Multiple myeloma is a deadly cancer of the plasma cells in

the bone marrow. When the disease is caught in its early

stages, treatment can prolong life by 3 to 5 years. More important,
early detection can decrease the amount of pain
and disability due to bony destruction and pathological
fractures. Unfortunately, almost half the patients die
within the first 3 months after diagnosis because of the
silent and deadly nature of the disease. Another 40 percent
of patients die within 2 years after diagnosis. Because early
diagnosis is not often made, only 10 percent of patients can
expect to live to the 5-year mark. Multiple myeloma most
often affects men ages 50 to 70.
Pathophysiology
In this disorder, cancerous plasma cells in the bone marrow
begin reproducing uncontrollably. These cells infiltrate
bone tissue all over the body and produce hundreds of tumors
that begin to devour the bone tissue. X-ray examination
may show holes in the bones, forming a Swiss cheese
pattern (Fig. 246). As more and more of these holes are
formed, the bone integrity becomes compromised and weak.
Multiple myeloma usually affects the bones of the skull,
pelvis, ribs, and vertebrae.
As the disease continues, the plasma cells infiltrate the
major organs, including the liver, spleen, lymph nodes,
lungs, adrenal glands, kidneys, skin, and GI tract. Because
the diagnosis is usually made only after widespread invasion
of the bones is well underway, the overall prognosis of patients
with this disease is poor. Although the overall result
of the disease is the devastating destruction of the bone and
widespread osteoporosis, death is often from sepsis.
Etiology
The cause of multiple myeloma is unknown, although it is
being researched. Some authorities believe this disease to be
related to chronic allergies and hypersensitivity reactions.
This line of thought stems from the fact that plasma cells
are the first line of defense and are the producers of the immunoglobulins
that help fight foreign bodies. For some reason
these defenders get out of control and begin to attack
the host, as well as foreign invaders. People who work in
rubber, leather, farming, and petroleum industries are more
likely to develop multiple myeloma. Radiation and chemical
exposure may also be factors.
Signs and Symptoms
Skeletal pain is the most common complaint. The patient
may describe the pain as constant severe back pain that in-
creases with exercise or movement. The patient may complain
about pain in the ribs. Other signs and symptoms include
achiness of the long bones, joint swelling and tenderness,
low-grade fever, and general malaise. Sometimes there
is evidence of early peripheral neuropathy secondary to vertebral
collapse and mild spinal cord compression. The patient
may be unable to feel the true temperature of bath water and
be burned or may be unable to feel wounds and infections on
the feet. In more severe cases of cord compression, the patient
may lose control of bladder and bowels. This is a true
oncological emergency. Prompt emergency treatment is necessary
to keep the patient from becoming paralyzed.
Occasionally the patient will have pathological fractures
of the long bones. These are fractures that occur with no
trauma, such as the person who breaks a leg just turning
over in bed or breaks a rib while sneezing. In advanced disease
there is anemia, weight loss, thoracic spinal deformities
from multiple rib destruction, and a loss of height because
of pathological fractures and compacting of the vertebrae.
Because calcium is mobilized from the bones and into
the blood, the patient is at risk for hypercalcemia. Signs and
symptoms include anorexia, nausea, vomiting, mental
changes (especially confusion), seizures, and weakness and
fatigue. Kidney stones may result as the excess calcium
passes through the kidneys.
Patients are susceptible to infection because of compromised
immune function. Pneumonia is a common finding in
patients with multiple myeloma. They may develop anemia
because of bone marrow dysfunction and reduced erythropoietin
formation by diseased kidneys.
Patients often develop kidney failure as the filtering capacity
of the kidney is blocked with calcium. Other factors
include recurrent infections and deposits of myeloma cells
in the kidneys.
Diagnostic Tests
A CBC shows moderate to severe anemia. Examination of
the WBC count may show an increase in the number of
white cells secondary to infection. X-ray examinations may
show changes in the lungs and diffuse osteoporosis in the
bones not already riddled with holes. Urine studies are positive
for the M-type globulins (Bence-Jones proteins) in 40
percent of patients. Bone marrow biopsy is done to confirm
the diagnosis and determine the diseases stage.
Blood chemistries often show an increased amount of
calcium in the blood. Hypercalciuria results as the calcium
released out of the bones is flushed out in the urine. An intravenous
pyelogram may be done to see how much calcium
is blocking the kidneys. A 24-hour urine collection is done
to evaluate protein excretion.
Medical Treatment
Long-term treatment of multiple myeloma consists of a twopronged
approach: (1) managing the disease and (2) managing
the symptoms. To manage the disease, high-dose
steroids (prednisone) and oral or intravenous chemotherapy
agents are given. The goal of drug therapy is to suppress the
plasma cell proliferation, which then helps decrease the
amount and speed of bone destruction.
The second approach is control of symptoms. The nurse
monitors the patient for signs and symptoms of hypercalcemia,
hyperuricemia, dehydration, respiratory infection,
renal problems, and pain. External beam irradiation may be
given to especially painful areas of bone involvement. Fortunately
this treatment is quite effective, usually decreasing
pain intensity in just a few days. The patient can expect to
have a daily (or perhaps a twice-daily) therapy treatment
over a course of 10 to 14 days, delivered directly to the
painful bony areas. Vigorous attention to administering
pain medications during the early course of treatment
greatly reduces the patients pain levels.
The patient may need a laminectomy if vertebral collapse
occurs. Because of demineralization of the bone, with
resulting large amounts of calcium in the blood and urine,
surgery for kidney stones and eventual dialysis for acute or
chronic kidney failure may be necessary.
A newer treatment involves high-dose chemotherapy
combined with stem cell transplantation. The patients own
peripheral stem cells can be removed and reinfused. These
stem cells can then differentiate into new, healthy cells.
Methods of cleaning the cells to prevent contamination
with malignant cells are being researched.
Nursing Care
Assess for fever or malaise that can signal the onset of infections.
Other conditions to be alert for include anemia,
hypercalcemia, fractures, and renal complications. Monitor
intake and output, and strain urine for stones. Elevated
BUN and creatinine levels will alert you to possible renal
failure. Report back pain, leg weakness, sensory loss, or loss
of bowel or bladder function, because these might indicate
spinal cord compression.
Keeping the patient mobile is very important. The physical
therapist and occupational therapist can help the patient
continue to be active. Bones in use are strongest, so
the patient should remain up and moving as much as possible
to help stimulate calcium resorption and decrease demineralization.
Assist the patient with walking because of the
risk of pathological fractures of the long bones. If the patient
is unsteady, use a walker or a support belt. Keeping the
patient up and active also decreases the risk of respiratory
complications. Urination also is enhanced in the patient
who does not need to rely on the use of a bedpan or urinal.
If the patient is bedridden, reposition him or her every 2
hours to prevent complications related to immobility; use a
lift sheet to move the patient gently and decrease the risk of
pathological fractures. Provide passive range-of-motion exercises
and encourage deep breathing.
Teach the patient the importance of good hydration at
all times to minimize complications of hypercalcemia. Administer
fluids so that daily output is never less than 1500
mL. Depending on time of year and the type and level of patient
activities, the patient may need to have an intake of
more than 4 L daily.
If hypercalcemia occurs, the physician will order an IV of
normal saline to infuse at a high rate followed by regular
administration of diuretics. The goal is to get the serum calcium
level below 10 mg/dL. Oral compounds are also available
to help keep the calcium level within normal limits.
See Home Health Hints for additional suggestions for patients
being cared for at home.