Multiple myeloma: Overview of management

Author: S Vincent Rajkumar, MD

Section Editor: Robert A Kyle, MD Deputy Editor: Rebecca F Connor, MD All topics are updated as new evidence becomes available and our peer review process is complete.

INTRODUCTION
Multiple myeloma (MM) is characterized by the neoplastic proliferation of clonal plasma cells producing a monoclonal immunoglobulin. These clonal plasma cells proliferate in the bone marrow and often result in extensive skeletal destruction with osteolytic lesions, osteopenia, and/or pathologic fractures. Additional disease-related complications include hypercalcemia, renal insufficiency, anemia, and infections. This topic reviews the overall treatment strategy for patients with MM. Further details regarding the selection of initial therapy, the treatment of relapsed and/or refractory disease, the use of hematopoietic cell transplantation, and the management of complications of MM are discussed separately.

VERIFY THE DIAGNOSIS
The first step in evaluating a new patient with MM is to verify the diagnosis since the premalignant stages of myeloma, namely monoclonal gammopathy of undetermined significance (MGUS) and smoldering multiple myeloma (SMM), may be easily misdiagnosed as MM if one is not careful (table 1 and algorithm 1). As an example, patients with MGUS may have renal failure due to diabetes or hypertension, or have bone lesions from other cancers. Such patients may be misdiagnosed with MM if these findings are incorrectly attributed to the plasma cell dyscrasia. Therefore, every effort should be made to determine whether the observed "end-organ damage" is truly secondary to the underlying plasma cell disorder or to an unrelated process. (See "Multiple myeloma: Clinical features, laboratory manifestations, and diagnosis", section on 'Diagnosis'.)

Unlike persons with MGUS and SMM, all patients with a confirmed diagnosis of MM require treatment. Without effective therapy, symptomatic patients die within a median of six months [1]. In contrast, patients with SMM may remain stable for prolonged periods. As such, if there is doubt about whether the patient has SMM or MM, a reasonable approach is to re-evaluate the patient in two or three months and to delay therapy until the correct diagnosis is evident. The patient should be instructed to monitor for symptoms related to MM and contact the provider immediately should there be a change in his or her condition.

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