Blogs

Decoding the Diagnosis, Exploring Newer Treatments in Multiple Myeloma from an Indian perspective

Persistent bone pain. Unexplained anaemia. Deteriorating renal function. When these findings coexist in an older adult, could they indicate multiple myeloma?

Multiple myeloma is a clonal plasma cell malignancy characterised by the production of monoclonal immunoglobulins or their light chains in many patients. Its presentation can be insidious, with symptoms and laboratory abnormalities often overlapping with common age-related conditions.

With no established routine population-wide screening programme, early recognition depends on clinical suspicion and appropriate diagnostic evaluation.

Multiple Myeloma in India: The Burden

India recorded an estimated 19,426 new cases of multiple myeloma in 2022, according to published cancer burden estimates. The disease predominantly affects older adults, although younger individuals can also be affected.

Recognising its clinical and biochemical manifestations is therefore important across primary care, internal medicine, nephrology, orthopaedics and oncology.

Presenting Features: Clinical Clues to Recognise

Patients may present with one or more of the following:

Bone pain: Persistent back, rib or other skeletal pain; pathological fractures may occur.

Fatigue and weakness : Often associated with anaemia.

Recurrent infections : Related to impaired normal antibody production and immune dysfunction.

Renal manifestations : Reduced kidney function, sometimes presenting as acute kidney injury.

Features of hypercalcaemia : Nausea, constipation, excessive thirst, polyuria or confusion.

Skeletal complications : Vertebral compression fractures and lytic bone lesions.

These manifestations are not specific to multiple myeloma. Their persistence, severity or coexistence should prompt further evaluation.

What Should Raise Suspicion?

Key abnormalities that may support further investigation include:

Complete blood count: Normocytic normochromic anaemia is common.

Renal function: Elevated creatinine or reduced estimated glomerular filtration rate.

Serum calcium: Hypercalcaemia, which may reflect myeloma-related bone disease.

Total protein and albumin: Elevated total protein or an increased globulin gap may provide a clue, although neither is consistently present.

Serum protein electrophoresis and immunofixation: Used to detect and characterise monoclonal proteins.

Serum free light-chain assay: Helps identify abnormal light-chain production, including cases with no readily detectable intact monoclonal immunoglobulin.

Urine studies: Assessment for monoclonal light chains, where indicated.

Peripheral blood smear: Rouleaux formation may be present but is neither sensitive nor specific.

 MRI or PET scan 

A normal total protein level or absence of a visible monoclonal spike on serum protein electrophoresis does not exclude multiple myeloma.

Establishing the Diagnosis

Diagnosis requires integration of clinical findings, laboratory investigations, bone marrow assessment, and imaging.

The International Myeloma Working Group criteria incorporate evidence of clonal bone marrow plasma cells or biopsy-proven plasmacytoma, together with myeloma-defining events. These include attributable CRAB features—hypercalcaemia, renal impairment, anaemia and bone lesions—or specified biomarkers associated with a high risk of progression to symptomatic disease.

Emerging Treatment Options: Moving Beyond Conventional Therapies

The treatment landscape for multiple myeloma has evolved considerably, with newer therapies targeting malignant plasma cells more precisely and harnessing the immune system to control the disease. The advances are expanding options, particularly for patients whose disease has returned or become resistant to standard treatments. However, eligibility, toxicity, cost and access remain important considerations. Availability of newer therapies also varies across treatment settings, including India.

The goal is not simply to achieve a response, but to pursue deeper and more durable disease control while preserving quality of life.

The Clinical Takeaway

In older adults, unexplained anaemia, persistent skeletal pain, renal dysfunction or an increased globulin gap should not automatically be attributed to ageing or comorbidities.

The challenge is to connect the clinical and laboratory findings early enough to consider a plasma cell disorder in the differential diagnosis. In a disease without routine population-wide screening, clinical vigilance remains essential to timely diagnosis and appropriate referral.

Dr. Ashish Joshi
M.D D.M
Consultant Cancer Physician
MOC Cancer Care & Research Centre, Borivali & Vileparle .