Multiple Myeloma Diagnosis & Treatment
Diagnosis
If you have symptoms that may signal multiple myeloma, your doctor will examine you and ask you questions about your health and your medical history.
How is multiple myeloma diagnosed?
One or more of the following tests may be used to find out if you have multiple myeloma. These tests also may be used to find out if treatment is working.
Blood and urine tests determine calcium levels and changes in abnormal proteins that multiple myeloma produces. In the blood, these proteins are called paraproteins. A test called serum protein electrophoresis (SPEP) measures paraproteins. In the urine, these proteins are called Bence-Jones proteins. They are measured by collecting a 24-hour urine sample and running a urine protein electrophoresis (UPEP).
A blood test called an immunofixation (IFE) test, may help find small traces of abnormal proteins. Immunoglobulins and light chains are checked in the blood; myeloma can make increased levels of these proteins. These tests are also followed in the blood to evaluate how the disease is responding to treatment.
Bone marrow aspiration and biopsy: For the majority of patients, myeloma is found in the bone marrow. Plasma cells that turn into cancer cells define myeloma and plasma cells normally reside in the bone marrow. This test not only informs whether someone has myeloma, but also provides information on how aggressive the cells are which helps with prognosis and appropriate treatment planning.
Biopsy: Multiple myeloma can cause tumors called plasmacytomas in the bone or soft tissue around the bone. These tumors may be biopsied, or surgically removed and examined under a microscope for the presence of cancer cells.
Imaging tests, which may include:
- X-rays
- PET (positron emission tomography) scans
- MRI (magnetic resonance imaging) scans
- Bone density scan
- CT or CAT (computed axial tomography) scans
These tests may not be performed in all cases. However, they can help your doctor detect complications associated with multiple myeloma, like bone lesions, and also determine if cancer has spread.
Treatment
If you are diagnosed with multiple myeloma, your doctor will discuss the best options to treat it. This depends on several factors, including the type and stage of the cancer and your general health.
Your treatment for multiple myeloma will be customized to your particular needs. One or more of the following therapies may be recommended to treat multiple myeloma or help relieve symptoms.
Watchful waiting
For patients with asymptomatic (smoldering) myeloma or monoclonal gammopathy of undetermined significance (MGUS), a watchful waiting approach may be appropriate. The watchful waiting approach involves closely monitoring multiple myeloma without active treatment.
Chemotherapy
Chemotherapy is the usual starting point in treating multiple myeloma. It uses special drugs that kill fast-growing cells, like multiple myeloma cells. MD Anderson offers the most up-to-date and advanced chemotherapy options.
Targeted therapy
MD Anderson is among just a few cancer centers in the nation that are able to offer targeted therapies for some types of multiple myeloma. Targeted therapy is a broad term used to describe drugs that specifically target weaknesses of the cancer cells. This can mean targeting the blood vessels that feed tumors or attacking specific genetic and proteins of cancer. Ultimately, by targeting the weaknesses of cancer, these treatments help stop its growth and spread.
Immunotherapy
Immunotherapy is one of several innovative targeted therapies performed by MDAnderson. It uses your own immune cells to fight off cancer cells. Usually, the immune system does not attack cancer cells because they produce special proteins that help them blend in with other cells. Immunotherapy drugs interfere with the production of these proteins, triggering an immune response to fight off your cancer. There are a few different methods used for immunotherapy, including:
- Monoclonal antibodies, including Darzalex (daratumumab) and Empliciti (elotuzumab)
- Chimeric antigen receptor T cells (CAR T cells), which are genetically modified T cells that fight the myeloma directly
- Bispecific t cell engagers, which help activate and get your own immune cells next to myeloma cells in your body to kill them
- Cytokine therapies
- Vaccine therapy
Radiation therapy
Radiation therapy often plays a valuable role in providing quick pain relief and decreasing the risk of fractured bones. It involves using a high-energy beam to quickly kill cancer cells in a specific area. Radiation therapy can help prevent nerve compressions by attacking soft tissue collections of myeloma cells (plasmacytomas). It is also useful for targeting plasma cell tumors present in one location (solitary plasmacytoma). In these situations, radiation therapy alone is often used as the primary treatment.
A typical radiation treatment plan for a patient with multiple myeloma includes five sessions a week for approximately two weeks. We use computed tomography (CT) scan based radiation planning, immobilization devices to minimize patient movement during treatment, and modern radiation planning techniques that permit focused radiation delivery. Our Radiation Oncology Center treats more than 100 multiple myeloma and plasmacytoma patients each year, with a team of four skilled radiation oncologists who specialize in the management of patients with hematologic malignancies. Our ultimate goal is to administer effective, safe, modern radiation therapy while limiting toxicity.
Stem cell transplants
A stem cell transplant (or bone marrow transplant) replaces defective or damaged bone marrow cells with your own healthy blood-forming cells. First, your doctor will remove some of your healthy, blood-forming stem cells. Then, you will receive high-dose chemotherapy to kill off the diseased bone marrow cells. Finally, your healthy blood-forming stem cells will be transplanted in place of the diseased tissue. If a stem cell transplant is needed, MD Anderson has one of the most active and advanced programs in the nation.
Plasma exchange
High levels of abnormal proteins can lead to thickening of the blood. The liquid component of your blood, called the plasma, can be removed and replaced with normal plasma from a healthy donor. This can quickly relieve symptoms of increased blood thickness (hyperviscosity) until chemotherapy/immunotherapy has a chance to destroy the multiple myeloma cells that produce the abnormal protein.
Learn more:
After completing a course of treatment, there are few words that sound better to a patient than “complete remission.” It’s an indication that the treatment has worked, and there is no evidence of cancer based on scans or lab tests.
However, there is a different phrase that can be somewhat confusing to patients – minimal residual disease (MRD). This term is used often by physicians when treating patients with blood cancers, such as leukemia, lymphoma or multiple myeloma.
MRD refers to cancer cells remaining after treatment that can’t be detected by those same scans or tests. But what exactly does it mean for patients?
To learn more about minimal residual disease, we spoke with leukemia specialist Ghayas Issa, M.D., of MD Anderson’s Myelodysplastic Syndromes (MDS) and Acute Myeloid Leukemia (AML) Moon Shot® team. Here’s what he shared.
How do you explain minimal residual disease to patients?
Minimal residual disease is a small number of cancer cells left in the body after treatment. These cells have the potential to come back and cause relapse in our patients.
In leukemia, for example, we look for response after chemotherapy treatment by looking under the microscope for cancer cells present in a bone marrow biopsy. When there are no cancer cells present, and the bone marrow is making normal cells, we call that a complete response.
However, we know that if we don’t do further treatment, a portion of these patients will experience a relapse. That means there were some leukemia cells hiding that we weren’t able to detect under the microscope. That is minimal residual disease, or perhaps a better term is measurable residual disease. Typically, these cells don’t cause any symptoms, but they have the potential to lead to a relapse.
If we can’t detect minimal residual disease under the microscope, how do we test for it?
We now have much more sensitive assays available to us that allow us to quantify MRD. These could include next generation genetic sequencing, where we can analyze bone marrow samples for genetic mutations. If there are mutations present, that means there is minimal residual disease, even though we can’t see anything under the microscope.
We can also use a technique called flow cytometry, which allows us look in the same samples for abnormal proteins on the surface of cells. By determining how many cells have abnormal proteins detected, we can get a better sense of residual cancer cells. Using these new assays, we routinely try to quantify whether a patient has MRD following standard treatment.
What are the implications for a patient who has evidence of minimal residual disease after treatment?
That’s difficult to say, because it’s not the same across all types of blood cancers. Some patients with MRD will have different responses than others. In general, if a patient has MRD, we need to do additional treatments to work toward the best outcome. If we do nothing, we know that the residual cells will cause a relapse.
It also depends on the timing of the MRD test. In my leukemia patients, if there is MRD after the first cycle of chemotherapy treatment, it tells me that I probably need to give more treatment — either a different medication or a different course of treatment. If there is still MRD after many rounds of chemotherapy, that is an indication that the patient may need to have a stem cell transplant, when otherwise it might not have been appropriate.
Ultimately, MRD is a marker that we need to be more aggressive in our treatment to try and prevent the cells from coming back.
What can cancer researchers learn from the residual cancer cells?
We can learn a great deal. These cancers can adapt to treatment, meaning the cancer we start with is not the same as what we have after treatment. By studying the minimal residual disease, we can learn more about what is left after treatment.
That helps us to do several things. First, it allows us to modify our treatment, either by adding medications that target specific vulnerabilities in the cancer cells, including medications that are especially good at killing even residual cells, or doing a stem cell transplant, which is able to take care of residual cells.
Currently, I work with a wonderful team through the MDS and AML Moon Shot to study these residual cancer cells in order to find new vulnerabilities. Through our research, we’re hoping to identify new treatments that we can use in the future to specifically eliminate minimal residual disease.
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