On-line version ISSN 2309-8309
Print version ISSN 1681-150X
SA orthop. j. vol.8 n.4 Pretoria Jan. 2009
HF VisserI; A VisserII; CH SnyckersIII; R GollerI; R PoolIV; JG MyburghV
IMBChB(Pret); Senior Registrar, Department Orthopaedic Surgery, University of Pretoria
IIMBChB(Pret); Senior Registrar, Department Clinical Pathology, University of Pretoria, National
IIIMBChB, MMed(Orth)(Pret); Consultant, Department Orthopaedic Surgery, University of Pretoria
IVMBChB(Pret), MMed(Haemat); Head of Department, Department Haematology, University of Pretoria, National Health Laboratory Service TAD
VMBChB, MMed(Orth)(Pret); Acting Head of Department, Department Orthopaedic Surgery, University of Pretoria
PURPOSE OF THE STUDY: Despite the relatively high incidence of multiple myeloma reported worldwide, South African statistics seem to be significantly lower. Our purpose in doing this study was to determine whether patients with suspected immunosecretory disorders are being appropriately evaluated and followed up. Secondary purposes include an impression of the most common clinical features prompting investigation as well as the stage of disease at time of diagnosis.
DESCRIPTION OF METHODS: All patients investigated for immunosecretory disorders by serum or urine electrophoresis over a 4-year period were included in this study. Each patient's laboratory and radiological data were evaluated to determine the true diagnosis, and assess the comprehensiveness of the investigation.
SUMMARY OF RESULTS: In total, 582 patients were included - 39 patients had multiple myeloma (6.7%). A single case of plasmacytoma and plasma cell leukaemia was identified. Waldenström's macroglobulinaemia was identified in seven patients (1.2%) and monoclonal gammopathy of undetermined significance (MGUS) in 83 patients (14.3%). Due to the risk of progression from MGUS to multiple myeloma, patients need to be re-evaluated biannually, shown to be the case in only 11% of cases.
Of all the malignant disorders (48 cases) the majority of patients were diagnosed in an orthopaedic setting (45%), followed by internal medicine (39%). Radiological abnormalities were the most common clinical finding prompting investigation, with lytic lesions or osteoporosis seen in 50%, pathological fractures in 17% and neurological manifestations noted in 18% of cases.
The majority of patients who could be staged were diagnosed at a relatively late stage of disease, rendering the prognosis worse than in early disease. This suggests a relatively low index of suspicion in our clinical setting.
CONCLUSION: Multiple myeloma and related disorders are commonly encountered in the orthopaedic setting. Although the sample size is small, this data suggests that patients are diagnosed late in disease progression and often not evaluated appropriately. A clear protocol should be established to actively exclude this diagnosis if it is suspected.
“Full text available only in PDF format”
1. Kyle R, Rajkumar S. Criteria for diagnosis, staging, risk stratification and response assessment of multiple myeloma. Leukaemia 2009;23(1):3-9. [ Links ]
2. Miller M. Review of Orthopaedics. 5th ed, ed. Saunders. 2008: Saunders. [ Links ]
3. Kyle R. Historical review. Multiple myeloma: An odyssey of discovery. Br J Haem 2000;111:1035-44. [ Links ]
4. WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues. 4th ed. World Health Organization Classification of Tumours, ed. S. Swerdlow, et al. 2008, Lyon: Internation Agency for Research on Cancer. [ Links ]
5. Ruiz-Arguelles G, et al. Multiple myeloma in Mexico: A 20-year experience at a single institution. Archives of Medical Research 2004;35:163-7. [ Links ]
6. Miguel J, et al. Conventional diagnostics in multiple myeloma. EJC 2006;42:1510-9. [ Links ]
7. Caers J, et al. Multiple myeloma - an update on diagnosis and treatment. Eur J Haem 2008;81:329-43. [ Links ]
8. Kyle R, et al. Review of 1027 patients with newly diagnosed multiple myeloma. Mayo Clin Proc 2003;78:21-33. [ Links ]
9. Dvorak C. Common complaints, difficult diagnosis: Multiple Myeloma. JAm AC Nurse Prac 2006;18(5):190-4. [ Links ]
10. Preston D, Cusumi S. Cancer incidence in atomic bomb survivors, Part III. Leukemia, lymphoma and multiple myeloma,1950-1987. Radiat Res 1994;137:S68. [ Links ]
11. Lewis E. Leukemia, multiple myeloma, and aplastic anaemia in american radiologists. Science 1963;142(3598):1492-4. [ Links ]
12. Potter M. Experimental models of immunoglobulin-secreting tumors. in: Wiernik PH, Carnellos GP, Dutcher JP, Kyel RA (Eds). Neoplastic Diseases of the Blood, 1996. 3rd edition Churchill Livingstone, New York: p. 423. [ Links ]
13. Doody M, Linet M. Leukemia, lymphoma and multiple myeloma following selected medical conditions. Cancer Causes Control 1992;3:449. [ Links ]
14. Sitas F, et al. The spectrum of HIV-1 related cancers in South Africa. Int J Cancer 2000;88:489-92. [ Links ]
15. Mqoqi N, et al. Incidence of histologically diagnosed cancer in South Africa 1998-1999. National Cancer Registry of South Africa, National Health Laboratory Service, Johannesburg. 2004. Dec: p. 1-62. [ Links ]
18. //info.cancerresearch.org/cancerstats/types/mutiplemyeloma/incidence/ Accessed 14 July 2009. 2005 [cited]. [ Links ]
19. Kyle R, Rajkumar S. Multiple myeloma. N Engl J Med 2004;351(18):1860-73. [ Links ]
20. Rosinol L, Blade J. Smoldering multiple myeloma: natural history and recognition of an evolving type. Br J Haem 2003;123:631. [ Links ]
21. Kyle R, Rajkumar S. Monoclonal gammopathies of undetermined significance: a review. Imm Rev 2003;194:112-39. [ Links ]
22. Cesana C, Klersy C. Prognostic factors for malignant transformation in monoclonal gammopathy of undetermined significance and smoldering multiple myeloma. J Clin Oncol 2002;20:1625. [ Links ]
23. Blade J. Clinical practice. Monoclonal gammopathy of undetermined significance. N Engl J Med 2006;355(26):2765-70. [ Links ]
24. Kyle R, Therneau T. A long-term study of prognosis in monoclonal gammopathy of undetermined significance. N Engl J Med 2002;564. [ Links ]
25. Vavricka S, et al. Serum protein electrophoresis: an underused but very useful test. Digestion 2009;79:203-10. [ Links ]
26. Dispenzieri A, et al. International Myeloma Working Group guidelines for serum-free light chain analysis in multiple myeloma and related disorders. Leukaemia 2009;23:215-24. [ Links ]
27. Lahtinen R, Laakso M. Randomised, placebo-controlled multi-centre trial of clodronate in multiple myeloma. Finnish Leukemia Group. Lancet 1992;340:1049. [ Links ]
28. Angtuaco E, et al. Multiple myeloma: clinical review and diagnostic imaging. Radiology 2004;231(1):11-23. [ Links ]
29. Silberman J, Lonial S. Review of peripheral neuropathy in plasma cell disorders. Hematol Oncol 2008;26:55-65. [ Links ]
30. Eby C. Pathogenesis and management of bleeding and thrombosis in plasma cell dyscrasias. Br J Haem 2009;145:151-63. [ Links ]
Dr A Visser
This article is the sole work of the authors. No benefits of any form have been received from a commercial party related directly or indirectly to the subject of this article although a grant has been applied for.