From the Guidelines
Multiple myeloma is characterized by several key hematologic signs, including anemia, elevated total protein level with a monoclonal spike, hypercalcemia, renal insufficiency, and elevated erythrocyte sedimentation rate (ESR). The most common finding is anemia, typically normocytic and normochromic, occurring in approximately 70% of patients at diagnosis due to bone marrow infiltration by plasma cells and decreased erythropoietin production 1. Patients often show an elevated total protein level with a monoclonal spike on serum protein electrophoresis, reflecting the overproduction of immunoglobulins by malignant plasma cells. Hypercalcemia is present in about 15% of patients at diagnosis due to increased osteoclast activity. Renal insufficiency with elevated creatinine occurs in roughly 20-30% of patients. Laboratory tests frequently reveal an elevated erythrocyte sedimentation rate (ESR) and increased serum viscosity. Thrombocytopenia and leukopenia may develop as the disease progresses and bone marrow function becomes more compromised. Peripheral blood smears might show rouleaux formation (red blood cells stacked like coins) due to paraproteinemia. Bone marrow examination typically reveals an increased percentage of plasma cells (>10%), often with abnormal morphology.
Some of the key hematologic signs of multiple myeloma include:
- Anemia, typically normocytic and normochromic
- Elevated total protein level with a monoclonal spike on serum protein electrophoresis
- Hypercalcemia due to increased osteoclast activity
- Renal insufficiency with elevated creatinine
- Elevated erythrocyte sedimentation rate (ESR) and increased serum viscosity
- Thrombocytopenia and leukopenia as the disease progresses
- Rouleaux formation on peripheral blood smears due to paraproteinemia
- Increased percentage of plasma cells (>10%) on bone marrow examination, often with abnormal morphology. The diagnosis of symptomatic multiple myeloma requires the presence of ≥10% clonal plasma cells on BM examination or a biopsy-proven plasmacytoma, and evidence of end-organ damage, such as hypercalcemia, renal insufficiency, anemia, or bone lesions, as outlined in the CRAB criteria 1.
The combination of anemia, monoclonal protein, and bone marrow plasmacytosis is crucial for diagnosis and monitoring disease progression. The European Myeloma Network guidelines emphasize the importance of prophylaxis and supportive treatment for osteolytic disease, pain, anemia, renal insufficiency, infections, pain, thromboembolic events, and peripheral neuropathy in the management of myeloma patients 1. Additionally, the use of erythropoiesis-stimulating agents (ESAs) can help increase hemoglobin levels in patients with symptomatic anemia, as recommended by the American Society of Hematology (ASH) and American Society of Clinical Oncology (ASCO) guidelines 1.
From the FDA Drug Label
Neutropenia was reported in 15% of patients and was Grade 3 in 8% of patients and ≥ Grade 4 in 2%. Thrombocytopenia was reported in 32% of patients. Thrombocytopenia was Grade 3 in 22%, ≥ Grade 4 in 4%, and serious in 2% of patients, and the reaction resulted in bortezomib discontinuation in 2% of patients Anemia NOS 209 (18) 65 (6)
The hematologic signs for multiple myeloma include:
- Anemia: 18% of patients
- Neutropenia: 15% of patients, with 8% being Grade 3 and 2% being ≥ Grade 4
- Thrombocytopenia: 32% of patients, with 22% being Grade 3,4% being ≥ Grade 4, and 2% being serious 2
- Decreased platelets: 88% of patients, with 18% being Grades 3-4 3
- Decreased lymphocytes: 83% of patients, with 50% being Grades 3-4 3
- Decreased leukocytes: 68% of patients, with 18% being Grades 3-4 3
- Decreased neutrophils: 55% of patients, with 15% being Grades 3-4 3
- Decreased hemoglobin: 47% of patients, with 6% being Grades 3-4 3
From the Research
Hematologic Signs for Multiple Myeloma
The hematologic signs for multiple myeloma include:
- Anemia, which is characterized by a decrease in hemoglobin levels 4
- Presence of abnormal clonal plasma cells in the bone marrow, leading to uncontrolled growth and potential for destructive bone lesions, kidney injury, and hypercalcemia 5, 4
- Renal failure, which can be attributed to the plasma cell disorder 6, 7
- Hypercalcemia, which is a common feature of multiple myeloma 5, 6, 7
- Bone marrow clonal plasmacytosis ≥60% 6, 7
- Serum involved/uninvolved free light chain (FLC) ratio ≥100 (provided involved FLC is ≥100 mg/L) 6, 7
Diagnostic Criteria
The diagnosis of multiple myeloma requires:
- ≥10% clonal bone marrow plasma cells or a biopsy-proven plasmacytoma plus evidence of one or more multiple myeloma defining events (MDE) 6, 7
- Evidence of CRAB (hypercalcemia, renal failure, anemia, or lytic bone lesions) features felt related to the plasma cell disorder 6, 7
- Presence of >1 focal lesion on magnetic resonance imaging (MRI) 6, 7
Prevalence of Hematologic Signs
Approximately 73% of patients with multiple myeloma have anemia, 79% have osteolytic bone disease, and 19% have acute kidney injury at the time of presentation 4