Zero to GP - GP Revision Podcast

Myeloma - Essential GP Revision

• Thomas Watchman • Season 1 • Episode 19

Share episode

Use Left/Right to seek, Home/End to jump to start or end. Hold shift to jump forward or backward.

0:00 | 11:43
SPEAKER_01

Hi, this is Tom, and welcome to the Zero to GP Podcast. In this episode, we're going to be going through the key stuff you need to know about myeloma for your GP exams. As always, the format of these episodes is I'll present you with cases, ask you questions, I want you to come up with your answer, and then we'll go through an explanation. If you're setting your AKT exam anytime in the next 12 to 24 months, I recommend checking out the Zero to GP Revision Resources. That's the AKT revision book, which contains all the keynotes you need for your exams. The zero to GP.com website, which contains flashcards, questions, short answer questions, and a fact trainer tool, as well as all the notes for the AKT exam. And I've got an upcoming AKT revision course in London on the 13th of September 2026. So make sure to check that out. A link to everything is in the description. So let's get straight into this episode. So you got a 70-year-old man and he presents with three months of fatigue. He's also got unexplained weight loss, he's and then you do some blood tests and it comes back showing a normocytic anemia. So his red blood cells are a normal size, normal color, but there's just too few of them. He's anemic. So as the video title suggests, you're suspecting myeloma. The first question I've got for you is what's the most common presenting symptom of myeloma? A hint is that it's not in this case that we've described so far. So what's the key presenting symptom to look out for and should make you think about myeloma? The key answer here is bone pain, particularly pain affecting the back, specifically the thoracic back, or the ribs. If you see bone pain in an older patient, particularly over 60, think about myeloma. Next question is what are the key symptoms of myeloma? These are the symptoms you remember with that classic mnemonic for myeloma. So can you remember what those are?

SPEAKER_02

These are the crab symptoms.

SPEAKER_01

So C is for hypercalcemia, the calcium level is raised. A uh R is for renal failure, so uh renal impairment, when you check the usenes, the EGFR is down, the creatinine is up. A is for anemia, particularly a normocytic, normochromic anemia. So an a normal appearing red blood cell, but just too few of them and a low hemoglobin. And then the final B in the mnemonic is bone lesions and bone pain. Next question I have is what's the basic pathophysiology of myeloma?

SPEAKER_00

What's going on in the condition?

SPEAKER_01

The key feature or the key pathophysiology of myeloma is it's a cancer where there's mutated plasma cells, which are B cells or B lymphocytes. These mutated plasma cells produce an excessive amount of a para protein. And a para protein is an abnormal antibody or a part of an antibody. So there's excessive paraprotein production by mutated plasma cells. These plasma cells, these mutated plasma cells, will have bone marrow, bone marrow infiltration. So because they're excessively reproducing, these plasma cells, you get tumors containing lots of plasma cells that infiltrate the bone marrow. Remember, the bone marrow is responsible for producing red blood cells, white blood cells, platelets. So if you've got infiltration of the bone marrow affecting the bone marrow, you'll the mutated plasma cells will affect the production of these other types of cells. So you'll get low levels of red blood cells, low levels of white blood cells, and low levels of platelets. Another key feature of uh myeloma is myeloma bone disease. And this is caused by um local uh issues with uh bone production and turnover. So it affects normal bone turnover by suppressing uh osteoblasts and causing excessive osteoclast activity. So you get lytic bone lesions where there's reduced bone density in specific areas. So bone bone involvement is a main issue in myeloma as well. So to summarize, we've got the 70-year-old man, he's got fatigue, let's say he's got back pain, weight loss, and pallor, so you're suspecting he's anemic, and you're suspecting myeloma. The next question I have for you is let's say you suspect a myeloma in a patient presenting to you, what initial tests do you need to offer that patient to detect myeloma? Often on the blood requesting form you can just put myeloma screen, or people say you need to do a myeloma screen. What's actually involved in a myeloma screen? Well, there's five main things. The first is a full blood count, so you want to detect anemia. The second is a serum calcium level. You want to detect a high calcium or hypercalcemia. Next, you need inflammatory markers, specifically plasma viscosity or ESR. So PV or ESR. The fourth thing is serum protein electrophoresis, and this is how you detect that power protein, that abnormal protein being produced by the plasma cells. And the final one is serum-free light chains. And these are parts of an antibody or parts of that power protein. The next question I have for you is when do you test for the Bence Jones protein in the urine? Often people say, Well, you've done this myeloma screen. Are you also going to do Bence Jones protein? My question for you is when would you do the Bence Jones protein test? You can do a Bence Jones protein if the serum-free light chain test is not available. If it's available, uh you just do serum-free light uh light chains, you don't need to do the Bentz protein test. Next question I have is when would you admit this patient if it comes back if they come back with hypercalcemia, a raised calcium level?

SPEAKER_02

When do they need admission?

SPEAKER_01

Generally, you'd admit a patient whose corrected calcium level is above three millimoles per liter. If it's below three millimoles per liter, um you you can just refer them as you normally would on the two-week weight pathway. But above three millimoles per liter, they need admission for more urgent management to bring that calcium level down. The next question I have is let's say you do a two-week weight referral, suspecting um myeloma, it's come back with abnormal, um serum protein electrophoresis. What imaging is the specialist going to arrange first line for bone lesions? The key imaging investigation is a whole body MRI scan. You could second line do a CT or X-rays, but the first line imaging investigation for bone lesions is a whole body MRI scan. It's more sensitive, it's gonna pick up bone lesions better. Okay, separate case now. We've got a 68-year-old woman, and she has some blood tests and it and she returns for the blood results. Incidentally, you pick up that she's got 7.6 grams per liter of an IgG monoclonal para protein on her blood result. And you think, oh, uh, this is abnormal, and she's saying, what do we need to do about this? All her other blood tests are normal, and she reports that she feels completely well. She's got no health concerns, and her examination is normal.

SPEAKER_02

So my question for you is, what's your suspected diagnosis here?

SPEAKER_01

This patient has monoclonal gamopathy of undetermined significance, or MGUS. This basically means you incidentally found a raised monoclonal paraprotein, but the patient is otherwise well. She doesn't have any of the crab features of myeloma, and so you're not concerned there's a kind of systemic thing going on. So we don't really know why she's got a para protein or how significant it is, which is why you get this name of monoclonal gamopathy of undetermined significance or MGUS. So my next question for you is what's the management, what's the general management of MGUS? Generally, it's managed by monitoring. So that have blood test to look for any kind of progression, so rise in the monoclonal para protein, um, and to look for other things like anemia or hypercalcemia or renal impairment. Um, and then if any uh if there's any symptoms that develop, you would refer them, or if the power protein is rising, you'd refer them. Or if you have any concerns, just talk with hematology. The final question I have for you is what's the main risk with MGUS?

SPEAKER_02

So we kind of touched on it.

SPEAKER_01

The risk with MGUS is that it progresses to myeloma. And this happens uh in about 1% per year. So there's about a 1% risk of progression to myeloma every year in a patient with MGUS. Although this varies significantly depending on the type of power protein, the level of the power protein, and other individual patient factors, but roughly around 1% per year. So thanks for listening to this episode on myeloma. Hopefully that was helpful. Do leave a comment if you found it helpful, and don't forget to check out the Zero to GP AKT revision resources, and I'll see you in the next episode.