In this final stage the pain control by bone disease or side effects to the treatment tends to be a very important point in clinical practice. Radiation therapy may be effective to relieve pain of soft tissue or skeletal injuries. Vertebral augmentation and bisphosphonates may be beneficial. Often, to relieve bone pain is needed while opioids action that is necessary to avoid the non-steroidal anti inflammatory because they are potentially nephrotoxic.
Pain neuropathic can help blocking agents calcium (Gabapentin) channel or serotonin reuptake inhibitors noradrenaline (amitriptyline). It is important to work early together with a multidisciplinary team, for the control of symptoms and psychosocial support. Myeloma in the end cap is associated with increased risk of venous thromboembolism, which in turn increases immunomodulatory agents, in particular when combined with corticosteroids or cytotoxic agents.
Anemia can be treated with blood transfusions or erythropoietin-stimulating agents. Of the BCSH guidelines suggest to indicate such agents when hemoglobin is < 100 g/l.
Myeloma and their treatments decrease immunity and 10% of patients die, generally by infection, within 60 days. As preventive measures, the patient education and access to hematological assessment 24 hours are very important.
In this final stage will have already experienced several relapses and relapse treatment depends on previous treatment, the duration of remission, and the persistence of the toxicity and Comorbidities.
In general, again using the previous treatment, but only if it has given rise to a prolonged progression-free survival (≥12 months). The basis of the treatment of relapse are the modern agents combined with corticosteroids and sometimes with an alkylating agent.
In general, the first relapse is treated with a regimen of bortezomib while lenalidomide is used for a subsequent relapse. The prognosis for patients who do not respond to immunomodulatory agents and bortezomib is bad, with a median overall survival of 9 months.
This underscores the importance that these patients participate in clinical trials in order to allow them access to new treatments and the evaluation of its effectiveness.
Multiple Myeloma Staging Classification
Staged classification (stage) is the process of finding out how far the cancer has progressed, which is important for determining treatment options and prognosis. The prognosis is a prediction of the course of the disease, the expectation of survival. Knowing everything you can about staged classification allows you to participate more actively in information-based decision-making regarding your treatment.
Determination of the stage in which a multiple myeloma is found can be performed with the Durie-Salmon stage classification system. Although some doctors use this system, its value is limited, due to newer diagnostic methods. A new classification system called the International Staging System for Multiple Myeloma was recently created. It is mainly based on albumin and beta-2 microglobulin levels in the blood. Other factors that may be important are renal function, platelet count, and patient age.
The Durie Salmon stage classification system
This system is based on four factors:
- The amount of abnormal monoclonal immunoglobulin in the blood or urine: Large amounts of monoclonal immunoglobulin indicate that there are many malignant plasma cells that are producing that abnormal protein.
- The amount of calcium in your blood: Elevated calcium levels in your blood may be related to advanced bone damage. Because bones typically contain large amounts of calcium, the destruction of the bones releases calcium into the blood.
- The severity of bone damage, according to X-rays: Finding in x-rays of damaged multiple areas of bone indicates an advanced multiple myeloma.
- The amount of hemoglobin in the blood: Hemoglobin carries oxygen to red blood cells. Low haemoglobin levels mean that it is anemic and may indicate that myeloma cells occupy a significant portion of the bone marrow and that there is not enough room for normal bone marrow cells to produce enough red blood cells.
This system uses these factors to divide myeloma into three stages. Stage I indicates the least amount of tumor, and stage III indicates the greatest amount of tumor:
The number of myeloma cells is relatively small. All of the following features must be present:
- The haemoglobin level is slightly below normal (but greater than 10 g/dL).
- Bone x-rays are normal or show a single area of bone damage.
- Calcium levels in the blood are normal (less than 12 mg/dL).
- There is only a relatively small amount of monoclonal immunoglobulin in the blood or urine.
A moderate number of myeloma cells are present. Features are between stages I and III.
The number of myeloma cells is high. One or more of the following features must be present:
- Low haemoglobin level (less than 8.5 g/dL).
- High level of calcium in the blood (greater than 12 mg/dL).
- Three or more areas of bone destruction from cancer.
- Large amounts of monoclonal immunoglobulin in the blood or urine.
The international stage classification system
This system divides myeloma into three stages based only on serum microglobulin beta-2 levels and serum albumin levels.
Serum microglobulin beta-2 is less than 3.5 (mg/L) and albumin level is over 3.5 (g/L).
Neither stage I or III, which means:
The beta-2 microglobulin level is between 3.5 and 5.5 (with any albumin level).
Albumin is under 3.5 while beta-2 microglobulin is less than 3.5.
Serum microglobulin beta-2 levels are greater than 5.5.
Factors other than the stage that affect survival
- Kidney function : The level of creatiline in the blood (Cr) reflects how healthy the kidneys are. The kidneys remove this chemical from the body. When the kidneys are damaged by monoclonal immunoglobulin, creatiline levels in the blood rise, predicting a worse prognosis.
- Age : Age is important. In studies of the international stage classification system, older people with myeloma have shorter survivals.
- Marker index : The myeloma cell marker index, sometimes called plasma cell marker index, indicates how fast cancer cells are growing. This test is performed in specialized laboratories and uses myeloma cells from bone marrow samples. A high marker rate can predict faster accumulation of cancer cells and consequent very poor prognosis.
- Chromosomal testing : Bone marrow may be tested for chromosomes in malignant cells. Changes in certain chromosomes may indicate a more unfavorable prognosis. For example, changes in chromosome 13 will reduce a person’s chances of survival. Another genetic anomaly that predicts an unfavorable outcome is an exchange of material from chromosomes 4 and 14, known as translocation.