Can multiple myeloma cause chest pain?

Can Multiple Myeloma Cause Chest Pain?

Yes, multiple myeloma can directly cause chest pain through bone involvement, rib fractures, sternal lesions, and extramedullary plasmacytomas affecting the chest wall or mediastinum. 1

Mechanisms of Myeloma-Related Chest Pain

Direct Skeletal Involvement

• Lytic bone lesions of the ribs, sternum, or thoracic spine are the primary cause of chest pain in myeloma patients, reflecting the high prevalence of skeletal disease in this condition 1
• Point tenderness over the ribs, sternum, or thoracic spine on examination suggests focal myeloma bone disease 1
• Pain characteristically worsens with movement, coughing, or deep breathing—distinguishing it from cardiac ischemia 1
• The absence of radiation to arms or jaw, and lack of exertional triggers, further differentiates musculoskeletal myeloma pain from angina 1

Extramedullary Disease

• Extramedullary plasmacytomas can arise in the chest wall or pleura and produce localized chest pain, representing 3-4% of plasma cell disorders 1
• Mediastinal masses from extramedullary plasmacytomas may present with chest pain and dyspnea, and can precede full-blown multiple myeloma by months to years 2
• Sternal plasmacytomas can present as expansile lytic lesions with acute chest pain 3

Diagnostic Approach

Mandatory Cardiac Exclusion First

• The 2021 ACC/AHA Chest Pain Guidelines require cardiac evaluation first in any patient with acute chest pain; non-cardiac causes including myeloma are considered only after life-threatening cardiac conditions are ruled out 1
• This is critical because myeloma patients retain substantial risk for acute coronary syndrome and pulmonary embolism (VTE incidence 8-22 per 1,000 person-years, higher with IMiD therapy) 1

Imaging for Myeloma-Related Pain

• A conventional skeletal survey with dedicated rib and sternal views is recommended to detect lytic lesions or fractures responsible for chest pain 1
• Chest CT with contrast can identify expansile lytic lesions, mediastinal masses, or soft tissue plasmacytomas 3

Laboratory Confirmation

• Serum and urine protein electrophoresis with immunofixation, plus serum free-light-chain assays, document the underlying monoclonal protein and support active myeloma diagnosis 1

Pain Management Algorithm

Mild Pain (ADLs Preserved)

• Paracetamol up to 1 g four times daily is first-line; NSAIDs should be avoided due to heightened renal toxicity risk in myeloma patients 4, 1

Moderate Pain (Functional Impairment)

• Oral tramadol or codeine is advised, with gabapentin or pregabalin added for neuropathic components 4, 1

Severe Pain (Incapacitating)

• Transdermal fentanyl or buprenorphine patches, or oral oxycodone are appropriate for severe pain 4, 1
• Subcutaneous oxycodone or morphine may be used for rapid relief of acute severe episodes 4, 1
• All patients on opioids must receive prophylactic laxatives to prevent opioid-induced constipation 4, 1

Disease-Directed Interventions

Systemic Bone-Targeted Therapy

• Bisphosphonates (zoledronic acid or pamidronate) or denosumab reduce skeletal-related events and provide analgesia in myeloma-associated bone disease 1

Local Interventions

• Local radiation therapy (typically 20-30 Gy) achieves pain relief in >86% of patients with focal bone involvement, with median time to response of about 5 months 1
• Vertebroplasty or kyphoplasty can be employed for vertebral compression fractures causing chest-wall pain 1

Critical Pitfalls and Red Flags

Alternative Etiologies

• The European Myeloma Network cautions that chest or back pain may stem from non-myeloma causes; clinicians must remain vigilant for alternative etiologies 4, 1
• Myeloma patients have 7-fold higher risk of bacterial infections, making pneumonia a common cause of chest pain 5

Life-Threatening Complications

• Acute severe chest pain with dyspnea should raise suspicion for pathologic rib fracture with pneumothorax or pulmonary embolism 1
• Progressive chest pain with neurologic deficits may indicate spinal cord compression, requiring emergent MRI and prompt intervention 1
• Lenalidomide or pomalidomide carry VTE risk up to 70% without prophylaxis, especially during the first four months; aspirin 100 mg daily suffices for low-risk patients, whereas LMWH or warfarin is indicated for higher-risk individuals 4, 1
• Thalidomide therapy can precipitate dangerous bradycardia, necessitating monthly Holter monitoring 1

Prognosis

• Chest pain from myeloma-related bone disease generally improves within weeks to months after effective anti-myeloma therapy and supportive measures 1
• Solitary plasmacytomas treated with radiation achieve excellent local control (>80%) but have 50% risk of progression to systemic myeloma within ten years 1