Prepared by:

Maribec V. Pagaduan
A 69 year old male complained of pain
in his lower back upon bending over in
his garage.
He worked in a petroleum plant for 15
years.
He also complained of easy fatigability.
A radiograph of the spine shows a
compression fracture of the lumbar
vertebrae at L2 L3.
Further evaluation reveals
normocytic anemia, hypercalcemia,
and a high globulin fraction. Bone
marrow biopsy was also done.
 Other name: Plasma cell myeloma
Second most common hematologic
malignancy.
It affects osseous and non-osseous
tissues.
 The cause of myeloma is unknown
High occurrence among the following:
- Those exposed to radiation
warheads
- Myeloma has been seen more
commonly than expected among farmers,
wood workers, leather workers, and
those exposed to petroleum products.
 Occurrence: 2-4/100,000
Age: Increases with age
Median Age of Px: 65 y/o
Gender: More men than women
Race: More common in Blacks than in
Caucasians, Asians low incidence.
 Composition
1.The PARENCHYME RED
BONE
2.The STROMA MARROW
-Continuous
replacement of
old bone tissue
by new bone
tissue

2 types of cells
1. Osteoblasts
2. Osteoclasts
 Used to determine
size and shape of
RBCs, WBCs and
platelet precursors
and to examine
various
maturational
abnormalities.
Gold standard for
diagnosing MM
 Non destructive
method of inspection L2-L3
Each specimen under
Compression

evaluation will have

differences in density,
thickness, shapes,
sizes, or absorption
characteristics
Randomly distributed, rounded, punched out lytic
lesions throughout the skull.
 Patient Normal
WBC 3.4 X 103/uL (3.3-11.0)
Neut 9% (44-88)
Lymph 27% (12-43)
Mono 4% (2-11)
Eos 0% (0-5)
Baso 0% (0-2)
RBC 3.2 X 106/uL (3.9-5.0)
Reticulocytes 1.% (0.5-1.5)
Hgb 8.6 g/dL (11.6-15.6)
HCT 26.1 % (37.2-50.4)
MCV 81.5 fL (79-99.0)
MCH 26.8 pg (26.0-32.6)
MCHC 32.9 g/dL (31.0-36.0)
Plts 110 thousands/uL (130-400)
Test Patient Normal
Glucose 90 mg/dL (65-110)
Creatinine 1.9 mg/dL (0.7-1.4)
BUN 29 mg/dL (7-24)
Uric Acid 9 mg/dL (3.0-8.5)
Cholesterol 199 mg/dL (150-240)
Calcium 12 mg/dL (8.5-10.5)
Protein 10.9 g/dL (6-8)
Albumin 3.7 g/dL (3.7-5.0)
LDH 270 U/L (100-225)
Alk. Phos. 210 U/L (30-120)
AST 50 U/L (0-55)
GGTP 35 U/L (0-50)
Bilirubin/Bil. Direct 0.7 mg/dL/(.11 mg/dL) (0.0-1.5)/(.02-18)
 Patient Normal
Test
pH 6 (5.0-7.5)
Protein 3+ (Neg)
Glucose Neg (Neg)
Ketone Neg (Neg)

Occult blood Neg (Neg)

Color Yellow (Yellow)
Clarity Clear (Clear)
Sp. Grav. 1.050 (1.010-1.055)
WBC 3/HPF (0-5)
RBC 1/HPF (0-2)
 A process of separating electrically
charged particles in solution by
passing an electric current through
the solution

Particularly used to determine

whether the humoral immunity
function normally or not.
 Marked, single spike in
gamma

Albumin 1 2

Diseases :
Multiple myeloma
Characterized by
Waldenstroms
proliferation of a single clone
macroglobulinemia
of plasma cells
Amyloidosis
Plasma cell leukemia
MAJOR CRITERIA
I. Plasmacytoma by biopsy
II.>30% marrow plasmacytosis
III.Monoclonal gammopathy
Serum: IgG > 3.5 g/dL, IgA >2 g/dL
Urine: >1 g/d of Bence Jones Proteins
MINOR CRITERIA
A.10-30% marrow plasmacytosis
B.Monoclonal gammopathies with lower values
than above
C.Lytic bone lesions
D.Suppressed normal immunoglobulins
 Durie-Salmon Staging System
Stage Criteria Estimated Tumor
Burden, x 1012 cells/m2
I All of the following:
1. Hemoglobin >100 g/L (>10 g/dL) <0.6 (low)
2. Serum calcium <3 mmol/L (<12 mg/dL)
3. Normal bone x-ray or solitary lesion
4. Low M-component production
a. IgG level <50 g/L (<5 g/dL)
b. IgA level <30 g/L (<3 g/dL)
c. Urine light chain <4 g/24 h

II Fitting neither I nor III 0.61.20

(intermediate)
III One or more of the following:
1. Hemoglobin <85 g/L (<8.5 g/dL) >1.20 (high)
2. Serum calcium >3 mmol/L (>12 mg/dL)
3. Advanced lytic bone lesions
4. High M-component production
a. IgG level >70 g/L (>7 g/dL)
b. IgA level >50 g/L (>5 g/dL)
c. Urine light chains >12 g/24 h
 Age: 69 y/o, Male, Hx of working in a petroleum plant

DNA is damaged during the development of stem cell into a B cell

Development of malignant plasmablasts

Produce adhesive molecules and bind to Bone Marrow Stromal Cells

Malignant plasmablast grows into malignant plasma cells

Uncontrolled proliferation of malignant plasma cell clones

Production of Production of
Formation of
Paraproteins Bence Jones
Plasmacytomas
(M-protein) Protein
 Formation of
Plasmacytomas

Compression of Release of IL-6 and TNF

surrounding bone
tissue, bone marrow Recruitment and
and nerve endings activation of osteoclasts HYPERCALCEMIA

Osteoclasts attach to
Destruction of
bone tissue Calcium is released
Bone marrow
stem cells PAIN and enters the
bloodstream
Protein digesting enzyme Acids
osteoblasts
Digestion of collagen and fibers Dissolves bone minerals

bone
deposition
PUNCHED-OUT Continuous bone destruction
OSTEOLYTIC LESIONS
PATHOLOGIC
Hematopoesis FRACTURE
 Hematopoiesis

RBC Megakaryocytes WBC

ANEMIA Platelets Leukopenia

Easy fatigability Susceptibility to

infection

THROMBOCYTOPENIA

Susceptibility to
bleeding
 Age: 69 y/o, Male, Hx of working in a petroleum plant

DNA is damaged during the development of stem cell into a B cell

Development of malignant plasmablasts

Produce adhesive molecules and bind to Bone Marrow Stromal Cells

Malignant plasmablast grows into malignant plasma cells

Uncontrolled proliferation of malignant plasma cell clones

Production of Production of
Formation of
Paraproteins Bence Jones
Plasmacytomas
(M-protein) Protein
 Production of
Paraproteins
(M-protein)

Serum Monoclonal Normal Plasma cell

Antibodies breakdown

Disrupted antibody
Binds with other serum
mediated immunity
protein

Normal Antibody
production
HYPERVISCOSITY
SYNDROME
Susceptibility to
infection
Susceptibility to
bleeding
 Age: 69 y/o, Male, Hx of working in a petroleum plant

DNA is damaged during the development of stem cell into a B cell

Development of malignant plasmablasts

Produce adhesive molecules and bind to Bone Marrow Stromal Cells

Malignant plasmablast grows into malignant plasma cells

Uncontrolled proliferation of malignant plasma cell clones

Production of Production of
Formation of
Paraproteins Bence Jones
Plasmacytomas
(M-protein) Protein
 Production of Bence
Jones Protein

Glomeruli filters large

amounts of Bence-
Jones Protein

ANEMIA Excreted in
Proteinaceous
urine
inclusion bodies
RBC UREMIA accumulates in
Production the tubules
elimination of
erythropoietin nitrogenous
waste
Blockage of tiny kidney
tubules
Cellular degeneration and
impairment of kidney/tubular PROTEINURIA
function
Chronic Pain
Activity intolerance
Risk for Infection
Fear/Anxiety
 Trials of Arsenic Trioxide in Multiple Myeloma
Mohamad A. Hussein, MD
 Anatomy and Physiology by Tortora, 11th ed.
Clinical Physiology by Moran Campbell

Pathophysiology By Porth, 4th ed.

Harrisons Principles of Internal Medicine, 17th ed.

Wintrobes Clinical Hematology,

Blood and Bone Marrow Pathology by Wickramasinghe

and McCullough