Multiple myeloma bone pain

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Multiple myeloma bone pain , Bone disease is one of the leading causes of morbidity and
deterioration of the quality of life in patients with myeloma, multiple that produces pain, fractures and hypercalcemia. Between 70% and 80% of the patients have evidence of bone disease at the time of the diag diagnosis and most of the patients are going to suffer at some point of the disease.

Bone disease is produced by infi ltration of plasma cells mielomatosas in the bone marrow and release of cytokines, which block the normal repair of bone and activate their destruction.

Location and types of injury

The bones which usually affect are those where the bone marrow It is active in adults: spine, skull, pelvis bones, ribs and in the areas around the shoulders and hips. Are rarely affected the regions of lower arms and legs and hands and feet. This is very important since these areas generally feature
you is completely preserved.

The affected areas of bone are often “holes” on radiographs, they are lytic lesions. These lesions make the bone more fragile and can break the absence a blow or excessive force, giving place to pathological fractures.

The loss of thickness of the vertebrae can also cause fractures. When the vertebrae are fractured, they tend to be compressed and crushed. This It is called the fracture compression. They have as a result a
loss of height, greater curvature of the spine and pain.

Occasionally, patients develop a lesion called plasmacito solitary bone Ma, which is a tumor formed by plasma cells mielomatosas without infi lter out the bone marrow.

This condition can be cured of one It is effi cient with radiotherapy, although a small percentage of patients You can later develop myeloma.

In very few cases there is an increase in the formation of bone around the myeloma cells, receiving the name of myeloma osteosclerotico.

Multiple myeloma bone painTo learn more about the causes that make the bone disease affects to patients with myeloma and on mechanisms that hide behind of This is necessary to know the normal activity of the bone.

Bones are composed of an outer layer deposit of mineralized, the cortical bone and inside softer, spongy tissue where it It is the bone marrow.

Although bone is formed by minerals and is hard, remains a living tissue, in continuous renewal, with blood vessels, nerves and cells. Among these cells, there are 2 very important that control normal activity of the bones. These cells are:

  • blasts: cells that form new bone.
  • Osteoclasts: cells that wear out the old bone.

The process of renewal which takes place is known as bone remodeling and maintains thickness, strength and health of bones throughout then body.

Normally, the rate of formation and bone wear is the same, so that the
bone mass remains constant.


Myeloma cells cause the destruction of the bone to produce, in the medullar stroma, substances known as cytokines, contact to activate the osteoclasts (TNFα, IL-1, Il-6,…) and inhibit the action of the
osteoblasts (DKK1).

At the same time, osteoclasts produce factors that stimulate the growth of cells mielomatosas, in special Il-6. This results in a vicious circle of dependency between myeloma and bone cells in the bone marrow microenvironment call. Are these processes cause loss bone mass and lytic lesions in patients with myeloma.


Bone disease is the most common symptom present at the time of the diagnosis of the disease. Between testing and more common tests to diagnose of myeloma bone disease include:

1.- Bone series

Conventional radiography is the best method for detecting the existence Myeloma bone disease. Is the diagnosis and fi NISH the treatment or during this one does the emergence of new bone lesion is suspected. Is usually performed a series of 13 films including: Rx side of skull, Rx thorax, pelvis Rx, Rx of the long bones of the arms and legs (both humeri and femora) and anterior lateral and postero Rx of cervical, dorsal and lumbar spine.

X-rays may show areas of loss of mineralization (osteopenia/osteoporosis), lytic lesions, fractures and vertebral crushing.

If x-rays does not show any damaged area, but sos the patient may suffer from bone disease, others can be used you pecha imaging techniques that can show in greater detail a particular
area. These additional diagnostic imaging techniques include:

2.- Magnetic resonance

It detects the infi ltration by myeloma in the bone (exist or not bone destruction) and adjacent tissues: plasmacytomas. He is done if in-depth testing of areas like the column, are required to assess affectation of the vertebral canal and Medulla Thorn. MRI does not involve radiation.

3.- TAC

Tomography gives information earlier than conventional Radiology bone disease. You can use if you need a detailed assessment of a small area in which it is believed that there may be bone damage or
to detect plasma cells in soft tissue: plasmacytoma. Also can be used to locate the exact area in which to apply the treatment with radiation therapy.

4.- PET-CT

The PET-CT, of recent use in myeloma, is a technique that is injects a drug with low level of radiation, showing areas with a pronounced carbohydrate metabolism. You can show the difference between
a tissue healthy and one abnormal and can also detect infi ltration outside bone marrow (plasmacytoma). The results of initial investigations suggest that it might be useful to keep track of the disease
bone, especially in the case of non-secretory myelomas, which does not exist detectable in blood or urine paraprotein. Other less commonly used techniques are:

5.- Bone scan

Useful technique to detect bone metastases of various tumors, detecting activity (minimal in Myeloma) osteoblastic. Shown in these patientsfractures and calcification of tissue in plasmacytoma. Bone densitometry Useful to assess the severity of diffuse bone loss (osteopenia/osteoporosis) and to measure the improvement occurring with treatment.


Myeloma bone disease may cause the following symptoms and
signs in the patient:

1.- Osteopenia

Osteopenia is a generalized loss of bone mineralized, hard of
differentiate from osteoporosis, given the usual advanced age of these patients. It is an early sign and it can cause small fractures due to spinal compression and fractures of the ribs, causing pain and discomfort.

2.- Compression fractures and kyphosis

The vertebrae may have “holes” (lytic lesions) that can cause
crushing in a way that is more striking than the vertebral stress fractures caused by the (smaller) osteopenia. Sometimes, the crushing can modify the shape of the spine (kyphosis) and cause a loss of height.

3.- Lytic lesions

In addition to osteopenia, myeloma can also cause injury lytic, that normally occur in the skull, spine, pelvis, the ribs and long bones of the arms and legs. Are presented in form of “holes” on radiographs.
Pathological fractures  Fractures can occur spontaneously or by a mild hit in  ribs, sternum, pelvis and long bones of the arms and the legs.

4.- Compression of the spinal cord

It is a complication that occurs sometimes because the infi ltration of the cells in the column mielomatosas press the spinal cord. It can occur suddenly or slowly over time. If the compression is
mild, symptoms may include mild pain in the back, weakness, tingling and changes in sensitivity, often affecting arms and legs.

If more importantly, is usually pain, weakness means cativa and disorders in the Elimination of urine and bowel movements. The compression of the spinal cord It is a serious problem and that accurate, if it is important, radiotherapy treatment urgent, since if it is not treated it can degenerate into a paralysis.

4.- Hypercalcemia

When a bone is worn releases calcium into the bloodstream, exceeding the capacity of the body to maintain normal levels. A high level of calcium in the blood is known as hypercalcemia. It can cause symptoms tiredness, loss of appetite, nausea, vomiting, constipation, increased thirst, disorientation, drowsiness, and general weakness. Hypercalcemia It may exist at the time of diagnosis, being less common once started the treatment and when patients receive a bisphosphonates
a regular basis.

5.- Pain

Bone pain is the most frequent symptom and usually appears in the middle zone
and lower back, hips, ribs or where bone lesions due to myeloma (lytic lesions) have occurred. The intensity of the pain experienced varies depending on the person. Typically worsens with
the movement and improves with rest. The pain may get worse slowly with the time or do so suddenly and severely, which can be a sign a fractured bone.


The treatment of myeloma, chemotherapy or the new molecules: thalidomide, Lenalidomide, Bortezomib, and/or radiotherapy in the case of solitary bone plasmacytoma, is one of the most effective ways control increased wear bone, correct the hypercalcemia and relieve pain.

In some cases, bone disease continues to be a problem, need treatments that can slow down their activity, relieve symptoms and sometimes correct the complications that occur. Among these
treatments include bisphosphonates, radiation therapy, orthopedic surgery and analgesics.

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