Symptoms of myeloma

Myeloma commonly affects the bones of the spine (vertebrae), so its most common symptom is back pain. Some people also become shorter. Other bones may also be affected such as the ribs, skull or pelvis. Other symptoms may include any of the following:

• Excessive tiredness and lethargy due to a lack of red blood cells (anaemia).
• Kidney problems caused by the paraproteins produced by the myeloma cells. Kidney damage can cause tiredness and anaemia.
• Repeated colds, coughs and other infections (particularly chest infections) because of a shortage of normal antibodies.
• Weakening of the bones by the myeloma cells, which may increase the risk of fractures.
• Loss of appetite, feeling sick, constipation, depression and drowsiness caused by too much calcium in the blood (hypercalcaemia). The excess calcium is released into the blood from the damaged bones.
• Unexplained bruising and abnormal bleeding (for example, nosebleeds or bleeding gums) because the number of platelets in the blood has decreased.
• Pins and needles, numbness, tingling or weakness in the feet or legs; or difficulty passing urine or opening the bowels. Any of these symptoms could mean that a myeloma tumour is pressing on the spinal cord (known as cord compression). Contact your doctor immediately if you think that this may be happening to you.

If you have any of the symptoms in this list, it is important to see your doctor as soon as possible. But remember, many of these symptoms can occur in other conditions. Most people with the above symptoms will not have myeloma.

Occasionally myeloma will be found by a blood test done for another reason, when the person has no symptoms.

How myeloma is diagnosed

Usually you begin by seeing your family doctor (GP), who will examine you and arrange for you to have any tests or x-rays that may be necessary. Your GP will refer you to hospital for these tests and for specialist advice and treatment.

• At the hospital
• Bone marrow sample
• Cytogenetics
• X-rays
• Blood and urine tests

At the hospital

At the hospital, the specialist will ask you about your general health and any previous medical problems, before examining you.

Samples of your blood and urine will be taken and examined to check your general health and how well your kidneys are working. These tests will also show whether there are any paraproteins (the abnormal proteins that are produced by myeloma cells) in your blood and urine.

If the blood test shows that a paraprotein is present, your doctor will want to take a bone marrow sample and do some further tests. These are done so that the doctor can plan the best treatment for your situation.

Bone marrow sample

A sample of bone marrow is usually taken from the back of your hipbone (pelvis) or, sometimes, the breast bone. It will be examined to see if it contains any myeloma cells.

The bone marrow sample is taken under a local anaesthetic. You will be given a small injection to numb the area and the doctor will gently pass a needle through the skin into the bone. The doctor will draw a small sample of liquid marrow into a syringe to be looked at later under the microscope (bone marrow aspirate). The doctor will then take a small core of marrow from the bone (a trephine biopsy).

The test can be done on the ward or in the outpatients department. The whole procedure takes about 15–20 minutes. It may feel uncomfortable while the marrow is drawn into the syringe but this should only last for a few seconds. You may be offered a short-acting sedative to reduce any pain or discomfort during the test. You may feel bruised after the test and have an ache for a few days. This can be eased with mild painkillers.

Cytogenetics

Each cell in the body contains chromosomes, which are made up of genes. The genes control all activities of the cell. In myeloma there may be changes in the structure of the chromosomes within the myeloma cells, but not the normal cells of the body. The tests on the blood and bone marrow samples will often include a chromosome analysis to look for any particular changes in the chromosomes. These tests, known as cytogenetic tests, may help to decide on the best treatment and predict how well the myeloma may respond to that treatment.

X-rays

These will be taken to check for any damage that may have been done to your bones by the myeloma cells. You will usually have x-rays taken of your whole body, which is known as a skeletal survey.

Blood and urine tests

If the tests show that you have myeloma, your doctor will want to do regular blood tests to measure the level of paraprotein in your blood, to check for anaemia and hypercalcaemia (a raised level of calcium in the blood), and to make sure that your kidneys are working properly.

Samples of your urine will be taken to test for a particular paraprotein known as the Bence Jones protein. This may involve taking a container home and collecting your urine for 24 hours.

In a few people with myeloma, standard blood and urine tests are unable to measure the level of paraprotein. A new test which detects very small amounts of paraprotein, called the Freelite test, may be used.

Further tests for myeloma

Your doctors may suggest that you have further tests which can give more detailed information about the bones and organs of the body.

• MRI scan
• CT scan
• Ultrasound scan
• PET scan
• Waiting for your test results

MRI scan

An MRI (magnetic resonance imaging) scan uses magnetic fields to build up a series of cross-sectional pictures of the body. During the test you will be asked to lie very still on a couch inside a metal cylinder that is open at both ends. The whole test may take up to an hour and is painless – although the machine is very noisy. You will be given earplugs or headphones to wear.

Before going into the room you should remove all metal belongings. You should also tell your doctor if you have ever worked with metal or in the metal industry, or if you have any metal inside your body (for example, a cardiac monitor, pacemaker, surgical clips, or bone pins).

You may feel claustrophobic inside the cylinder, but you may be able to take someone with you into the room to keep you company. It may also help to mention to the staff beforehand if you do not like enclosed spaces. They can then offer extra support during your test.

CT scan

A CT (computerised tomography) scan takes a series of x-rays which builds up a three-dimensional picture of the inside of the body. Sometimes CT scans can be better at showing bone damage than an ordinary x-ray. The scan is painless but takes longer than an ordinary x-ray (it will last approximately 30 minutes).

Ultrasound scan

An ultrasound scan uses sound waves to look at internal organs. It may be done to see if your kidneys have been damaged by the myeloma.

PET scan

PET (Positron Emission Tomography) scans are a new type of scan and you may have to travel to a specialist centre to have one. They are not always necessary but you can discuss with your doctor whether one would be useful in your case.

A PET scan uses low-dose radioactive glucose (a type of sugar) to measure the activity of cells in different parts of the body. A very small amount of a mildly radioactive substance is injected into a vein, usually in your arm. A scan is then taken a couple of hours later. Areas of cancer are usually more active than surrounding tissue and show up on the scan.

Waiting for your test results

It will probably take several days for the results of your tests to be ready and this waiting period will obviously be an anxious time for you. It may help if you can find a relative or close friend you can talk things over with. You may wish to ring our cancer support speclialists or another support organisation for emotional support.

Staging of myeloma

The stage of a cancer is a term used to describe its extent and how much it is affecting the body. Knowing the extent of the myeloma helps doctors to decide on the most appropriate treatment.

Generally, myeloma is divided into three stages, which indicate the effect the disease is having on the body and how quickly or slowly it may develop. A commonly used staging system for myeloma, known as the Durie-Salmon system, is described below.

This staging system is based upon how the disease is affecting the:

• red blood cells (haemoglobin, Hb)
• calcium level in the blood
• amount of paraproteins
• bones.

Stage 1 The myeloma is at an early stage. The number of red blood cells is either normal or only slightly reduced. The amount of calcium in the blood is normal. There are low levels of paraproteins in the blood or urine. The bones either appear normal or there is a single plasmacytoma. There may be no symptoms.

Stage 2 The myeloma is at an intermediate stage, between stage 1 and stage 3.

Stage 3 The myeloma is at a more advanced stage. It has caused one or more of the following:

• the haemoglobin has dropped to quite a low level and anaemia is quite severe
• the level of calcium in the bloodstream has risen greatly
• three or more bones are affected and fractures may occur
• there are high levels of paraproteins in the blood or urine.

Stages 2 and 3 are also further divided depending upon how well the kidneys are working. As well as a number, the different stages are given a letter, either A or B. For example, you may have stage 2A or 3B.

A Kidney function is normal, or little affected by the myeloma.

B Kidney function is abnormal.

A second staging system for myeloma, that has recently been developed, looks at the levels of particular blood proteins: beta-2 microglobulin and albumin. This newer staging system, known as the International Staging System, also contains three stages. It can help doctors to stage the myeloma more accurately.

Stage I The beta-2 microglobulin is less than 3.5mg/L and the albumin level is greater than or equal to 3.5g/dL.

Stage II Both the beta-2 microglobulin level and the albumin levels are less than 3.5, or the beta-2 microglobulin level is between 3.5 and 5.5mg/L.

Stage III The beta-2 microglobulin level is greater than or equal to 5.5 mg/L.

If myeloma comes back after initial treatment it is known as relapsed or recurrent myeloma.