Multiple myeloma and fever of unknown origin: a need for therapy

Abstract

British Journal of Cancer (2005) 93, 266. doi:10.1038/sj.bjc.6602693 www.bjcancer.comPublished online 12 July 2005& 2005 Cancer Research UKSir,In their concise review on evolving treatment strategies formyeloma, Morgan and Davies (2005) stated that ‘early death was,and still is, a significant problem, and addressing the causes of thisis important including early diagnosis, the treatment of infection,hydration and the choice of the most appropriate chemotherapy’.The most common presenting symptoms of the disease are fatigue,bone pain and recurrent infections. The latest classificationsystem, recently released from The International Myeloma Work-ing Group (2003), highlighted the importance to distinguishbetween asymptomatic and overt myeloma, because only thelatter requires active treatment. According to this statement, thebiological activity of the disease, more than the tumour mass,is the foremost guide to the therapy. The related organ or tissueimpairment (ROTI) that meets the criterion for the diagnosisconsists of hypercalcemia, renal insufficiency, anaemia or bonelesions (a group of findings referred to as CRAB). However, weneed to understand that some of the clinical features of the disease,as the degree of anaemia, are not completely explained by theplasma cellular infiltrates or paraprotein secretion. Althoughuncommonly, myeloma can present as fever of unknown origin(FUO) (Mueller et al, 2002; Lambotte et al, 2003). In these cases thefever is attributable to the disease itself, and indeed no infectionsare demonstrable, even with extensive work-up. Moreover, thefever cannot be abated with antibiotics although chemotherapyworks well (Mumoli et al, 2004). It is not already known if themodulation of the interaction between the neoplastic clone andthe marrow microenvironment, as is the case during therapywith bortezomib, could reverse this kind of presentation; thiscould in turn result in delaying chemotherapy, at least in patientsnot eligible for transplantation procedures. Morgan and Daviesconclude saying that in the future it will be desirable to describemyeloma as a treatable disease with prolonged survival andgood quality of life if the correct treatment decisions are made.We agree with this and we add, moreover, if the correct diagnosishas also been made. We therefore suggest that FUO shouldbe mentioned as an indication for diagnosis and therapy inmyeloma patients.