Multiple myeloma is a malignant proliferation of plasma cells that is not curable with standard therapy. The disease can cause significant disability and tends to occur in older individuals, so the care must be comprehensive with palliation of symptoms a major goal. This chapter will review the supportive care recommended for patients with myeloma, after providing basic information regarding the biology and available standard chemotherapy.

Biology/natural history

Plasma cells differentiate from B lymphocytes and normally function to produce antibodies. Antibodies are plasma proteins produced to help the cellular immune system fight foreign matter such as bacteria. Antibodies are found in the gamma globulin fraction on serum protein electrophoresis (SPEP). One clone of plasma cells produces one specific antibody (idiotype) so that when one plasma cell becomes malignant the clone of abnormal cells all produce the same idiotypic protein. As these cells proliferate, more antibody is produced and this leads to a monoclonal (“M”) spike on the SPEP. Plasma cells normally comprise less than 5% of bone marrow cells.

A number of staging systems have been developed for myeloma. Criteria to make a diagnosis of multiple myeloma include marrow plasmacytosis of greater than 10%, presence of an M-protein (for IgG usually greater than 3 g/dl) in the serum on SPEP, and at least one of the following: (1) anemia; (2) M-protein (or light chains only greater than 1.0 g/24 hour) in the urine (usually measured by a 24-hour urine collection); (3) lytic bone lesions demonstrated on a skeletal survey, or osteoporosis only but with greater than 30% plasma cells in the bone marrow; (4) renal insufficiency; or (5) hypercalcemia.