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Multiple myeloma is named for the "clock face" appearance of the cancer cells when seen under a microscope. They infiltrate virtually all of a patient's bone marrow. In X-ray images of multiple myeloma, it looks like holes have been punched out of the bone. 

A skull X-ray taken from the side shows typical findings of multiple myeloma and multiple "punched-out" holes. The arrow is pointing at one of the larger holes. 

Multiple myeloma cells come from changed plasma cells. Plasma cells are white blood cells that secrete antibodies as part of the immune response. The changed plasma cells produce abnormal amounts of an antibody protein. No one knows the exact cause or location of the cellular change.

Multiple myeloma is not confined to a specific bone or location within a bone. It tends to involve the entire skeleton. When only one lesion is found it is called a plasmacytoma. Most doctors believe that plasmacytoma is simply an early, isolated form of multiple myeloma. 

Multiple myeloma occurs spontaneously. Patients exposed to ionizing radiation and the pesticide dioxin may develop the disease. Infection with some viruses (HIV and human herpesvirus 8) has also been associated with multiple myeloma. No known risk factors are inherited. 

Patients usually complain of bone pain. Other symptoms include:

• Fatigue
• Feeling ill
• Fever
• Night sweats

Weight loss is not common in the early stages.

Physically, patients are pale with diffuse bone tenderness, especially around the sternum (breastbone) and pelvis (hips).

Pathologic fractures (fractures caused by tumors) occur frequently. Patients will often have their multiple myeloma first discovered when they develop this kind of fracture. The spine is the most common location for a pathologic fracture to occur. It can also happen in the ribs and pelvis. 

This X-ray, taken from the side, shows the lower end of a patient’s femur near the knee. Multiple myeloma has weakened the bone and resulted in a pathologic fracture (black arrow). The white arrow is pointing at one of the “punched out” holes typically seen on X-ray. 

Reproduced from Johnson TR, Steinbach LS (eds.):  Essentials of Musculoskeletal Imaging. Rosemont, IL. American Academy of Orthopaedic Surgeons, 2004, p. 145.

Compression of the spinal cord occurs in up to 5% of patients. This causes pain in the back and legs and numbness and weakness in the legs.

Patients who have high levels of calcium in their blood may experience nausea, fatigue, confusion, constipation, and frequent urination.

Patients with anemia may experience fatigue, weakness, and shortness of breath with exercise.

In advanced cases, patients typically have recurrent infections and can have kidney failure. 

Several tests are used to confirm a diagnosis of multiple myeloma, including X-rays, bone scans, a bone biopsy, and a blood test.

Multiple myeloma appears on X-rays as decreased bone density with a lot of punched out holes in the bone. These destructive lesions are not surrounded by the white rim of bone typically seen in other types of destructive lesions. A bone scan may show which bones are involved with multiple myeloma, but often the lesions cannot be seen. If a bone scan is negative, a skeletal survey is usually performed. This consists of X-rays of many different parts of the skeleton. 

These X-rays show typical lesions caused by multiple myeloma. (Left) A lesion in the tibia (shinbone). (Right) Two lesions at the lower end of the femur (thighbone) near the knee. 

The diagnosis is made when a large number of abnormal plasma cells are found in the patient's bone marrow. The doctor obtains this marrow through a bone biopsy.

A blood test can confirm the diagnosis. The patient's blood is checked for abnormal antibodies produced by myeloma cells.

Some forms of multiple myeloma produce proteins that can be detected with a urine analysis.

Patients may also have:

• Anemia (low red blood cell count)
• Leukopenia (low white blood cell count)
• Thrombocytopenia (low platelet count)
• Hypercalcemia (high calcium level in the blood) 

Multiple myeloma is currently not curable. Chemotherapy may prolong life expectancy and decrease symptoms.

Research in multiple myeloma has been evolving rapidly. Currently, there are a number of new biologic agents entering various stages of clinical studies.