Multiple myeloma (MM) is a malignant disease caused by the abnormal proliferation of monoclonal plasma cells in the bone marrow. MM is most common in middle age and old age, with more men than women between the ages of 50 and 60, and the ratio of men to women is about 2:1. MM starts slowly and can be asymptomatic for months to years. The common symptoms include anemia, bone pain, low fever, bleeding, infection, renal insufficiency, and progression of the disease, which may result in enlarged liver and spleen lymph nodes, recurrent infections, bleeding, high viscosity syndrome, renal failure, etc. MM accounts for 1% of all tumors and 10% of hematologic tumors. The natural course of the disease is 0.5~1 year, and the survival period is significantly prolonged after treatment or long-term “survival with disease”. Hao Hongling, Department of Hematology, Hebei Provincial People’s Hospital
Diagnosis
(A) Clinical manifestations
1. Clinical manifestations caused by infiltration of MM tumor cells
(1) Bone pain, bone deformation and pathological fracture: bone pain is the most common early symptom, accounting for about 70%, mostly lumbosacral, sternal and rib pain. Pathological fractures can exist in multiple places at the same time. Myeloma infiltration of bones may cause local masses. In a few cases, only a single bone is damaged, which is called isolated myeloma. (2) Anemia and bleeding: anemia is more common and is the first symptom, with light anemia in the early stage and severe anemia in the later stage. Thrombocytopenia, bleeding symptoms are more common, skin and mucous membrane bleeding is more common, and serious internal and intracranial bleeding is seen. (3) Extramedullary infiltration: Extramedullary infiltration is mostly seen in the liver, spleen, lymph nodes and kidney infiltration, mild and moderate enlargement of the liver and spleen, enlarged lymph nodes in the neck and myeloma kidney. Neurological infiltrates can lead to limb paralysis, drowsiness, coma, diplopia, blindness, and vision loss in some patients in early or late stages. If there is concurrent polyneuropathy (P), organomegaly (O), endocrinopathy (E), monoclonal immunoglobulinemia (M) and skin changes (S), it is called POEMS syndrome. Those with isolated lesions seen only in soft tissues are called extramedullary myeloma. MM can develop into plasma cell leukemia.
2. Symptoms caused by myeloma cells secreting large amounts of M protein
(1) Secondary infection: Due to the reduction of normal polyclonal immunoglobulin and neutrophils, MM patients are prone to infections, mostly bacterial, but also fungal and viral, most commonly bacterial pneumonia, urinary tract infections, sepsis, and viral infections are common with herpes zoster. (2) Renal impairment: 50% to 70% of patients have protein, red blood cells, white blood cells, tubular type in urinalysis, chronic renal failure, hyperphosphatemia, hypercalcemia, hyperuricemia, and uric acid stones can be formed. (3) Hyperviscosity syndrome: The incidence is about 2% to 5%, with increased plasma viscosity, slow blood flow, tissue stasis, and hypoxia. Dizziness, flowering, visual impairment, and sudden syncope and impaired consciousness can occur. (4) Amyloidosis and Raynaud’s phenomenon: The incidence of amyloidosis is 5% to 10%, often occurring in the tongue, skin, heart, gastrointestinal tract, skin, ligaments, etc. If the M protein is cold globulin, it can cause Raynaud’s phenomenon.
(B), diagnosis and differential diagnosis
1, plasma cells >10% in bone marrow with abnormal plasma cells (myeloma cells) or bone marrow biopsy for plasmacytoma. It is the main diagnostic basis.
2, The presence of large amounts of monoclonal immunoglobulin (M protein) in the serum, IgG>25g/L; IgA>10g/L; IgD>2.0g/L; IgE>2.0/L; IgM>10g/L or the presence of monoclonal immunoglobulin light chain (native-weekly protein) in the urine, with light chain excretion>2.0g/24 hours.
3. Osteolytic lesions without other causes or extensive osteoporosis. Among them, round and oval penetrating chisel-like osteolytic lesions, which are the typical X-ray manifestations of the disease, are commonly found in the skull.
The diagnosis of MM can be established by the presence of cytologic criteria or any one of the cytologic criteria plus any one of the other criteria; those with only 1 and 3 are nonsecretory MM and need to be further differentiated as nonsynthetic or synthetic but nonsecretory.
In cases with only 1 and 2 (especially in the absence of primary and juvenile plasma cells in the bone marrow), reactive plasmacytosis and monoclonal gammaglobulinemia unspecified (MGUS) must be excluded. In addition, it must be differentiated from osteolytic damage of metastatic carcinoma and bone tuberculosis.
Treatment essence
(I) Chemotherapy
Generally, various combination chemotherapy regimens are used, and each regimen can be chosen for first-time patients; after complete remission is achieved with chemotherapy, VCAP and MEPP regimens are used.
MP regimen is the classic regimen for MM, M is Marfan 0.25mg/(kg・d)×1~4 d or 0.1~0.15mg/(kg・d)×1~7d, and Prednisone 60mg/(m2・d) is taken simultaneously with Marfan. The M2 regimen is also widely used by clinicians at home and abroad, and the CHOP regimen is the classic regimen for malignant lymphoma and has good efficacy in MM. Excessive chemotherapy is not beneficial.
(II) Symptomatic and supportive treatment
1, infection: bacterial infection, antibiotics should be used.
2, hypercalcemia: increase the amount of rehydration, drink more water to make urine volume > 2000ml per day, to promote the excretion of calcium. In case of emergency, adrenal corticosteroids, isotonic saline, calcitonin, etc. can be applied.
3.Hyperuricemia: rehydration, oral or intravenous sodium bicarbonate, 100ml/time of allopurinol.
4, anemia: apply androgens, recombinant human erythropoietin (rhEPO), and infuse concentrated red blood cells as appropriate.
5, renal failure: maintain urine volume up to 100ml/h, actively deal with hypercalcemia, and perform hemodialysis treatment if necessary.
(C), radiation therapy
Radiotherapy can make the mass disappear and relieve local pain, and irradiation of 200-300cGy bone pain can be reduced.
(iv) Interferon
High-dose alpha-interferon can inhibit the value-added of myeloblastoma. The clinical application of interferon combined with chemotherapy for this disease can improve the complete remission rate of chemotherapy chemotherapy. Usage: (3-5) × 106 units subcutaneously, 3 times a week for 4-6 weeks.
(E), hematopoietic stem cell transplantation (HSCT)
Autologous hematopoietic stem/progenitor cell transplantation as a bone marrow salvage measure makes high-dose chemotherapy and radiotherapy practically feasible. Since autologous peripheral blood HSCT is easier to collect, less contaminated with tumor cells and faster hematopoietic reconstruction, it has gradually replaced autologous bone marrow transplantation, but the following problems remain unresolved. Autologous peripheral blood stem cell grafts contain a certain amount of tumor cells, which may become one of the sources of later relapse. One of the current methods to remove tumor cells is to perform a small purification of CD34+ cells. When is the best time to perform the transplantation is still debated. The results of a prospective randomized clinical trial showed no significant difference between early transplantation and transplantation after relapse. However, the former had a high quality of life.
The pretreatment regimen prior to transplantation is to kill as many tumor cells as possible, and currently the common pretreatment regimen is high-dose Marfalan, or Marfalan + total body irradiation. There is no tumor cell contamination in allogeneic hematopoietic stem/progenitor cell transplantation, and there is a graft-versus-myeloma (GVM) effect after transplantation. The transplant-related morbidity and mortality rate is close to 40%, and only a few patients survive for a long time. However, this option is currently the only way to aspire to a cure for MM.
(vi) Molecular level therapy
Following the traditional chemotherapy, interferon and stem cell transplantation approaches for multiple myeloma. In order to further improve the prognosis of MM, some new strategies have emerged in molecular level therapy, such as using bone marrow neovascularization, cell surface receptors, and DNA molecules of myeloma cells as targets to induce apoptosis of myeloma cells or block them in G1 phase, regulate the bone marrow microenvironment, or regulate the interaction between bone marrow microenvironment and myeloma cells, or block the transformation of osteoclast precursor cells into osteoclasts. These new therapeutic approaches have been shown to be effective in clinical and animal studies. The main drugs currently available in this area are response arrest, bisphosphonates, protease inhibitors, arsenic agents and anti-IL-6 antibodies or IL-6 blockers.
Care essentials
Common nursing problems in multiple myeloma include: pain; somatic mobility disorder; risk of infection; risk of injury; abnormal urination; and anxiety. The care plan for each nursing problem is detailed below.
(A) Pain
1. Associated factors: (1) Plasma cell infiltration of bone and bone marrow. (2) Pathological fracture.
2.Main manifestations: the patient feels lumbosacral, thoracic and limb bone wandering intermittent bone pain, which is progressively aggravated. Moaning and sighing, sad face, panic, forced body position.
3.Nursing goal: Complaint of pain relief, performance with comfort.
4.Nursing measures: (1) Care, considerate, comfort and sympathy for the patient. (2) Explain the cause of pain to the patient to reduce his fear. (3) Bed rest, assist the patient to meet the needs of life. (4) Instruct the patient to use pain medication and closely observe the pain-relieving effect of pain medication. (5) Select non-pharmacological measures to bring about pain relief, such as using relaxation techniques/distraction techniques so as to divert the patient’s attention from the pain, and massage the patient’s lesions appropriately to reduce muscle tension and increase comfort. (6) Give the patient a comfortable position. Various treatments are completed centrally so as not to interfere with the patient’s rest, to ensure sufficient rest and sleep time for the patient, and to reduce noise and activity.
5. Focus on evaluation: pain site, nature, degree, characteristics of the attack, duration. Factors causing pain exacerbation/remission.
(II) Somatic mobility disorder
1.Related factors: (1) Osteoporosis. (2) Destruction and compression of the thoracic and lumbar spine and compression of the spinal cord leading to paralysis. (3) Weakness after chemotherapy.
2. Main manifestations: (1) Paraplegia. (2) Passive body position.
3. Nursing goals: (1) return to active status; (2) no complications of inactivity, as evidenced by intact skin, no thrombophlebitis, and normal defecation.
4.Nursing measures: (1) During bed rest, assist the patient in washing, eating, urinating and defecating and personal hygiene. (2) Assist the patient to change position every 1-2h while lying in bed, keep the patient’s limbs in functional position, use air ring and air cushion appropriately, scrub the skin of the whole body with warm water daily, keep the skin clean and dry, and prevent bed sores. (3) Paraplegic patients should prevent the atrophy of lower limbs, closely observe the pressure on limbs, give limb massage, and carry out passive or active limb exercises. (4) Encourage the patient to cough and breathe deeply. If there is no contraindication, drink 2000-3000ml/24h of water and take measures to prevent constipation (adequate fluid intake, multi-fiber food, trunk activity, stool softeners, etc.).
5, focus on the evaluation: (1) the degree of activity much affected. (2) The occurrence of any complications of inactivity.
(C), the risk of infection
1. Associated factors: (1) Infiltration of paddle cells with increased M-globulin. (2) Bone marrow suppression/weakness. (3) Low immune response. (4) Chemotherapy side effects.
2. Main manifestations: If infection occurs, chills, fever, sore throat, cough, coughing, urinary frequency, urinary urgency, oral ulcers, perianal pain, etc. may occur.
3.Nursing goal: the patient has no/reduced occurrence of infection, manifested as no fever, sore throat, cough, coughing sputum, urinary frequency, urinary urgency, oral ulcers, perianal pain, etc.
4. Nursing measures: (1) Do protective isolation, wash hands carefully before/after contact with the patient, and reduce visitation into the staff. Patients wear masks and go to less crowded places, especially do not contact with patients suffering from colds. (2) Keep indoor air fresh, open windows twice a day for 15-30 min each time, and disinfect with 0.5% peroxyacetic acid spray in the morning and afternoon each day, disinfect the floor and bed units with 0.5‰84 disinfectant mopping solution, and change bed clothes regularly to keep clean. (3) Instruct the patient to maintain good hygiene habits, wash hands carefully before meals and after stools; do not eat unclean raw food; cut nails regularly, scrub clean with warm water all over the body, keep the skin clean all over the body; wash hair once a week. (4) Instruct and assist the patient to do a good job of oral, ocular, nasal, perianal and vulva care, for example, assist the patient to rinse the mouth after three meals, and use the commonly used mouthwash (saline, oral tide, oral health, Dobei’s liquid, etc.) alternately to remove food residues and keep the mouth clean; wash both ears with a cotton swab dipped in 0.02% chlorhexidine solution daily, and use 0.1% streptomycin nasal drops. Use chloramphenicol eye drops, educate patients not to dig their nostrils; maintain good defecation habits, wash the vulva and perianal area after each stool, scrub the perianal area with 0.02% potassium permanganate solution or sitz bath for 20 min, rinse or scrub the vulva with 0.1% Neosporin solution. (5) Do the care of various intubations and strictly comply with the principles of aseptic technique operation.
5. Key evaluation: (1) Monitor the body temperature, with or without fever. (2) No symptoms of infection
(IV), injury risk
1.Related factors: (1) Bone marrow suppression or debilitation. (2) Tumor plasma cell infiltration release and activation of osteoclasts leading to osteoporosis or even osteolytic destruction. (3) Thrombocytopenia and M protein affects platelet function. (4) M protein causes coagulation dysfunction. (5) damage to blood vessel wall in case of hyperglobulinemia and amyloidosis; (6) abnormal liver function.
2. Main manifestations: susceptible to pathological fracture, rhinorrhea, easy bleeding of gums, skin purpura, anemia.
3. Nursing goals: (1) Reduce pathological compression fractures and post-fracture complications. (2) To be able to take measures to prevent bleeding and reduce bleeding.
4. Nursing measures: (1) Sleep on a hard bed and wear a belt around the waist to prevent rib fractures and vertebral compression fractures. (2) Encourage the patient to get out of bed as much as possible to prevent further decalcification of the bones, and assist or provide assistive devices, such as crutches, if necessary, to prevent trauma during activities; reduce unnecessary trauma. (3) Use small needles as much as possible to improve puncture accuracy and reduce the number of punctures, and apply local skin pressure for 5~7 min after puncture until no bleeding. (4) Maintain good bowel habits, consume sufficient amount of water/fiber-like food, or give stool softeners as prescribed by the doctor to prevent dry stools to prevent constipation, and instruct the patient not to force stool. (5) Instruct the patient to use a soft-bristled toothbrush and prohibit toothpicks to pick teeth. (6) The temperature of drinking water, food and bathing water should not be too high, usually around 40℃. (7) Educate the patient not to scratch the skin, not to rise and stand suddenly to prevent postural hypotension causing syncope and trauma.
5. Key evaluation: (1) The presence or absence of fracture and the site and extent of fracture. (2) The presence or absence of bleeding and the site and amount of bleeding.
(E) Abnormal urination
1. Associated factors: (1) Immunoglobulin deposition (free light chain). (2) Hyperuricemia. (3) Paraplegia. (4) Excessive blood calcium deposition.
2. Main manifestations: (1) Renal failure and hypuria. (2) Urinary incontinence. (3) (Urinary retention.
3. Nursing goals: (1) Maintain optimal renal function and water balance in and out. (2) No complications due to abnormal urination.
4. Nursing measures: (1) Give nephropathy drinking measures and limit salt intake to 2-3g per day; follow medical advice for rehydration and accurately record 24h water intake and output. (2) When urinary retention is present, firstly use methods that facilitate urination, such as listening to the sound of water flow and warm water rinsing the perineum. (3) If urinary incontinence occurs, first of all, care, considerate and comfort the patient, eliminate the patient’s worries and fears, change the wet bed sheet and pants in time, keep the bed sheet clean and dry, insert the catheter if necessary, and leave the catheter at the bedside. (4)Do the care of indwelling catheter: strict aseptic catheterization, urine in urine bag dumped at any time, urine bag can not be higher than the level of the pubic symphysis, prevent retrograde infection of urine, urine bag replaced every other day, strict disinfection, prevent repeated opening of the interface, daily cleaning of the perineum with 0.1% Neosporin cotton balls, keep the catheter open, open regularly, generally every 4h. (5) Prepare for dialysis when renal failure occurs with oliguria.
5. Key evaluation: (1) Monitor urine volume and evaluate the patient’s renal function. (2) The occurrence of any urinary tract complications.
(F), anxiety
1. Relevant factors: (1) Physical threat of disease. (2) Change in health status and change in role function.
2. Main manifestations: (1) Insomnia, dry depression, inability to control their emotions. (2) Premonition of misfortune and remorse. (3) Easily agitated, love to blame others, criticize themselves. (4) Inattentiveness.
3. Nursing goals: (1) Recognize the manifestations (symptoms) of anxiety. (2) Concentration, mental relaxation, and elimination/reduction of anxiety.
4. Nursing measures: (1) Record the level of anxiety; patiently explain the condition to the patient, eliminate the patient’s psychological tension and concerns, so that he/she can actively cooperate with the treatment and get sufficient rest. (2) Take the initiative to introduce the environment, the patient’s supervising physician and nurse to eliminate the patient’s sense of unfamiliarity and increase the sense of security. (3) Make frequent rounds of the ward to understand the patient’s needs, help the patient solve problems, and establish a good nurse-patient relationship with the patient. (4) Assist in identifying appropriate coping mechanisms to proactively adopt adaptive behaviors. (5) Remain calm and patient while nursing, speak slowly and calmly with the patient, and try to answer head questions from the patient. (6) Instruct the patient to use relaxation techniques such as slow deep breathing, whole body muscle relaxation, practicing qigong, listening to music, etc. (7) Use medications appropriately, understand adverse reactions, and observe the efficacy of medications. (8) Closely observe the patient’s emotional changes and behavior for any abnormalities to avoid accidents.
5. Focus on evaluating: (1) The degree of anxiety. (2) Coping skills and effectiveness of anxiety control.