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A living library of credible information for patients of multiple myeloma and their caregivers.
Hi, Sally, how you doing?
It's good to be recording another podcast after
a little break over the summer.
Yeah, it's good to be back.
And I think we've had some time, haven't
we, Jam, to think about, you know, when
we're seeing patients in clinic, which pods we
haven't done.
And I think today's podcast might cover one
of those gaps, actually, which is an area
which is relevant to a lot of our
patients, actually, as they live with myeloma, but
particularly some people when they're, they're first seeing
us.
Yeah, absolutely.
So today, we're going to talk about plasmacytoma.
Now, I think, you know, when you're diagnosed
with any cancer, I mean, actually, to be
honest, when you go and see any doctor,
right, the terms and the words can get
very confusing.
So this term, plasmacytoma, what does it, what
does it mean, Sally?
And how does it relate to myeloma?
Yeah, thanks, Jam.
I mean, as many of our listeners may
be so familiar with these terms now, but
we're going to work on the premise that
there are some non-experts who are also
listening as well.
And so some of you may recall from
our previous episodes that the cells that go
wrong in myeloma are called plasma cells.
And so a plasmacytoma is a fancy medical
way of referring to a lump of these
cells all stuck together within the body, often
from or arising from the bone in the
in the strictest sense of the word.
So a plasmacytoma is simply a mass of
these abnormal plasma cells, which relate to myeloma
as well.
Yeah, so it's, I mean, for whatever more
technical term, it's a it's a lump of
myeloma.
So a lot of people, when we talk
about myeloma, they they can understand the concept
of, you know, breast cancer or colon cancer
as a group or an area or even
like, you know, a small ball of cancer
cells.
So sometimes when we're diagnosing myeloma, and of
course, talking to people for the first time,
we explain that this cancer is sort of
widely spread in your bone marrow.
And that's, that's normal for myeloma.
But it can behave in slightly different ways.
And you can get discrete areas or lumps
of myeloma without that widespread bone marrow involvement.
Definitely, you've come up with a great point
there, Jam.
And this is where it does warrant explanation.
People can have myeloma with plasmacytomas, without plasmacytomas,
they can develop plasmacytomas, they can have a
variant of a plasmacytoma, or they can have
a plasmacytoma in isolation.
And that is why it's so confusing.
There you go.
That solved it.
I would say let's go through all those
one at a time.
But I can't even remember the first one
that you said.
I think a part of the complexity is
because, and this I think does, you know,
this does really apply to quite a lot
of blood cancers, right?
You know, blood cells and the white blood
cells that drive a lot of these hematology
cancers, white cells are supposed to get everywhere
in your body, because they're there, trying to,
you know, kill the bad guys, and, you
know, being part of immune system surveillance.
So they have the ability to get all
over the place.
The cells in these plasmacytomas, or the cells
that we see widespread in the bone marrow
and myeloma, the cells are the same.
They're plasma cells, these antibody producing cells, malignant
cells.
But sometimes, you know, to use an example,
we we might see someone who noticed a
lump growing somewhere.
And it could be even, you know, in
and around the neck, or it could have
been discovered when a surgeon was doing a
colonoscopy, because they had some symptoms in their
bowel, and a biopsy has been done.
And it shows, oh, these are these are
plasma cells.
So we've actually got a diagnosis of a
plasma cell cancer, okay, which, which broadly, we've
been talking about is myeloma, but from from
from a lump of, of plasma cells, a
plasmacytoma.
Yeah, definitely.
And I think you made a great point,
Jan, in that patients can present and say,
actually, I've noticed something changing, I've noticed something
growing.
Now, often that's from a from a bone,
particularly when people have relapsed and been living
with myeloma for a while, they might say,
I'm really worried, my disease has come back,
because I've got some pain, but also I've
noticed this lump.
And really importantly, the plasmacytomas when they occur
aren't necessarily painful, it may be a painless
lump.
And that's where, you know, we as a
clinical team and the patients communicating with us
what's going on is so important, because just
because it doesn't hurt doesn't mean it's not
important.
No, indeed.
So just to go through a little bit
of the way in which we define these
conditions.
So, Sally, there is a condition that is
not multiple myeloma called solitary plasmacytoma.
Okay.
Now, that is a disorder where essentially, the
first time we get to meet people is
that they have a diagnosis of malignant plasma
cells.
So this is, you know, this is a
type of tumour.
But those tumour cells are broadly in one
location only.
And they either have absolutely nothing in their
bone marrow, because these people, we always look
in the bone marrow, because it could just
be that this is actually part of multiple
myeloma.
But if you find nothing in the bone
marrow, then we call that a solitary plasmacytoma.
But in some situations, you may find a
very small number of plasma cells in the
bone marrow.
And we still call this a solitary plasmacytoma,
with what we say minimal marrow involvement.
So it is confusing, even just as I
articulate that, that's quite hard to understand, isn't
it?
Do you know what, Jam?
I mean, I think we were having a
chat before we started recording.
It's like, oh, well, hopefully this, this episode
should be pretty easy.
But it's like everything in myeloma, you delve
into it, you're like, oh, my goodness, it
is actually quite complicated.
But you're quite right.
The difference between myeloma and plasmacytoma, isolated plasmacytomosis,
in myeloma, you've got these abnormal cells in
your bone marrow, above 10% of the
cells in the bone marrow are myeloma cells.
When you've got a solitary plasmacytoma, you've got
one lump.
And then when you look in the bone
marrow, you don't have that many plasma cells,
it's less than 10%.
And sometimes there's no abnormal plasma cells.
Occasionally, there's a few.
And that's really how you tell the difference.
It's about counting the cells in the bone
marrow, but also looking through scans to check
that that lump actually is only one lump.
There's not an extra lump somewhere else, because
that also changes things, doesn't it?
Yeah.
So scans are really important.
PET scans, or whole-body MRI.
Generally, for plasmacytomas, PET CT is very good.
If you have more than one, and your
bone marrow is clear, then that is also
that can happen sometimes.
And that's called, you know, multiple plasmacytomas.
But that's treated exactly as you would multiple
myeloma.
Because essentially, the way that the cancer has
developed, it's the plasma cells are not multiplying
in the bone marrow.
But you know, various lumps are sort of,
you know, growing in different parts of the
body.
Yeah, definitely.
So just to recap on that, then you
sort of got the ends of the spectrum,
haven't you?
You've got myeloma, where you've got lots of
abnormal cells in your bone marrow, and you
may or may not have these lumps, that
needs treatment with what we would describe as
chemotherapy.
Then you've got somewhere in the middle, a
person who might have a few lumps in
their body, and they may or may not
have abnormal cells in the bone marrow.
And that still needs chemotherapy.
But then there's sort of the other end
of the spectrum is just one lump, not
much in the bone marrow at all.
And that requires different treatment, because that's what
we call a solitary plasma cytoma.
Yeah, and then the right at the end,
then you have a solitary lump plasma cytoma
with nothing in the bone marrow.
So it's all it's all a spectrum.
And you know, throughout both our clinics, Sally,
and clinics throughout the country, solitary plasma cytoma
is diagnosed quite a lot.
And it has a discrete way of being
treated.
Now, it's important to understand where these lumps
can be because, you know, I mentioned a
couple of scenarios, you know, you talked about
these areas arising from bone.
And that is the most common thing.
These plasma cytomas arise from bone, and we
call them solitary plasma cytoma of bone.
But actually, you can get them in any
organ, you can get them in the bowel,
you can get them in sort of other
soft tissues, muscle, the head and neck.
They, you know, if you look through the
literature, you can find sort of case reports
of solitary plasma cytomas in lots of different
places.
And sometimes the first we will know about
them is our surgical colleagues or other colleagues
who've done diagnostic tests.
Because sometimes the symptoms may be just because
I've noticed a lump, or it depending on
the organ they're in, there may be symptoms,
you know, attributable to to how the lump
is, you know, affecting that organ.
I don't like keep saying the word lump
continually.
But it feels like better than mass or
some other kind of kind of description.
So, so yeah, so they can arise from
anywhere, basically.
Don't be shy about lumps, Jan.
It totally describes what they are, doesn't it
really?
And they can pop up anywhere.
And I guess the key thing is, is
with any lump, just to lean into that
word a bit more.
First thing you need to do if you've
spotted it as a doctor or GP or
whoever, is actually pop a needle into it
to check that you know what's it what's
it's made of.
And often actually, particularly with plasma cytomas, which
aren't coming out of the bone, the it
can be a surprise.
Because let's say, for example, you've got a
plasma cytoma in your breast tissue, of course,
a lump in the breast, one automatically associates
that, for example, with breast cancer, and suddenly
you have a biopsy done, you're like, oh,
no, it's this weird thing called a plasma
cytoma.
It's like, oh, my goodness, I wasn't expecting
that.
And that often means something completely different from
what you're expecting.
So it can come as quite a surprise,
actually, this diagnosis, people might prepare themselves for
another problem.
And actually, lo and behold, it's not it's
a weird blood disorder.
Yeah, so that's not.
So that's not breast cancer, Sally.
It's hard, right?
So this is a lump in the breast,
the tumour, but it's not breast cancer, because
in breast cancer, the cancer is from the
cells that are supposed to be in the
breast anyway.
These are just abnormal malignant plasma cells that
have traveled to the breast.
And that's where the cancer has decided to
make its home.
And I mean, that's a good place to
start, Sally, because actually, for a lot of
these plasma cytomas that are not associated with
the skeleton, they can be surgically excised.
And in, you know, a number of situations,
often, they can be cured with surgery.
And it's not unusual for those plasma cytomas
that are not associated with the bone, for
people's bone marrows to actually be clear.
Yeah, definitely, they can be clear.
And by that, I mean, nothing in them.
And you speak about them having been excised.
And sometimes that's actually by accident.
So you see example of continue with the
example of breast cancer, you know, you go
for your screening, or you feel a lump,
a lump is found, and you're listed for
surgery, and they take out, take out the
mass, they take out the lump, and it's
only then when that mass is sent off
to the lab for analysis, people say, hang
on a minute, it's something totally different.
And actually, then at the point of the
person receiving the diagnosis of plasma cytoma, it's
all been removed.
And so actually, sometimes the surgery almost happens
by accident.
You know, we don't necessarily always need to
treat plasma cytomas with surgery.
In fact, in most cases, we would perhaps
choose not to, but sometimes it happens anyway.
And when it has happened, and it's all
been taken out, that might be enough.
Absolutely.
For the ones that arise from bone, it's
not unusual for people to present with pain,
you know, a topic that we've covered a
lot on the pod.
But, you know, to, you know, to sort
of cite a recent example from my clinic,
you know, a man in his 80s, just
increasingly struggling with some back pain and tingling
down his legs.
He had an MRI done.
And just around the middle of his spine,
there was a sort of a big tumor
coming out around his what we call T12,
which is the sort of the bottom of
the thoracic spine.
It was biopsied.
So often in that situation, you know, it's
not feasible or appropriate, you can't remove the
whole tumor.
So you take a sample and was found
to be a plasma cell tumor, a plasma
cytoma, with a scan showing that there was
there was nothing else anywhere.
And in his bone marrow, there was just
a very small number of plasma cells, like
about 2%.
So not no myeloma in the bone marrow,
but you can see a couple of abnormal
plasma cells.
So pain was his main issue.
And this was only the only abnormal sort
of tumor.
So you can't excise that.
So in this sort of setting, Sally, what
is the what is that sort of the
recommended and sort of standard of treatment in
this sort of setting?
Yeah, so these isolated plasma cytomas from the
bone, the standard treatment is radiotherapy.
Or we and you, our listeners may have
heard this referred to as radical radiotherapy, which
just adds another layer of complexity.
But to dive into radiotherapy a little bit,
it's where, you know, radiotherapy waves are targeted
at a tumor where they know the tumor
is sensitive to that.
It's almost like targeting with heat or with
light.
And that causes the tumor or the lump
of abnormal cells to melt away.
And there are different doses you can give.
And by doses, you mean, you come back
different for different periods of time.
And the strength of the radiotherapy or the
heat to use that analogy is different.
And actually, the reason why the doses might
be different as in solitary plasma cytoma, you
want to be sure if you can, it's
going to go away for good.
And so you give larger doses over a
longer period of time.
And that's why it's called radical radiotherapy.
It's meaning you're trying to do something radical
and fix that cancer for good.
So yeah, radical means broadly higher doses.
Now, we've touched on radiotherapy in previous podcasts,
and it can be very effective for pain.
But when it's given for pain, it's often
only given for a couple of days.
Whereas in this sort of setting, Sally, people
might have, you know, three weeks of treatment,
sometimes a bit longer.
And it's a slightly, you know, well, it's
a very different approach to chemotherapy, you know,
they mark out on the body where they
have to sort of, you know, you know,
zap the tumor, as it were, and then
you go into a machine every day, often
only for a couple of minutes.
And it's what we call fractionated.
So it's given, they found out over many
years, it works better if you give a
little bit every day, and it builds up.
And these plasma cytomas are very sensitive to
radiotherapy.
People complete the radiotherapy.
And number one, if people have pain, it
helps with that immediately.
Number two, the tumors hopefully shrink away totally.
And repeating a scan three months after the
end of treatment will tell us how well
people have done.
So my patient that I described, he has
had the radiotherapy, pain improved quite quickly, actually.
But it takes time for the full impact
of radiotherapy to happen.
And that's why you wait a few months
to see how well it's worked.
And actually, depending on where the plasma cytoma
is, you know, if they are in different
organs, we try to give radiotherapy if that
is appropriate.
Now, there may be reasons in certain organs
where you have to give certain doses or
a smaller dose because of the sort of
the impact of side effects.
And, you know, Sal, both you and me
are not radiotherapy experts.
And, you know, at some point in the
next year, we're hoping to get a radiotherapy
expert just to talk about it a little
bit more.
So people understand, you know, in the context
of these sorts of disorders, myeloma related disorders,
why radiotherapy is used.
Yeah, definitely.
I mean, it's a whole specialist area in
and of itself, isn't it, Jam?
And our colleagues who tend to be oncologists
who are trained in radiotherapy are real experts
in their fields, not least because actually different
lumps require different doses of radiotherapy.
But also, it depends on where the lump
might be in the body, how, as you
said, really, how much you can give.
And that's partly because, to go back to
my analogy, it's almost like burning the tissues
with the radio waves.
And there are some areas in the body
where you really might not want that to
be a problem for the normal tissue sat
next to the lump.
And so actually, there's other factors to take
into account.
Or is the lump, for example, if it's
in the tummy, is it moving around a
bit?
So it's a really complicated area.
You know, if you've got questions, of course,
reach out to us about them, but hold
them as well.
Because like you say, Jam, I think us
getting one of our colleagues on will really
help shed light on that field.
Indeed.
So Sally, just to use the example of
my patient, he actually asked me very, very
pertinent questions.
But why would you not give me some
chemotherapy as well?
You know, I've read a little bit about
myeloma.
I know that chemotherapy is very effective in
this setting.
Why are people just treated with radiotherapy in
this setting?
Yeah.
So I think if you imagine this, almost
like you've got one lump isolated to one
place, and you can treat that, and you
can get rid of that for good in
the majority of cases, it won't crop up
there again.
And then everywhere else in your body, there's
very little going on, then actually, you've almost
converted that person from having a potential condition
like myeloma, to having not much of a
condition at all, they may have this more
benign condition that they're left with after the
treatment, like NGUS, monoclonal gammopathy of unknown significance.
And so actually, it may be for a
significant number of people, you can monitor them,
and we would want to monitor them with
scans and with blood tests, but nothing will
change.
And so therefore, why give them loads of
chemo, when actually, they may be well for
many, many, many years thereafter, and in fact,
some people never need any more treatment than
that for the rest of their lives.
Thank you, Sally.
The rate of progression to myeloma is an
important thing that we always go through with
our patients who are going through radiotherapy, and
the location of the plasma cytoma, and whether
they have any of those plasma cells in
their marrow, they are two key determinants of
whether people get myeloma.
So I think it's really important to say
that for people with a plasma cytoma that
comes out of bone, they have a much
higher risk of progression to myeloma.
And broadly, maybe 40 to 50% of
people might progress within two years.
Yeah, I think it very much depends, doesn't
it, from what we understand on how many
abnormal cells there are, as you said, Jan,
in the bone marrow.
If we use that 10% cutoff I
spoke about before, you've got 8%.
That's quite a lot.
Whereas if you've got, I don't know, one
in every 300 cells might be a myeloma
cell, that looks quite different.
And if you've got none at all, then
your risk really is quite low.
So it's, again, it's a spectrum, and it
sort of reflects how dynamic the conditions can
be.
And actually, for a lot of the plasma
cytomas that are not associated with bone, their
risk of progression to myeloma is much, much
lower.
And it's more normal for them to have,
you know, clear bone marrows without any of
the plasma cells.
Yeah, definitely much, much more likely.
Although, just to add another layer of complexity
to our conversation, it is different if you're
dealing with people who have developed lumps of
myeloma, be that plasma cytoma or outside the
body, when they have already had treatment for
myeloma.
And in that case, new lumps growing outside
of the bone marrow, actually, you know, you
need to keep an eye on that.
That can mean that you might need slightly
different treatment.
So yes, if this is at the very
beginning, it's good news if it's outside the
bone marrow, or outside the bones.
If you've been living with myeloma, and you've
developed a lump outside the bones, that's slightly
different, and it has a different prognosis.
It's an extremely important distinction to make.
Your doctors may use this term extra medullary,
which I think we should just define.
That means not associated with bone, essentially.
So as you very rightly say, Sally, if
you have myeloma, and you have extra medullary
disease, so I don't know, for example, disease
in your liver, as an example, at diagnosis,
that's a bad thing, unfortunately.
And at different stages in the journey, if
there's extra medullary disease, that's also a bad
thing.
At diagnosis, if there is a solitary extra
medullary plasma cytoma, then that's often highly treatable,
and not a bad prognostic thing.
That can be difficult to understand.
But actually, you know, looking at these things
over many decades, that's the way it looks
from seeing how people have got on with,
you know, the various treatments that they've had
in those contexts that I've just mentioned.
Yeah, and I think that goes back to
that really confusing thing I said earlier about
how diverse this is, is that looking at
these lumps in isolation does not tell you
the whole story, you need to look at
what else is going on in the body.
And that changes the story, it changes what
the doctor may say to the patient or
their family in that clinic.
Because, you know, you then fulfil a different
kind of, a different path almost, you've got
a different path ahead of you in terms
of what to expect, and how your condition
might behave.
It is a complex area, it's somewhat complicated
as well, just to throw in a final
curve ball, I hope, by the fact that
people living with myeloma, at diagnosis may or
may not have bone problems, may or may
not have extra medullary disease, but they may
develop it when they relapse, because we know
the myeloma disease changes.
And as your myeloma comes back, you might
go on to develop a lump in the
bones, a plasma cytoma or extra medullary disease.
So it's very dynamic as well.
And so it's a complex area.
And that's where the blood tests are important,
the bone marrow is important, the imaging is
important, because that gives you the whole picture
about what's going on at that point in
time with that person in front of you.
Indeed, it does.
I think what's really helped us treat plasma
cytomas better over the last few years is
a real improvement in the type of imaging
we can do and how quickly we can
get whole body scans, especially PET and MRI,
because they really do give you excellent information
on you know, where they are.
And you know, looking at it sequentially, how
quickly they're growing.
And with PET CT, you know, one of
our first episodes was with a, you know,
Dr. Buver, a radiology expert, you know, PETs
are very helpful, because they tell you about,
you know, whether the tumor is active, the
plasma cytoma is active, active, you know, myeloma
or plasma cytoma cells, they take up this
radioactive sugar.
So you know, you give the radiotherapy, and
then you wait three months.
And normally, if it's worked well, there's there's
no abnormal cells there anymore.
So that radioactive sugar is not being taken
up.
And it's really important to wait because if
you, you know, radiation causes inflammation, okay.
And I think what's important to say, if
you're going through radiotherapy, it's very common to
give some steroids at the same time, you
know, we can't get away from it, can
we?
You know, it's like in almost every episode,
we have to mention steroids.
It comes back to steroids.
But actually, you know, dexamethasone is a very
important tool for our radiotherapy colleagues.
Because, you know, the act of radiation killing
cancer cell causes inflammation.
And that can actually make things a little
bit worse initially, as well.
So you may get swelling of the actual
tumor.
And if, if that plasma cytoma is, I
don't know, pressing on nerves, for example, it's
like, well, why am I getting worse?
It's not because the treatment's not working.
It's because you're getting swelling from sort of
tumor kill.
And that's where our friend dex is important.
And the other thing to say about plasma
cytoma, solitary plasma cytoma is that it's very
common to have the abnormal proteins, right?
These power proteins and light chains.
And, you know, when you irradiate the plasma
cytoma, the plasma cells die, and you see
these proteins going away as well.
So there are other clues that the, that
the treatment is, is working.
You know, even if you can only stop
myeloma for, you know, two to three years
for a bone plasma cytoma with radiotherapy, it's
absolutely worth it, right?
Because, you know, it's relatively non toxic, it's
a month of treatment.
And, you know, the field is moving so
quickly, you know, when that person needs for,
you know, what we call, you know, combination
treatment in the future, because myeloma has developed.
Hopefully, you're able to give more effective treatment.
And you can give it in good time,
because you know what you're looking for, right?
The monitoring piece afterwards is very important.
Yeah, I mean, I think you speak to
a really important point there, Jamin, so much
that some people with plasma cytoma do get
myeloma.
But if you treat the plasma cytoma there
and then, and control it and get rid
of it, and then keep a close eye
on them, you've pushed back that treatment date
to actually developing full blown myeloma.
And in that time, there's, I mean, God,
based on what's happened over the last few
years, significant improvements.
So for some people, radiotherapy gets rid of
the plasma cytoma and the problem for good.
For other people, it just sort of stalls
it for a fixed period of time, which
is quite hard to predict.
When you when you speak to doctors, they
might have a go at trying to guess
when when things might return, but it's so
different in everybody.
It's hugely variable, isn't it?
Indeed, it is.
And I think if you are in the
process of going through your sort of investigations
and treatment for solitary plasma cytoma, I think
the things to really ask your doctor, you
know, and just sort of a checklist for
you, right?
Make sure you've had some proper whole body
imaging.
Okay, it's really, really important.
I think before we had really good scans,
I think Sally, a lot of people were
incorrectly treated a solitary plasma cytoma.
But with a more sensitive test, they would
have been treated for myeloma.
And actually, unfortunately, a lot of people came
to harm.
Now, it's no one's fault.
It's just that our diagnostic tests were not
as good.
But they really are good now and make
sure that that scan has been properly reviewed.
Do I have a solitary tumour?
Or are there more?
Also, have I had a bone marrow and
not just a bone marrow?
Have I had a bone marrow with where
possible the most sensitive tests that you have?
Because you would want to know I would
want to know, even if you can detect
a few abnormal sort of plasma cells, myeloma
cells in the bone marrow, it does change
your risk of progressing to myeloma.
And I think that's really important for people
to know.
And then assuming you're having radiotherapy, you know,
speak to the radiotherapy doctor, of course, and
just ask, you know, what is the dose
I'm having?
And why?
And depending on, of course, where the plasma
cytoma is, you know, what side effects should
I expect?
Am I going to get dexamethasone with this?
And then make sure if you've going through
radiotherapy, when am I going to have my
follow up scan, make sure the scan isn't
too early should be about three months after
the end of radiotherapy.
Yeah, what a brilliant summary, Jan.
Thanks for going through that.
And I think there's some incredibly useful pointers.
So I think maybe for the last few
minutes, can I fire a few questions at
you, just to see if we can kind
of just to recap really on what we've
spoken about, because it has actually been quite
complicated, hasn't it?
So someone comes to your clinic, and they've
got a mass or a lump coming out
of their arm, you organise a PET scan,
you organise a bone marrow, the PET is
only showing problems in the arm, and the
bone marrow doesn't show anything at all, what
are you going to do?
So we are going to take a biopsy
of that area.
And assuming that it shows it's a plasma
cytoma, a solitary plasma cytoma, that is a
solitary plasma cytoma of bone, and that would
be treated with what we call, as you
mentioned earlier, radical radiotherapy.
So I'd refer to one of our friendly
clinical oncologists, we have two very lovely ones
in Oxford.
And I would also be quite, you know,
positive to the patient about the side effects
in that site, you know, you mentioned the
arm, there are no, you know, there are
vital organs everywhere, but you know, you're not
close to your your bowel or your, you
know, you're not going to get problems from
swallowing, because of side effects related to radiotherapy,
you can irradiate that area really well, I
think with minimal side effects.
And then I'd make sure, of course, I
checked all the myeloma proteins and all the
other normal bloods.
And go from there.
Great.
So I'm going to move that lump to
your tonsils.
It's not in your arm anymore.
It's dangling down from one of your tonsils.
You're struggling to speak, your voice has gone
a bit hoarse.
Next time, I've got to get the questions.
But it's really, it's it's a really, really
important point.
And just to, you know, briefly get, get
back to just just a couple of extra
things on the last one, even there's a
bone plasma cytoma, there's still a still a
high risk of progression to myeloma.
Even though there's nothing inside the no abnormal
cells within the bone marrow biopsy.
And you'd monitor that patient moving forwards, you
know, relatively carefully.
Thank you.
So the tonsils, so difficult area.
So they probably come from one of our
friendly ENT consultants.
So we would not normally see these patients
initially, right, they'd go to an ENT surgeon
problem swallowing.
And they, they see a lump or a
tonsil and maybe they excise it.
And it's a plasma cytoma.
So I think this is where we, you
know, need to work very closely with our
clinical oncology colleagues.
We of course, do the whole body scan
again, check that the area is solitary.
Check a bone marrow.
Is the bone marrow clear?
I'm guessing maybe it is.
So it's a solitary plasma cytoma in the
throat.
Now, if you give radical radiotherapy to a
throat, you know, people may not be able
to swallow for, I don't know, weeks.
I mean, it can be very bad, can't
it?
Yeah, it can be really unpleasant.
Yeah.
So this is where you need to sit
down with your surgeon and your radiotherapist and
your haematologist because possibly the surgeon has excised
the whole thing.
So maybe the whole lumps gone accidentally, because
again, you know, biopsying in that area is,
I think, more difficult than taking the whole
thing out.
So actually, you've taken it out, you do
a PET, there's nothing there.
Hopefully you've cured your patient.
Yeah, nothing there on the PET, nothing there
in the bone marrow.
That is good news, isn't it?
Okay.
So can I keep on going with the
quiz?
Or do you want to flip it around
and quiz me instead?
Oh, let me let me ask you one,
Sally.
So yeah, I've gone, you keep asking me,
you've got the question.
Okay, so We're a bit rusty after some
holidays.
So you've got, we're going to go back
to our person with a lump in the
arm, and you've done a bone marrow.
And actually this time, there's only one lump
in the arm.
And that is PET positive, nothing else on
the PET.
But the bone marrow shows that 20%
of the cells there are plasma cells, they're
myeloma cells.
So it's above the 10% cut off,
not loads, but 20% with a lump
on the arm.
What are you going to do?
Yeah, okay.
So we, it looks like we're dealing with
myeloma.
So by the definition of myeloma, this is
myeloma.
And, you know, going back to our earlier
episodes, I'd want to check that the kidneys
are okay.
And the blood count was okay.
Are they both all right?
Yeah, they're okay.
Yep.
So actually, but you have a sort of
a plasma cytome, so an area of myeloma,
a lump, but you've actually got myeloma in
the bone marrow.
So you treat that as myeloma.
So this patient would need combination chemotherapy.
And if there's a lot of pain associated
with that, with that area in the arm,
sometimes just starting chemo would be enough to
improve that pain or even steroids.
But if it's not, we would again offer
some radiotherapy, but not the radical radiotherapy that
we've been talking about, we would just offer
a lower dose of radiotherapy to help with
the pain, but they would be treated as
myeloma, basically.
Thank you.
And then my last one, and then I'll
desist.
It's not supposed to be an MDT, you're
making me do lots of work today.
This is excellent.
This is a good test.
Hopefully, you know, well, I think, you know,
hopefully our listeners, you know, if they fit
into the various of these categories, I think
they will find it really helpful.
So you still got your lump in your
arm.
But this time, there's also a lump on
the leg on imaging on a PET scan,
but nothing in the bone marrow.
What are you going to do?
Yeah, so more than one abnormal area, you
biopsied the arm, and it shows is shown
to be a plasma cytoma.
So you need to have a really good
radiologist.
Okay.
And I think you need to really look
at, you know, really speak to radiologists and
say, does this look like the same cancer?
Because of course, unfortunately, you can be diagnosed
with more than one cancer at one time.
So the first thing you need to think
is like, could this be something same?
Or could it be different?
If the radiologist said, look, this is the
same process, it looks the same, then that
is multiple plasma cytomas.
And you treat that as myeloma.
Yeah.
If the radiologist says, you know, it doesn't
take up quite as much abnormal sugar, or
it doesn't look quite right, I would try
and biopsy that lesion in the leg, because
we've all been surprised, right, in medicine.
And actually, sometimes you find things that you're
not expecting and maybe that area in the
leg is a benign something.
And then you're back to a solitary plasma
cytoma.
And hopefully, you know, controlling the condition for
many years, which is radiotherapy.
Brilliant, Jan.
10 out of 10.
You passed.
You can now go to clinic.
You are above board.
But thank you, Sally, for those scenarios, because
these are scenarios that like we deal with
in clinic day to day.
And almost like we just did a mini
sort of MDT there almost without, you know,
without the, you know, our radiologists and histology
colleagues, but these are the kind of things
that we we discuss.
And I hope that people listening, feel confident
that, you know, certainly up and down the
UK, we can really comment on UK practice,
you know, people discuss these things, you know,
together and in a collegiate way to make
sure that people are getting the right option.
Yeah, definitely.
You know, nothing is straightforward in myeloma or
indeed in medicine.
And for example, if you were to have
somebody who come into the waiting room say,
Oh God, I had this thing called a
plasma cytoma.
My doctor just told me the person next
to him was to say, No, I've had
that as well.
It doesn't necessarily mean you're going to have
the same treatment, usually variable.
So yeah, I hope this has been useful
for our listeners and for their relatives and
loved ones.
Please get in touch with questions.
And thank you for letting us jam and
I try and untangle this for you.
Yeah, no, really great episode, Sally and exciting
times coming in the next few weeks in
myeloma.
It's the International Myeloma Society meeting.
It's held once a year.
All the myeloma bods in the world will
be in Scotland, in Glasgow.
Sorry, that wasn't a Scottish accent.
It might have been a Scottish accent.
But this is the first time I think
for decades that this meeting has been in
the UK.
And so we're all going to Glasgow in
a couple of weeks.
And hopefully we're going to be doing a
podcast from up there, which will be very
exciting.
And then so we're going to update people
in October with some of the key highlights,
because, you know, just having had a skim
through there's, you know, there's some very cool
stuff being presented.
Yeah, it looks like a great programme should
hopefully be some fun, but a lot of
work.
And yeah, but do look out for that
podcast, be lots of patient voices on it
and some, some experts, international experts that you
may not have heard before.
So really looking forward to that jam should
be fun.
It should be brilliant.
Thanks very much, Sally.
And I'll see you at the next pod.
All right.
Take care.
Bye.