenious mutations in the malignant clone

13. Clinics I. Asymptomatic period II. Clinics III. Terminal stage

14. I. Asymptomatic period Duration 5-15 years Patients feel good Quantity of plasma cells in bone marrow is normal Always are present: high ESR, М- protein (protein electrophoresis) resistant proteinuria

15. II. Clinical features 1. Skeletal involvement 2. Marrow infiltration—features of bone marrow failure. 3. Amyloidosis 4. Renal failure occurs in up to one-third of patients and is caused by hypercalcaemia, infection, deposition of paraprotein or light chains, uric acid or amyloid. 5. Infection—lack of normal immunoglobulins (immune paresis)and neutropenia. 6. Hyperviscosity 7. Bleeding and Anemia 8. Neurologic Symptoms 9. Hypercalcemia

17. Skeletal involvement  Bone pain, typically in the back (spine) or chest (ribs) and less often in the extremities: bones with active bone marrow  The pain usually is aggravated by movement  Pathological fracture.  The patient's height may be reduced by several inches because of collapse of one or more vertebral bodies. Sudden onset of back pain in an individual older than 40 years, especially if the complaint is new for the patient, is sufficient to suspect the diagnosis of myeloma and should lead to a proper workup for the disease.

18. X-rays, CT scan or MRI show lytic lesions typically in skull and axial skeleton and/or osteoporosis, often with pathological fractures

22. Marrow infiltration, bone marrow failure Peripherial blood Myelogramm 1. Anaemia is frequent, often with neutropenia and thrombocytopenia. 2. Erythrocyte sedimentation rate (ESR) often >100 mm/h. 3. Blood film shows rouleaux with a bluish background staining, caused by the protein increase. Bone marrow shows >15% plasma cells, often with multinucleate and other abnormal forms Cell polymorphism (plasmoblasts, pro- plasmocytes, mature plasmocytes) He younger the cells are, the worse prognosis is. Bone aspirete may be normal (solitary, multi-focal forms)

23. A paraprotein in serum and/or Bence Jones protein (light chains) in urine with suppression of normal serum immunoglobulins is usual. The paraprotein is IgG in 70%; IgA in 20%; IgM is uncommon; IgD and IgE are rare. Total protein in serum is > 90-100 g/l: hyperglobuliemia, hypoalbuminemia. Resistant proteinuria Amyloidosis

24. Proteinuria The result of the Bence-Jones protein persistance in the urea. Warming test (urea becomes мутнеет при нагревании до 60 0, при дальнейшем нагревании помутнение исчезает. Is positive when the excretion of light chains is more than 1 g/day Can be detected in urea proteins electrophoresis

25. Light chains in urea Can be detected in small amount in tuberculosis, secondary amyloidosis, autoimmune diseases. At the same time there are light chains of the both types: κ и λ) In MM– only monoclonal light chains λ or κ

26. Amyloidosis In 15% or cases Amyloidosis may cause macroglossia, hepatosplenomegaly, cardiac or renal failure, carpal tunnel syndrome and autonomic neuropathy.

27. Myeloma kidney Myeloma kidney is characterized by the presence of large, waxy, laminated casts in the distal and collecting tubules. The casts are composed mainly of precipitated monoclonal light chains and are surrounded by multinucleated syncytial epithelial cells (giant cells). The casts result in dilation and atrophy of the renal tubules. Eventually the entire nephron becomes nonfunctional, and interstitial fibrosis may occur Renal glomeruli can be involved later

28. Myeloma kidney Proteinuria 1-15 g/l, more Mainly – light chain proteinuria, the quantity of albumin is small (glomeruli function stays normal for very long time) Despite severe proteinuria nephrotic syndrome doesn’t occur Renal failure occurs in up to one-third of patients and is caused by hypercalcaemia, infection, deposition of paraprotein or light chains, uric acid or amyloid.

29. Secondary immunodeficiency The reason is suppression of normal serum immunoglobulins: paraproteins are non-functional Igs The paraprotein is IgG in 70%; IgA in 20%; IgM is uncommon; IgD and IgE are rare. Frequent infectious complications (pneumonias, broncitises; pyelonephritises, other)

30. Hyperviscosity Because of a greater tendency for IgA to form polymers, patients with IgA myeloma more often have features of hyperviscosity, resulting in circulatory problems and leading to cerebral, pulmonary, and renal manifestations. Plasmapheresis is the appropriate treatment of the condition.

31. Bleeding problems Occur in 15% of IgG myelomas and 30% of IgA myelomas and may be due to platelet dysfunction or acquired coagulopathy. Thrombocytopenia, even with extensive bone marrow involvement, is rare in the early phases of the disease.

32. Neurologic Symptoms Are the result of compression by a soft-tissue plasmocytoma or bone fragments of a vertebral body on the spinal cord or on a nerve. In addition to back pain with radicular features, weakness or paralysis of the lower extremities and bowel or bladder incontinence may occur. Peripheral neuropathy is uncommon in MM and almost always is associated with amyloidosis. It is seen in osteosclerotic myeloma and sometimes is part of the polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, and skin changes (POEMS) syndrome.

33. Hypercalcemia In 20-40% of cases The cause is osteolysis Leads to lethargy, polyuria, polydipsia, constipation, nausea, vomiting, renal failure

34. III. Terminal stage Severe clinics Transformarion into acure plasmoblastic leucosis Production of pIg is often goes down despite the progress

35. Rare vatiants of MM D-myeloma E-myeloma M-myeloma Bence-Jones myeloma Nonsecretic myeloma Solitar myeloma Osteosclerotic myeloma

36. Diagnosis A monoclonal protein (M protein) is evidenced on serum protein electrophoresis as a spike or localized band in the β- or γ-globulin region in 90% and in the urine in 80 of patients Serum b2 microglobulin (b2M) often raised and higher levels correlate with worse prognosis.

37. Multiple myeloma: protein electrophoresis. Lane 22 shows a normal patient. Patient 23 has a paraprotein. The panel on the right shows that this paraprotein reacts with IgG (G) and l (L) antisera, and is therefore of IgG l type.

38. Data from lane 23 presented graphically and numerically. Name %g/LNormal (g/L) Albumin 27.2 24.835 – 47 Gammaglobulin 2.1 1.925 – 33 Paraprotein 47.6 43.4

39. Differetial diagnosis of MM 1. Other parapteinemias 2. Anemias 3. Renal diseases: glomerulonephritis, pyelonephritis, renal tuberculosis, amyloidosis, renal tumors, others 4. Cancer mts in bones 5. Osteosarcoma 6. Osteoporosis 7. Severe immunodeficites 8. Benign monoclonal gammopathy

40. Benign monoclonal gammopathy Also termed monoclonal gammopathy of undetermined significance, MGUS is an indolent disorder, more common than myeloma characterized by a low (< 20g/L) and stationary serum level of paraprotein, no reduction in normal immunoglobulins, absence of skeletal abnormalities and of Bence Jones protein and less than 10% plasma cells in the marrow. It may progress slowly to myeloma or lymphoma in approximately 10–30% of patients.

41. Treatment Symptomless patients who are stable with normal blood counts and renal function, no skeletal disease and low levels of paraprotein warrant observation rather than therapy.

42. Chemotherapy Initial treatment depends on age. In patients >65 years, induction is usually with melphalan and prednisolone or combination chemotherapy, e.g. Adriamycin, BCNU, cyclophosphamide and melphalan (ABCM) given intermittently every 4–6 weeks. Most patients will reach a stable (plateau) phase (clinically well with near normal blood count, <5% plasma cells in bone marrow, stable paraprotein level) after 4–6 cycles of treatment. This lasts 1–3 years. α-Interferon may prolong duration of plateau phase. Younger patients (<65 years) benefit from intensive induction with courses of, for example, vincristine, Adriamycin and dexamethasone (VAD) or cyclophosphamide, dexamethazone and thalidomide (CDT), followed by high-dose chemotherapy.

43. Most patients relapse and median survival is 4–6 years from diagnosis. Relapsed cases may be retreated with initial therapy or with other combinations, e.g. idarubicin and dexamethasone. New drug therapies include thalidomide and the proteosome inhibitor bortezimide (Velcade). Velcade blocks the cell cycle regulation, angiogenesis, migration and metastazing of malignant cells and results in apoptosis of plasma cells. Velcade may be used as monotherapy or in combinations with other.

44. The results of treatment Comlete remission – negative РIg in serum and urea, normal bone marrow; Comlete responce– reduction of serum protein mote than 75% and/or 90% reduction of urea protein; Partial response – reduction of РIg more than 50%, but less than 75%; Objective response (stabilisation, plato) – reduction of РIg more than 25%, but less than 50%; Absence of response– reduction of РIg less than 25% or progress.

45. Radiotherapy is helpful in relieving pain from localized skeletal disease; hemi-body radiotherapy may help to control systemic disease. Supportive care includes hydration to prevent/treat renal failure, Hydration, steroids and bisphosphonates for hypercalcaemia, antibiotics, erythropoietin and blood components. Bisphosphonates (e.g. oral sodium clodronate or ibandronate, or intravenous pamidronate or zoledronate) are useful in reducing skeletal complications and may improve survival. Surgery may be required for complications (e.g. pathological fracture, spinal cord compression). Plasma exchange is helpful in reducing the paraprotein level quickly.

46. Prognosis MM is a highly heterogeneous disease, with survival ranging from a few months to several years. The median survival achieved with standard treatment is approximately 3 years; a small percentage (5%) of patients survive more than 10 years. Prognostic data include haemoglobin level, serum levels of β2M, serum creatinine and extent of skeletal disease. The serum level of β 2 M is one of the most important prognostic factors in myeloma. β 2 M is a small protein that associates with human leukocyte antigen class I and normally is excreted by the kidneys. It reflects tumor load and renal function

47. Thank you for your attention! Questions are welcome.