Symptoms

Early in multiple myeloma, there might be no symptoms. When signs and symptoms happen, they can include:

• Bone pain, especially in the spine, chest or hips.
• Nausea.
• Constipation.
• Infections.
• Weight loss.
• Weakness.
• Kidney problems. Multiple myeloma may cause problems with the kidneys. It can lead to kidney failure.
• Low red blood cell count, called anemia. 

Diagnosis : Sometimes a health care professional finds multiple myeloma during a blood test for another condition. Other times your symptoms may lead your health care professional to test for multiple myeloma.

Tests and procedures to diagnose multiple myeloma include:

• Blood tests
• Electrophoresis: This test looks for M proteins in your blood. The M proteins made by myeloma cells can show up in a sample of blood. Blood tests also might find another protein myeloma cells make, called beta-2-microglobulin.
• Other blood tests give your health care team clues about your diagnosis. These tests might include tests that look at kidney function, blood cell counts, calcium levels and uric acid levels.
• Urine tests.M proteins can show up in urine samples. In urine, the proteins are called Bence Jones proteins.
• Bone marrow tests.Bone marrow biopsy and bone marrow aspiration are used to collect bone marrow samples for testing.
• The samples go to a lab for testing. In the lab, tests look for myeloma cells. Other special tests give your health care team more information about your myeloma cells. For example, the fluorescence in situ hybridization test looks for changes in the cells' genetic material, called DNA.
• Imaging tests.Imaging tests can show bone problems linked with multiple myeloma. Tests may include an X-ray, MRI scan, CT scan, or positron emission tomography scan, also called PET scan.

 

Treatment:

 Multiple myeloma is usually treated with drugs.

Chemotherapy used to be the main treatment in the past.

Doctors use the following drugs for multiple myeloma:

• Cytostatics are conventional chemotherapy agents that block the division of cancer cells.
• Corticosteroids are anti-inflammatory drugs. They help to fight the manifestations of multiple myeloma and reduce nausea due to chemotherapy.
• Immunomodulatory drugs help the immune system to fight cancer. They are often used during a remission to prevent the disease recurrence.
• Proteasome inhibitors block enzymes important for cell division. They are mainly used for maintenance therapy after achieving a remission.
• Monoclonal antibodies are drugs that target particular molecular targets (antigens) found in cancer cells. CD38 or SLAMF7 antibodies are used to treat multiple myeloma. They help the immune system to better find and destroy cancer cells.

Multiple myeloma can rarely be treated with a single drug. Doctors usually use combinations of two or three drugs. If they do not work, oncologists try other options. Sometimes they prescribe four (DCEP), six (DT-PACE), or even seven drugs at the same time to achieve a remission of the disease.

A treatment regimen usually includes maintenance and symptomatic treatment:

• Bisphosphonates do not affect the rate of progression of myeloma, but help to strengthen the bones. They relieve pain and reduce the risk of fractures.
• Transfusions of blood and its components involve the administration of red blood cells for anemia. If there are problems with blood clotting, a platelet mass is administered to patients.

• Radiation therapy

 Only a small number of patients with multiple myeloma need radiation therapy. In most cases, doctors can achieve a good result with the help of drug therapy alone.

Irradiation can be used in the following cases:

• for solitary plasmacytoma, as the main treatment option (this disease precedes multiple myeloma, and is characterized by the development of single tumor foci in the bones, less often in other organs);
• for irradiation of single foci of multiple myeloma that did not disappear after chemotherapy.
• if you need a quick result in case of complications, such as spinal cord compression (chemotherapy can also reduce a tumor size, but it works more slowly).

• Stem cell transplant

 A bone marrow transplant can be used in cases where other treatment options do not work. There are two transplant options:

• autologous (transplantation of a patient's own cells),
• allogeneic (stem cell transplant from a donor).

An autologous transplant is used to treat multiple myeloma. It is safer than an allogeneic one. In addition, patients do not have to look for a donor. Autologous transplantation procedures provide a long-term remission of the disease.

The essence of this treatment option is as follows:

1. stem cells are harvested from the patient's bone marrow or peripheral blood,
2. the patient receives high-dose chemotherapy, which destroys not only the tumor, but also the bone marrow, so the production of blood cells stops,
3. the patient is transplanted with his own stem cells to restore hematopoietic function. Cells are administered intravenously.

Some doctors recommend their patients with multiple myeloma to have two auto transplant procedures from 6 to 12 months apart. Such an approach is called a tandem transplant. Trials show that they increase the patient's life expectancy, and a relapse-free period as compared to a single transplant. However, this treatment method has a drawback: it causes more side effects. When having your consultation of the oncologist, check with him whether a tandem bone marrow transplant is suitable for you, or is it better to limit yourself to a standard procedure.

An allogeneic stem cell transplant (from a donor) for multiple myeloma is not considered a standard treatment. This can be used as part of clinical trials. This treatment option can be resorted to in the case of disease recurrence after an autologous transplant. The transplantation of stem cells from a donor is more dangerous, since the cells may not survive, and sometimes an immune reaction "graft versus host" occurs. However, if successful, this treatment is potentially more effective. First, donor cells are definitely free of myeloma residues. Secondly, after a successful transplant, the graft-versus-tumor effect is activated, so the remaining malignant cells in the body are destroyed.

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1-Diagnosis:

The program includes:

• Initial presentation in the clinic
• clinical history taking
• review of medical records
• physical examination
• laboratory tests:
• complete blood count
• biochemical analysis of blood test (general protein, calcium)
• inflammation markers (CRP, ESR)
• blood coagulation analysis (aPTT, PT, INR)
• differential blood count
• amount of Ki-67-positive plasma cells
• paraprotein (M-component) in blood and daily urine
• Bence-jones protein detection in urine
• ultrasound, X-ray of skeletal system, CT/MRI skeletal system examination (if clinically indicated)
• biopsy of the osteolytic focus with histological and immunohistochemical study
  (if clinically indicated)
• bone marrow aspirate and biopsy (if indicated clinically).
• nursing services
• tumor board: consultation of specialists in oncology, radiology, surgery
• treatment by chief physician and all leading experts
• explanation of individual treatment plan

Required documents

• Medical records
• MRI/CT scan (not older than 3 months)
• Bone marrow biopsy results (if available)

Price from: On request

Type of program: Outpatient

Expected duration of the program: 7 days

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2-Chemotherapy:

The program includes:

• Initial presentation in the clinic
• clinical history taking
• review of medical records
• physical examination
• laboratory tests:
• complete blood count
• biochemical analysis of blood
• urinalysis for Bence-Jones protein
• differential blood count
• protein electrophoresis
• immunofixation
• TSH-basal, fT3, fT4
• inflammation indicators (CRP, ESR)
• indicators of blood coagulation
• individual plan of the chemotherapy for 1 cycle
• the cost of medicines and symptomatic treatment:
• nursing services
• control examinations
• consultations of related specialists
• recommendations for further therapy

How program is carried out

During the first visit, the doctor will conduct a clinical examination and go through the results of previous laboratory tests and instrumental examinations. After that, you will undergo an additional examination, including laboratory assessment of liver and kidney function, ultrasound scan. Based on the received results, the doctor will elaborate the chemotherapy regimen. If necessary, related medical specialists will be involved in the elaboration of a treatment regimen (tumor board).

Chemotherapy is carried out as the day hospital procedure, without mandatory admission to the hospital. After the placement of a venous catheter, you will stay in a comfortable ward. An infusion system will be connected to the catheter, through which the required drug or a drug combination will be administered. All drugs are administered by intravenous drip, slowly, so the total duration of the infusion can be up to several hours. All this time, doctors and nurses will monitor your health condition closely.

After the course of chemotherapy, you will stay under medical supervision in the ward for a few more hours. If your general condition is good, your doctor will allow you to leave the hospital. You will receive the medical report with detailed recommendations regarding further treatment. In the future, you will be able to have a distant consultation with your attending physician and schedule the next course of chemotherapy, if necessary.

Required documents

• Medical records
• MRI/CT scan (not older than 3 months)
• Bone marrow biopsy results (if available)

Price from: on request

Type of program: Outpatient

Expected duration of the program: 5 to 21 days depending on treatment protocol.

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3-Radiotherapy:

The program includes:

• Initial presentation in the clinic
• clinical history taking
• review of medical records
• physical examination
• CT /MRI (if indicated clinically) 
• laboratory tests:
• complete blood count
• general urine analysis
• biochemical analysis of blood
• indicators of inflammation (CRP, ESR)
• CT simulation and planning of radiation therapy
• Physics calculation
• full course of radiation therapy with different modalities (3D, IMRT, VMAT) according to your treatment plan.
• individual plan of the chemotherapy, the cost of medicines is included
• symptomatic treatment (for side effects of radiotherapy that may developed).
• cost of essential medicines and materials
• nursing services
• control examinations
• consultations of related specialists
• explanation of future recommendations

How program is carried out

During the first visit, the doctor will conduct a clinical examination and go through the results of previous laboratory tests and instrumental examinations. After that, you will undergo an additional examination, including complete blood count, laboratory assessment of liver and kidney function. Based on the received results, the physician will conduct radiotherapy planning with the help of CT or MRI, make the permanent tattoo marks on the skin and conduct CT simulation to assess the accuracy of the rays and the radiation dose. If necessary, related medical specialists will be involved in the elaboration of a treatment regimen (tumor board).

Radiation therapy is carried out as an inpatient procedure, with mandatory admission to the hospital. Before each session the physician will assess your general condition and the marks on the skin. After that, you will be placed in a shielded radiation therapy room, on a special table.

Each radiation therapy session lasts less than half an hour (including preparation). All this time, doctors and nurses are monitoring your condition, you can communicate with them through a loudspeaker. The procedure is completely painless. Depending on the planned course of treatment, you will have from 1 to 3-5 sessions of radiation therapy a week.

After the completion of the radiation therapy course, you will undergo control examinations aimed at assessing your condition and efficacy of treatment. After that you will receive the medical report with detailed recommendations regarding further follow-up and treatment. In the future, you will be able to have a distant consultation with your attending physician and schedule the next course of treatment, if necessary.

Required documents

• Medical records
• MRI/CT scan, PET scan (if available)

Price from: on request

Type of program: Inpatient

Expected duration of the program: 15- 30 days

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4-Bone marrow transplantation:

The program includes:

• Initial presentation in the clinic
• case history collection
• general clinical examination
• laboratory tests:
• complete blood count
• general urine analysis
• biochemical analysis of blood
• TSH-basal, fT3, fT4
• tumor markers
• indicators of inflammation
• indicators of blood coagulation
• CT/MRI scans of the whole body
• needle biopsy of the bone marrow
• biopsy and histological examination of CSF (if indicated clinically)
• examination by experts of:
• Cardiology
• Otolaryngology
• Immunology
• Ophthalmology
• Infectious disease
• conducting high-dose chemotherapy or radiotherapy (for destruction of all marrow cells).
• CT simulation and Physics calculations
• autologous bone marrow transplantation
• isolation by neutropenic precautions in transplantation unit
• symptomatic treatment
• the cost of essential medicines and blood products
• nursing services
• stay in the hospital with full board
• elaboration of further recommendations

How program is carried out

During the first visit, the doctor will conduct a clinical examination and go through the results of the available diagnostic tests. After that, you will undergo the necessary additional examination, such as the assessment of liver and kidney function, ultrasound scan, CT scan and MRI.

Also, the doctor will conduct a bone marrow biopsy followed by cytological examination of the harvested material. This will help him to determine the histological features of your bone marrow (in particular, identify HLA system antigens) and the use of a person’s own stem cells. They typically involve harvesting your cells before beginning a damaging therapy to cells like chemotherapy or radiation. After the treatment is done, your own cells are returned to your body.

This type of transplant isn’t always available. It can only be used if you have a healthy bone marrow. However, it reduces the risk of some serious complications, including GVHD.

 

Before the procedure, you will receive chemotherapy, if necessary, in combination with radiation therapy. The course of chemo- or chemoradiation therapy lasts from 2 to 8 days.

The bone marrow transplant procedure is an intravenous infusion, i.e. the healthy bone marrow will be injected through a catheter, intravenously. You will stay in your room during the procedure. A bone marrow transplant is completely painless and does not require anesthesia.

 

During the period of healthy bone marrow engraftment, you will stay in a sterile ward. This is a necessary precaution because during this time your immune system is very weak and cannot withstand environmental pathogens. The risk of bleeding is also quite high, so you will be advised to avoid mechanical damage.

 

A relative or other close person may stay in the ward with you. You will not be allowed to go outside the department and leave your ward often. The rehabilitation period can last from 1 to 2 months.

When your complete blood count returns to normal, your doctor will schedule your discharge from the department. You will receive information about the rules that you will need to follow at home, the frequency and type of control examinations, and subsequent treatment measures. You will also receive a detailed medical report, which will reflect the entire course of treatment.

 

Required documents

• Medical records
• MRI/CT scan (not older than 3 months)
• Bone marrow biopsy results (if available)

Price from: on request

Type of program: Inpatient

Expected duration of the program: 57 days