Multiple Myeloma and Plasma Cell Disorders — MCQs
Which among the following statements is wrong?
Radiotherapy has the most significant therapeutic role in:
An elderly male patient presented with clinical symptoms and signs consistent with possible multiple myeloma. Electrophoresis shows an M spike, and immunofixation findings are shown below. Which of the following statements best corresponds to the findings?
A 60-year-old man presented to the emergency department with sudden-onset cough, yellow sputum production, and dyspnea, while taking amlodipine for hypertension. Chest X-ray revealed a left upper lobe alveolar infiltrate, and laboratory investigations showed Hb of 6 g/dL, BUN of 60 mg/dL, Creatinine of 2.8 mg/dL, Calcium of 12.3 mg/dL, total protein of 9 g/dL, and albumin of 4.2 g/dL. Echocardiogram revealed a dilated heart, and peripheral neuropathy was also present. What is the most common cause of death in patients with multiple myeloma?
ESR is increased in
Which of the following is most Likely to be fatal?
Amyloidosis shown in cardiac muscle is mainly due to which fibril?
What is a known complication of Parvovirus B19 infection?
A 63-year-old man comes to the physician because of a 3-month history of fatigue and constipation. He reports having dull pain in the left portion of the midback for 2 weeks that has persisted despite taking ibuprofen. His father died of prostate cancer at 70 years of age. The patient has smoked one pack of cigarettes daily for 45 years. Vital signs are within normal limits. Physical examination shows a left-sided varicocele both in supine and in standing position. Rectal examination shows a symmetrically enlarged prostate with no masses. Laboratory studies show: Hemoglobin 11.2 g/dL Serum Creatinine 1.0 mg/dL Calcium 11.8 mg/dL Urine Protein 1+ Blood 2+ Which of the following is the most appropriate next step in management?
A 40-year-old patient presents with complains of low back pain and development of pallor. During workup very high levels of urinary beta2 microglobulin was noted. X-ray skull was performed. Bone marrow aspiration shows >10% plasma cells and serum electrophoresis shows M protein >30 g/L. All are useful for management of this patient except?
Multiple Myeloma and Plasma Cell Disorders Indian Medical PG Practice Questions and MCQs
Question 1: Which among the following statements is wrong?
- A. M components are detected in chronic myeloid leukemia. (Correct Answer)
- B. In 20% of myelomas, only light chains are produced.
- C. Light chains are synthesized in slight excess normally in plasma cells.
- D. Qualitative assessment of M component can be done by electrophoresis.
Explanation: ***M components are detected in chronic myeloid leukemia.*** - This statement is **incorrect**. M-components (monoclonal proteins) are characteristic of **plasma cell dyscrasias** such as multiple myeloma, MGUS, and Waldenström macroglobulinemia [1]. - **Chronic myeloid leukemia (CML)** is a myeloproliferative neoplasm involving the granulocytic cell line, not plasma cells. CML does not produce M-components unless there is a **coincidental and unrelated plasma cell disorder**. - M-components arise from clonal proliferation of plasma cells producing a single type of immunoglobulin, which is not a feature of CML pathophysiology [2]. *Qualitative assessment of M component can be done by electrophoresis.* - This statement is correct. **Serum protein electrophoresis (SPEP)** is the primary tool for qualitative detection of M-components. - It provides qualitative information by demonstrating the presence of a monoclonal spike and its migration pattern in the gamma, beta, or alpha regions. - While SPEP also provides quantitative data (size/concentration), **immunofixation electrophoresis (IFE)** is subsequently used for specific typing of the heavy chain (IgG, IgA, IgM) and light chain (kappa or lambda). *In 20% of myelomas, only light chains are produced.* - This statement is correct. Approximately **15-20% of multiple myeloma cases** produce only monoclonal light chains without intact heavy chains [1]. - These are called **light chain myelomas**, and the light chains (Bence Jones proteins) are detected in urine and serum [2]. *Light chains are synthesized in slight excess normally in plasma cells.* - This statement is correct. Normal plasma cells produce a **slight excess of light chains** compared to heavy chains to ensure proper immunoglobulin assembly. - The excess free light chains are normally cleared by the kidneys, maintaining a balanced serum free light chain ratio (kappa/lambda ratio of 0.26-1.65). **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of White Blood Cells, Lymph Nodes, Spleen, and Thymus, pp. 606-609. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Blood And Bone Marrow Disease, pp. 616-617.
Question 2: Radiotherapy has the most significant therapeutic role in:
- A. Monoclonal gammopathy
- B. Tuberculosis
- C. Sarcomas (Correct Answer)
- D. Sarcoidosis
Explanation: ***Sarcomas*** - **Radiotherapy** plays a crucial therapeutic role in **sarcomas**, though typically as **adjuvant therapy** combined with surgical resection - Used for **local control** in soft tissue sarcomas, particularly when wide margins cannot be achieved - **Primary radiotherapy** is the treatment of choice for certain radiation-sensitive sarcomas like **Ewing's sarcoma** and in cases of **inoperable tumors** - Essential for reducing **local recurrence rates** in high-grade soft tissue sarcomas - Among the options listed, sarcomas have the **strongest and most established indication** for radiotherapy *Monoclonal gammopathy* - Generally **observation only** for MGUS (Monoclonal Gammopathy of Undetermined Significance) - Radiotherapy used only for **solitary plasmacytoma**, which is a specific localized manifestation - Multiple myeloma (if it progresses) is treated with **chemotherapy** and targeted agents, not radiotherapy as primary treatment *Tuberculosis* - An **infectious disease** caused by *Mycobacterium tuberculosis* - Treated exclusively with **anti-tubercular drug regimens** (RIPE: Rifampicin, Isoniazid, Pyrazinamide, Ethambutol) - Radiotherapy has **no role** in treating infections *Sarcoidosis* - A **systemic inflammatory condition** with non-caseating granulomas - Primary treatment is **corticosteroids** for symptomatic cases - Immunosuppressants used for refractory cases - Radiotherapy has **no role** in inflammatory/granulomatous diseases
Question 3: An elderly male patient presented with clinical symptoms and signs consistent with possible multiple myeloma. Electrophoresis shows an M spike, and immunofixation findings are shown below. Which of the following statements best corresponds to the findings?
- A. Multiple myeloma with increased IgM
- B. Multiple myeloma with increased IgG (Correct Answer)
- C. Multiple myeloma with increased IgA
- D. Waldenström macroglobulinemia
Explanation: ***Multiple myeloma with increased IgG*** - The immunofixation image shows a distinct, *monoclonal band (M spike)* in the **IgG lane (G)**, corresponding to the initial electrophoresis (ELP) M spike [1]. There is also a corresponding band in the **kappa light chain (K)** lane [1]. - The presence of a dominant band in IgG, along with a matching light chain (either kappa or lambda), indicates an **IgG monoclonal gammopathy**, which is characteristic of the most common type of multiple myeloma [1]. *Multiple myeloma with increased IgM* - This option would correspond to a strong, monoclonal band in the **IgM lane (M)**, which is not the case here. The 'M' lane in the image shows a faint/normal band, not an increased M spike. - Increased IgM monoclonal protein (M spike) is characteristic of **Waldenström macroglobulinemia**, not typically multiple myeloma [2]. *Multiple myeloma with increased IgA* - If the patient had IgA multiple myeloma, there would be a prominent monoclonal band in the **IgA lane (A)**, which is not observed in this immunofixation result. The 'A' lane shows a considerably smaller band compared to IgG. - IgA multiple myeloma is a less common subtype than IgG myeloma and would present with an IgA M spike [1]. *Waldenström macroglobulinemia* - Waldenström macroglobulinemia is characterized by a monoclonal gammopathy of the **IgM type**, which would present as a distinct M spike in the IgM lane [2]. - The immunofixation clearly shows an **IgG M spike**, ruling out Waldenström macroglobulinemia based on the type of monoclonal gammopathy [2]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of White Blood Cells, Lymph Nodes, Spleen, and Thymus, pp. 608-609. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of White Blood Cells, Lymph Nodes, Spleen, and Thymus, pp. 606-607.
Question 4: A 60-year-old man presented to the emergency department with sudden-onset cough, yellow sputum production, and dyspnea, while taking amlodipine for hypertension. Chest X-ray revealed a left upper lobe alveolar infiltrate, and laboratory investigations showed Hb of 6 g/dL, BUN of 60 mg/dL, Creatinine of 2.8 mg/dL, Calcium of 12.3 mg/dL, total protein of 9 g/dL, and albumin of 4.2 g/dL. Echocardiogram revealed a dilated heart, and peripheral neuropathy was also present. What is the most common cause of death in patients with multiple myeloma?
- A. Bleeding
- B. CHF
- C. Infection
- D. Kidney failure (Correct Answer)
Explanation: ***Kidney failure*** - **Renal impairment** is common in multiple myeloma due to **Bence-Jones proteinuria**, hypercalcemia, and amyloidosis, significantly contributing to morbidity and mortality. - The presented labs show elevated **BUN** (60 mg/dL) and **creatinine** (2.8 mg/dL), indicating significant kidney dysfunction, making it a highly likely cause of death in this context. *Infection* - While **infection** is a significant cause of death in multiple myeloma patients due to **immunodeficiency**, the immediate lab findings point more strongly to acute renal failure. - The patient's **cough** with **yellow sputum** and **alveolar infiltrate** suggest pneumonia, but other presented lab values are more indicative of advanced kidney damage. *Bleeding* - **Bleeding diathesis** can occur in multiple myeloma due to **platelet dysfunction** and **coagulation factor deficiencies**, but there is no direct evidence of severe bleeding in the provided case details. - The symptoms and lab findings provided do not directly support bleeding as the primary or most common cause of death in this patient's presentation. *CHF* - **Congestive heart failure (CHF)** can develop in multiple myeloma due to **amyloidosis** affecting the heart or due to severe anemia, which is present (Hb 6 g/dL). - While the echocardiogram revealed a **dilated heart**, the pronounced **renal failure** indicated by BUN and creatinine levels is a more direct and common cause of mortality in multiple myeloma patients.
Question 5: ESR is increased in
- A. Multiple myeloma (Correct Answer)
- B. Polycythemia
- C. Thalassemia
- D. Sickle cell disease
Explanation: ***Multiple myeloma*** [1] - **Erythrocyte sedimentation rate (ESR)** is commonly elevated due to inflammatory cytokines and the presence of abnormal proteins affecting blood viscosity [1]. - Patients often present with **bone pain** and can have **hypercalcemia**, which further contributes to an increased ESR [2]. *Thalassemia* - Typically presents with **microcytic anemia** but does not significantly elevate the ESR [3]. - The chronic hemolysis in thalassemia often results in a normal or slightly raised ESR, not markedly increased as seen in malignancies. *Polycythemia vera* - Characterized by excessive red blood cell production, leading to increased blood viscosity, but usually results in a **low or normal ESR**. - The inflammatory response is minimal, and the only changes in ESR are due to viscous blood rather than true inflammation. *Sickle cell anemia* - While patients may experience vasocclusive crises leading to inflammation, the overall ESR is generally normal or only mildly elevated. - The primary issue in sickle cell anemia is the **sickle-shaped red blood cells**, not significant changes in ESR levels [3].
Question 6: Which of the following is most Likely to be fatal?
- A. Osteochondroma
- B. Paget's disease
- C. Multiple myeloma (Correct Answer)
- D. Giant cell tumour
Explanation: No changes made because no provided references reached the relevance threshold of 7. The provided text fragments discuss coagulation factor deficiency (Waldenström macroglobulinemia), physiology of taste, and Lambert-Eaton Myasthenic Syndrome, which do not directly support the clinical descriptions of Multiple Myeloma, Osteochondroma, Paget's disease, or Giant Cell Tumour as presented in the explanation.
Question 7: Amyloidosis shown in cardiac muscle is mainly due to which fibril?
- A. AA (Amyloid A Protein Amyloidosis)
- B. AL (Immunoglobulin Light Chain Amyloidosis) (Correct Answer)
- C. ATTR (Transthyretin Amyloidosis)
- D. Atrial Natriuretic Peptide Amyloidosis (Theoretical Form)
Explanation: ***ATTR*** - Cardiac amyloidosis is mainly associated with **transthyretin amyloidosis** (ATTR), which is related to the deposition of **transthyretin fibrils** in the heart tissue [1]. - This type of amyloidosis often presents in patients with **senile systemic amyloidosis** or familial cases linked to mutations in the transthyretin gene [1]. *AA* - **AA amyloidosis** is usually secondary to chronic inflammatory conditions and does not primarily affect the cardiac muscle. - It is derived from **serum amyloid A protein**, differing from the fibrils associated with cardiac involvement. *AL* - **AL amyloidosis** results from the deposition of **light chain immunoglobulins**, typically related to plasma cell dyscrasias rather than the transthyretin fibrils affecting the heart. - This form of amyloidosis is distinguished by its systemic effects primarily in the kidneys and nervous system. *AANF* - **AANF amyloidosis** is not a recognized type of amyloidosis in medical literature related to cardiac involvement. - The primary fibrils associated with cardiac amyloidosis are either **transthyretin (ATTR)** or **light chain (AL)**, making this option misleading [2]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of the Immune System, p. 266. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Heart, pp. 580-581.
Question 8: What is a known complication of Parvovirus B19 infection?
- A. Erythema infectiosum
- B. Arthritis
- C. Aplastic anemia (Correct Answer)
- D. All of the options
Explanation: Aplastic anemia - Parvovirus B19 has a tropism for erythroid progenitor cells in the bone marrow, specifically targeting and destroying them [1]. - This destruction can lead to a transient aplastic crisis, especially in individuals with pre-existing hemolytic conditions, causing a severe drop in red blood cell production [1]. Erythema infectiosum - This is the most common clinical manifestation of Parvovirus B19 infection, also known as fifth disease, characterized by a "slapped cheek" rash [1]. - While it is a symptom or disease caused by the virus, it is not considered a complication in the sense of a secondary, adverse outcome. Arthritis - Arthralgia and arthritis are common manifestations of Parvovirus B19 infection, particularly in adults, especially women [1]. - Similar to erythema infectiosum, it is a direct clinical manifestation rather than a "complication" representing a secondary, undesirable event. All of the options - While erythema infectiosum and arthritis are common clinical presentations of Parvovirus B19, they are direct disease manifestations. - Aplastic anemia stands out as a true complication, representing a secondary and potentially severe adverse outcome due to the virus's specific cellular tropism [1].
Question 9: A 63-year-old man comes to the physician because of a 3-month history of fatigue and constipation. He reports having dull pain in the left portion of the midback for 2 weeks that has persisted despite taking ibuprofen. His father died of prostate cancer at 70 years of age. The patient has smoked one pack of cigarettes daily for 45 years. Vital signs are within normal limits. Physical examination shows a left-sided varicocele both in supine and in standing position. Rectal examination shows a symmetrically enlarged prostate with no masses. Laboratory studies show: Hemoglobin 11.2 g/dL Serum Creatinine 1.0 mg/dL Calcium 11.8 mg/dL Urine Protein 1+ Blood 2+ Which of the following is the most appropriate next step in management?
- A. Urine cytology
- B. CT scan of the abdomen (Correct Answer)
- C. Chest x-ray
- D. Serum protein electrophoresis
- E. Prostate biopsy
Explanation: ***CT scan of the abdomen*** - The patient's symptoms, including **fatigue**, **constipation**, **dull midback pain**, **anemia**, **hypercalcemia**, and **new-onset left-sided varicocele**, are highly concerning for a retroperitoneal malignancy, most likely **renal cell carcinoma** [1]. - A **CT scan of the abdomen** is the most appropriate next step to evaluate the kidneys and retroperitoneum for a mass, as it can characterize the varicocele etiology (tumor compressing the **left renal vein**) [1]. *Urine cytology* - **Urine cytology** is primarily used to detect malignant cells in the urine, typically for suspected bladder or upper urinary tract transitional cell carcinoma. - While there is hematuria, the overall clinical picture with **hypercalcemia**, **anemia**, and **varicocele** points to a broader retroperitoneal process rather than solely a urinary tract epithelial malignancy. *Chest x-ray* - A **chest x-ray** evaluates the lungs and mediastinum and would be useful for assessing for metastatic disease, particularly in the context of cancer. - However, given the strong localizing signs (left-sided varicocele, midback pain), the priority is to identify the primary tumor in the abdomen before scanning for distant metastases. *Serum protein electrophoresis* - **Serum protein electrophoresis** is used to detect and characterize monoclonal gammopathies, such as those seen in **multiple myeloma**. - While hypercalcemia can be associated with multiple myeloma, the presence of a **new-onset left-sided varicocele** is highly suggestive of a mass compressing the left renal vein, which is not typically seen in multiple myeloma. *Prostate biopsy* - A **prostate biopsy** would be indicated if there were suspicious findings on rectal exam (e.g., prostatic nodule) or an elevated PSA, suggesting prostate cancer. - The rectal exam showed a **symmetrically enlarged prostate with no masses**, and while the father had prostate cancer, hypercalcemia and a new varicocele are not typical primary manifestations of prostate cancer.
Question 10: A 40-year-old patient presents with complains of low back pain and development of pallor. During workup very high levels of urinary beta2 microglobulin was noted. X-ray skull was performed. Bone marrow aspiration shows >10% plasma cells and serum electrophoresis shows M protein >30 g/L. All are useful for management of this patient except?
- A. Lenalidomide
- B. Bortezomib
- C. Melphalan (Correct Answer)
- D. Autologous transplantation
Explanation: ***Melphalan*** - While melphalan is used in **multiple myeloma**, its high-dose application is primarily a conditioning regimen for **autologous stem cell transplantation**, rather than a standalone maintenance or initial therapy, especially in younger patients who are transplant-eligible. - Furthermore, alkylating agents like melphalan are associated with an increased risk of **secondary malignancies**, making their long-term use less favorable in transplant-eligible patients when newer, less toxic agents are available. *Lenalidomide* - **Lenalidomide** is an immunomodulatory drug (IMiD) that is highly effective in the treatment of multiple myeloma, often used in maintenance therapy post-transplant or as part of initial induction regimens. - It works by modulating the immune system and has direct anti-myeloma activity, making it a valuable tool in the management of this patient [1]. *Bortezomib* - **Bortezomib** is a proteasome inhibitor that is a cornerstone of initial induction therapy for transplant-eligible and transplant-ineligible multiple myeloma patients [1]. - It effectively inhibits the break down of cellular proteins, leading to apoptosis of myeloma cells, and is crucial for achieving deep responses. *Autologous transplantation* - Given the patient's age (40 years old) and likely fitness, **autologous stem cell transplantation** is a standard and highly effective treatment option for multiple myeloma, aimed at achieving deep and durable remissions [1]. - It involves harvesting the patient's own stem cells, then administering high-dose chemotherapy (often melphalan) to eradicate myeloma cells, followed by reinfusion of the stored stem cells to rescue hematopoiesis [1].
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