melphalan and Hypercalcemia

Renal failure, mostly related to myeloma cast nephropathy (MCN), is a frequent complication of multiple myeloma (MM), which occurs in up to 50% of patients during the course of the disease. Persistent renal failure in MM is associated with poor survival. Treatment of MCN relies on urgent symptomatic measures (alkalinisation, rehydration, correction of hypercalcemia, and withdrawal of nephrotoxic drugs), with rapid introduction of chemotherapy to efficiently reduce the production of monoclonal light chains (LC). Recent studies suggest that, in patients with MM and severe renal failure due to MCN, rapid removal of circulating LC, through intensive hemodialysis sessions using a new generation high cut-off dialysis membrane, might result in dialysis withdrawal in most patients. If the development of intensive therapy and new efficient chemotherapy agents (thalidomide, bortezomib, lenalidomide) has transformed the care and prognosis of MM, the modalities and safety of these therapeutic regimens in patients with renal failure remain to be defined. The association of bortezomib with dexamethasone should be considered currently as first-line treatment in patients with MM and impaired renal function.

Topics: Angiogenesis Inhibitors; Antineoplastic Combined Chemotherapy Protocols; Boronic Acids; Bortezomib; Clinical Trials as Topic; Contraindications; Cyclophosphamide; Dexamethasone; Fluid Therapy; Humans; Hypercalcemia; Immunoglobulin Light Chains; Kidney Failure, Chronic; Lenalidomide; Melphalan; Multicenter Studies as Topic; Multiple Myeloma; Myeloma Proteins; Prospective Studies; Protease Inhibitors; Pyrazines; Randomized Controlled Trials as Topic; Renal Dialysis; Thalidomide

We report a case of 77-year-old woman who presented with lumbago and hypercalcemia. Multiple myeloma (MM) was first diagnosed by serum protein electrophoresis and bone marrow aspiration, but intact parathyroid hormone (intactPTH) was also found to be high in the presence of persistent hypercalcemia with anorexia and nausea. After lowering serum calcium with bisphosphonate administration, parathyroidectomy was performed. Upon histologic examination, the tumor was determined to be parathyroidal chief-cell hyperplasia and the patient was treated with melphalan and prednisolone. The relationship between MM and primary hyperparathyroidism (I degree HPT) remains unknown. Although the co-existence of MM and I degree HPT was reported in 12 reports from various parts of the world, there was only 1 report in Japan. The present case is an example of successful treatment for a complicated disorder, and suggests that patients suffering from bone pain or hypercalcemia need to be examined both endocrinologically and hematologically.

Topics: Aged; Antineoplastic Agents; Female; Humans; Hypercalcemia; Hyperparathyroidism; Hyperplasia; Low Back Pain; Melphalan; Multiple Myeloma; Osteoporosis; Parathyroid Glands; Prednisolone

A dramatic improvement in the prognosis of multiple myeloma has been obtained since treatment with alkylating agents was introduced in the sixties. In recent years much effort has been made to ameliorate the obtained results by employing polychemotherapy schedules of treatment. However, no significant improvements with respect to the conventional melphalan-prednisone treatment, in terms of survival duration, have been observed. New therapeutic approaches, such as the use of biological response modifiers and the autologous or allogeneic bone marrow transplantation offer new perspectives for multiple myeloma patients. In this paper we discuss current trends in the therapy of multiple myeloma and of related complications.

Topics: Acute Kidney Injury; Alkylating Agents; Antineoplastic Combined Chemotherapy Protocols; Bone Marrow Transplantation; Humans; Hypercalcemia; Interferon Type I; Kidney Failure, Chronic; Melphalan; Multiple Myeloma; Prednisone; Recurrence

Topics: Adrenal Cortex Hormones; Animals; Antineoplastic Combined Chemotherapy Protocols; Bleomycin; Breast Neoplasms; Cyclophosphamide; Dacarbazine; Doxorubicin; Drug Therapy, Combination; Dyspnea; Fluorouracil; Hodgkin Disease; Humans; Hypercalcemia; Leukemia; Leukemia, Lymphoid; Lymphoma; Mechlorethamine; Melphalan; Methotrexate; Multiple Myeloma; Palliative Care; Prednisone; Procarbazine; Receptors, Glucocorticoid; Vinblastine; Vincristine; Vomiting

Patients with benign monoclonal gammopathy or smouldering multiple myeloma should not be treated. The plasma cell labelling index utilizing tritiated thymidine or a monoclonal antibody to 5-bromo-2-deoxyuridine is helpful in differentiating patients with benign monoclonal gammopathy or smouldering myeloma from those with overt myeloma. Although combinations of chemotherapeutic agents seem to produce a greater number of objective responses than does melphalan-prednisone, a significant difference in survival has not been proved. Possibilities for future treatment include chemotherapy with large intravenous doses of melphalan, very small doses of cyclophosphamide or melphalan, the administration of hydroxyurea before chemotherapy, combination of interferon with alkylating agents, autologous bone marrow transplantation, and improvement of the soft-agar colony-forming assay for myeloma cells. The therapeutic use of monoclonal antibodies to plasma cell antigens may be possible in the future. Much more needs to be learned about the biologic basis of myeloma before real progress can be made.

Topics: Acute Kidney Injury; Anemia; Antibodies, Monoclonal; Antineoplastic Combined Chemotherapy Protocols; Blood Viscosity; Bone Diseases; Bone Marrow Transplantation; Drug Resistance; Humans; Hypercalcemia; Kidney Failure, Chronic; Melphalan; Multiple Myeloma; Prednisone; Spinal Cord Compression; Time Factors

Topics: Acute Kidney Injury; Altretamine; Anemia; Bacterial Infections; Bone Neoplasms; Cyclophosphamide; Doxorubicin; Drug Therapy, Combination; Humans; Hypercalcemia; Interferons; Kidney Failure, Chronic; Melphalan; Meningeal Neoplasms; Multiple Myeloma; Spinal Cord Compression; Vinblastine; Vincristine; Vindesine

The M-2 protocol (vincristine, cyclophosphamide, BCNU, melphalan, and prednisone) was administered monthly to 63 evaluable patients with advanced chronic lymphocytic leukemia. Complete remission (absence of all clinical and bone marrow evidence of leukemia) and partial response (greater than 50% decrease in organ enlargement and reduction of WBC count to below 15,000 x 10(6)/liter) were achieved in 17% and 44%, respectively, for a total response rate of 61%. The median survivals from therapy of patients achieving a CR, RR, or no response were 73+, 40, and 14 mo respectively. The median survival time from onset of treatment for stages II, III, and IV disease were 47, 20 and 19 mo, respectively, which was not statistically different from historical controls. However, when untreated patients are compared to this latter group, a significant survival advantage from diagnosis was found (p = 0.01), stressing the importance of prior therapy as the only unfavorable prognostic factor. Although complete remissions in CLL, as reflected in apparently normal bone marrow B-lymphocyte markers, can be induced wih acceptable morbidity, the majority of patients relapse after cessation of therapy. An alternative approach to the M-2 protocol will be needed to eradicate the disease.

Topics: Antineoplastic Agents; Antineoplastic Combined Chemotherapy Protocols; Carmustine; Cyclophosphamide; Drug Therapy, Combination; Female; Femur Head Necrosis; Humans; Hypercalcemia; Leukemia, Lymphoid; Male; Melphalan; Neoplasms, Multiple Primary; Paresthesia; Prednisone; Prognosis; Thrombocytopenia; Vincristine

Topics: Antineoplastic Agents; Drug Therapy, Combination; Humans; Hypercalcemia; Kidney Diseases; Melphalan; Multiple Myeloma; Myeloma Proteins; Pain; Prognosis

The basic pathologic process in multiple myeloma is the neoplastic proliferation of a single clone of plasma cells. Although the events which trigger autonomous cell growth are not well understood, the secretion of an M component, a serum or urinary immunoglobulin molecule or a light chain fragment by the vast majority of myeloma cells has provided a biologic marker which has greatly facilitated the study of this disease Some of the more recent clinical concepts which have evolved from studies on the plasma cell and the immunoglobulin molecule are discussed.

Topics: Alkylating Agents; Amyloidosis; Bacterial Infections; Blood Viscosity; Bone Diseases; Clone Cells; Hemostasis; Humans; Hypercalcemia; Kidney Failure, Chronic; Melphalan; Multiple Myeloma; Paraproteins

Topics: Adrenal Cortex Hormones; Adrenocorticotropic Hormone; Anemia; Anemia, Hemolytic, Autoimmune; Blood Urea Nitrogen; Glucocorticoids; Humans; Hypercalcemia; Immunoglobulins; Leukemia; Lymphoma; Melphalan; Multiple Myeloma; Myeloma Proteins; Prednisone; Waldenstrom Macroglobulinemia

The impact of high dose dexamethasone containing regimens with or without the novel agents thalidomide and bortezomib on the reversal of renal failure (RF) was evaluated in 41 consecutive newly diagnosed patients with multiple myeloma (MM) treated in a single institution. RF was reversed in 73% of all patients within a median of 1.9 months. In patients treated with dexamethasone and novel agents (thalidomide and/or bortezomib) the reversibility rate was 80% within a median of 0.8 months. Severe RF and significant Bence Jones proteinuria were associated with a lower probability of RF reversal. Patients who responded to treatment achieved RF reversal more often than in those who did not (85% versus 56%, p=0.046). In conclusion, RF is reversible in the majority of newly diagnosed MM patients treated with high-dose dexamethasone containing regimens. The addition of novel agents induces a more rapid RF reversal.

Topics: Adult; Aged; Aged, 80 and over; Antineoplastic Combined Chemotherapy Protocols; Bence Jones Protein; Boronic Acids; Bortezomib; Dexamethasone; Doxorubicin; Female; Humans; Hypercalcemia; Kidney Failure, Chronic; Male; Melphalan; Middle Aged; Multiple Myeloma; Myeloma Proteins; Proteinuria; Pyrazines; Thalidomide; Treatment Outcome; Vincristine

In order to study whether oral bisphosphonate therapy might prevent or reduce skeletal-related morbidity in patients with newly diagnosed multiple myeloma who required chemotherapy, 300 patients were included in a randomized multi-centre trial. Patients were given oral pamidronate at a dose of 300 mg daily, or placebo, in addition to conventional intermittent melphalan/prednisolone (and in some cases alpha-interferon) treatment. With a median treatment duration of about 550d, no statistically significant reduction in skeletal-related morbidity (defined as bone fracture, related surgery, vertebral collapse, or increase in number and/or size of bone lesions) could be demonstrated. Pamidronate treatment also did not have any influence on patient survival or on the frequency of hypercalcaemia. However, in patients treated with pamidronate there were fewer episodes of severe pain (P=0.02) and a decreased reduction of body height of 1.5 cm (P= 0.02). The overall negative result of the study is attributed to the very low absorption of orally administered bisphosphonates in general.

Topics: Administration, Oral; Aged; Anti-Inflammatory Agents; Antineoplastic Combined Chemotherapy Protocols; Body Height; Bone Diseases; Diphosphonates; Double-Blind Method; Female; Fractures, Bone; Humans; Hypercalcemia; Male; Melphalan; Multiple Myeloma; Pain; Pamidronate; Prednisolone; Treatment Failure

In 1989, a prospective randomized multicenter study was initiated in order to determine the safety and efficacy of oral clodronate in myeloma patients. The primary objective of this long-term trial is to evaluate whether supportive clodronate is able to prevent or retard the progression of bone disease and reduce the occurrence of characteristic complications: pain, pathologic fractures, and hypercalcemia. We now report first results as an interim analysis, including data obtained from 26 patients (total number of Tübingen patients n = 36) who entered the study at the Medizinische Universitätsklinik Tübingen. Patients were randomized to receive either chemotherapy alone (melphalan 15 mg/m2 i.v. on day 1 and prednisolone 60 mg/m2 orally on days 1-4 every 4 weeks (control group) or in combination with 1600 mg clodronate/day orally as a single dose for a period of at least 1 year. Repeated radiologic examinations in addition to hematologic and biochemical analysis were performed in order to evaluate the skeletal status with respect to lytic bone lesions and osteoporosis and the course of serum M protein and light chain excretion into urine. Clodronate treatment resulted in a significant decrease of serum calcium concentrations and of biochemical indices for bone resorption. No clodronate-related toxicity or hypocalcemia was observed. In patients treated with chemotherapy alone, this effect was less marked and discontinuous. Clodronate-treated patients developed fewer progressive bone lesions (significant for lytic, not for osteoporotic lesions). No hypercalcemic episodes occurred in the clodronate-treated patients, but there were six episodes in the control group. Whereas the number of vertebral fractures was evidently less is clodronate-treated patients, three of those patients suffered from multiple fractures of long bones and ribs. All together, 12 pathologic fractures occurred in five clodronate-treated patients, whereas in the control group 23 pathologic fractures occurred in the same number of patients during the whole observation period. The final analysis of all multicenter included patients should clarify these findings. There was a significant finding that clodronate proved to have an analgesic effect.

Topics: Adult; Aged; Analgesia; Bone Diseases; Bone Resorption; Calcium; Clodronic Acid; Female; Fractures, Bone; Humans; Hypercalcemia; Male; Melphalan; Middle Aged; Multiple Myeloma; Osteoporosis; Prednisolone; Prospective Studies

The authors report the results obtained from the treatment of 13 cases of myeloma by cyclic chemotherapy (melphalan) applied after cellular synchronization with vincristine. The clinical results (maximum 2 years after treatment) were good in 11 cases out of 13. The following laboratory values quickly returned to normal: sedimentation and calcaemia, but there was little change in the immunoglobulins.

Topics: Aged; Anemia; Blood Sedimentation; Bone Neoplasms; Clinical Trials as Topic; Drug Therapy, Combination; Female; Follow-Up Studies; Humans; Hypercalcemia; Male; Melphalan; Middle Aged; Mitosis; Multiple Myeloma; Pain; Periodicity; Vincristine

The effect of certain disease parameters on remission and survial time was evaluated in 482 patients with multiple myeloma treated with intermittent courses of melphalan-prednisone combinations. Increasing degrees of anemia, hypercalcemia, azotemia, and high serum myeloma protein levels were associated with progressive lifespan shortening. The short survival of patients with anemia and hypercalcemia was associated with short remissions in responding patients with these abnormalities. The extent of tumor mass was defined from specific laboratory parameters reported by Durie to be associated with large numbers of plasma cells. More advanced stages of myeloma were associated with higher frequencies and degrees of normal immunoglobulin depression. The response rate was not affected by the tumor mass grade, but increasing tumor mass was associated with a shorter lifespan. Greater degrees of tumor reduction were associated with longer remission and survival times. Patients in whom a marked tumor reduction was rapid had shorter survival and remission times than patients who responded more slowly.

Topics: Aged; Anemia; Drug Therapy, Combination; Female; Humans; Hypercalcemia; Immunoglobulins; Male; Melphalan; Middle Aged; Multiple Myeloma; Myeloma Proteins; Plasma Cells; Prednisone; Prognosis; Remission, Spontaneous; Serum Albumin; Time Factors; Uremia

Topics: Aged; Bence Jones Protein; Blood Urea Nitrogen; Clinical Trials as Topic; Cyclophosphamide; Female; Follow-Up Studies; Humans; Hypercalcemia; Immunoglobulin A; Immunoglobulin G; Male; Melphalan; Middle Aged; Multiple Myeloma; Serum Albumin

Topics: Adult; Antineoplastic Combined Chemotherapy Protocols; Boronic Acids; Bortezomib; Cesarean Section; Chemoradiotherapy; Cisplatin; Combined Modality Therapy; Contraindications; Cyclophosphamide; Cytarabine; Dexamethasone; Doxorubicin; Etoposide; Fatal Outcome; Female; Hematopoietic Stem Cell Transplantation; Humans; Hypercalcemia; Idarubicin; Infant, Newborn; Lenalidomide; Male; Melphalan; Methylprednisolone; Multiple Myeloma; Myeloma Proteins; Osteolysis; Plasmacytoma; Postpartum Period; Pregnancy; Pregnancy Complications, Neoplastic; Pregnancy Outcome; Pyrazines; Remission Induction; Spinal Cord Compression; Thalidomide; Thoracic Vertebrae; Transplantation, Autologous

The authors report the case of an 82 year old woman hospitalized for hypercalcemia associated with low serum phosphate. Multiple myeloma was first diagnosed. However, despite chemotherapy, hypercalcemia persisted and she was subsequently diagnosed as primary hyperparathyroidism; eucalcemic state was then obtained after parathyroidectomy. Fifteen similar cases are reported in the literature and the mechanisms and implications of such an association are discussed.

Topics: Aged; Aged, 80 and over; Female; Humans; Hypercalcemia; Hyperparathyroidism; Immunoglobulin kappa-Chains; Immunoglobulin Light Chains; Melphalan; Multiple Myeloma; Parathyroidectomy; Prednisone

Topics: Aged; Aged, 80 and over; Calcium; Cyclic AMP; Etidronic Acid; Humans; Hypercalcemia; Hyperparathyroidism; Immunoglobulin G; Immunoradiometric Assay; Male; Melphalan; Multiple Myeloma; Parathyroid Hormone; Phosphorus; Prednisone; Ultrasonography

Topics: Aged; Antineoplastic Combined Chemotherapy Protocols; Blood Viscosity; Carmustine; Cyclophosphamide; Humans; Hypercalcemia; Male; Melphalan; Multiple Myeloma; Paralysis; Plasmapheresis; Prednisone; Seizures; Serum Globulins; Vincristine

Topics: Animals; Bence Jones Protein; Blood Viscosity; Cat Diseases; Cats; Dog Diseases; Dogs; Hemorrhagic Disorders; Hypercalcemia; Hypergammaglobulinemia; Kidney Diseases; Lymphoma, Non-Hodgkin; Melphalan; Multiple Myeloma; Waldenstrom Macroglobulinemia

Patients with asymptomatic or smoldering multiple myeloma should not be treated but should be observed closely for progression. For symptomatic myeloma, chemotherapy is indicated. Melphalan, the agent of choice, should be given with prednisone for 1 week of every 6 weeks, If melphalan brings no response, or response and then relapse, cyclophosphamide (Cytoxan) should be give intravenously every 4 weeks or orally every day. BCNU, CCNU, and doxorubicin (Adriamycin) have also shown activity in myeloma. Hypercalcemia occurs in one-third of patients and should be countered with hydration, corticosteroids, Neutra-Phos, or mithramycin. Long-term hemodialysis has achieved some success. The combination of sodium flouride and calcium carbonate produces new bone formation; it seems a useful adjunct in treatment for myelomatous bone disease. Radiation should be utilized only for severe, localized pain or for solitary lesions. Survival with multiple myeloma varies, mean durations being 2 to 3 years. Multivariate analysis indicates that serum creatinine and calcium levels are the most significant indicators regarding 2-year survival. We have found monoclonal proteinuria not significantly more frequent with renal insufficiency than with normal renal function, renal insufficiency not significantly more frequent with lambda than with kappa chains, and survival not significantly greater with IgG myeloma than with IgA.

Topics: Anemia; Bacterial Infections; BCG Vaccine; Carmustine; Cyclophosphamide; Fractures, Bone; Humans; Hypercalcemia; Kidney Failure, Chronic; Melphalan; Multiple Myeloma; Mycobacterium bovis; Prognosis

The treatment of rapidly progressive skeletal demineralisation in myelomatosis has been studied with the help of metabolic calcium balance in two patients; In one, osteoporosis accelerated during treatment with melphalan and prednisolone, although he remained normocalcaemic throughout, suggesting that osteoporosis was aggravated by corticosteroid therapy. In the other patient, who was initially hypercalcaemic, conventional treatment produced clinical remission before eventual relapse with more hypercalcaemia and skeletal dissolution. Both patients were then treated with mithramycin alone, and, although neither obtained haematological remission, bone pain was relieved, hypercalciuria and hypercalcaemia were abolished, and calcium balances proved that mithramycin was effective in restoring calcium equilibrium. The results indicate that mithramycin may abolish excessive bone resorption in myelomatosis and that severe bone dissolution may occur in the absence of hypercalcaemia. Regular determination of 24-hour urinary calcium excretion as well as of plasma-calcium is important in monitoring process. Mithramycin should be considered in the early treatment not only of hypercalcaemia but also of severe hypercalciuria, if these complications do not rapidly remit during the first course of conventional myeloma therapy, with or without steroids. Finally, these results add to evidence that a humoral factor may be responsible for osteoclast stimulation in myelomatosis.

Topics: Aged; Calcium; Cyclophosphamide; Drug Therapy, Combination; Female; Humans; Hypercalcemia; Injections, Intravenous; Male; Melphalan; Middle Aged; Multiple Myeloma; Osteolysis; Phosphorus; Plicamycin; Prednisolone; Water-Electrolyte Balance

Management of some diverse complications of plasma cell myeloma is reviewed with respect to prevention when possible and prompt treatment when necessary. A series of 102 patients from the Duke University Medical Center was surveyed to ascertain the approximate frequency with which renal failure, hypercalcemia, infection, hyperviscosity syndrome, and neurologic disorders occur. Selected patient studies and additional data from the literature emphasize aspects of these complications amenable to therapy aside from that directed at plasma cell growth.

Topics: Acute Kidney Injury; Bacterial Infections; Blood Urea Nitrogen; Blood Viscosity; Bone Neoplasms; Cephalothin; Cyclophosphamide; Cytarabine; Female; Fluoxymesterone; Furosemide; Gentamicins; Humans; Hypercalcemia; Kidney Failure, Chronic; Male; Melphalan; Middle Aged; Multiple Myeloma; Neurologic Manifestations; Plicamycin; Renal Dialysis

Topics: Blood Viscosity; Bone Diseases; Cyclophosphamide; Fluorides; Humans; Hypercalcemia; Melphalan; Multiple Myeloma; Myeloma Proteins; Pain; Phosphates; Plasmapheresis; Prednisolone; Procarbazine; Vincristine

Topics: Analgesics; Anti-Bacterial Agents; Cyclophosphamide; Exercise Therapy; Glucocorticoids; Humans; Hypercalcemia; Melphalan; Multiple Myeloma; Radiotherapy

Topics: Administration, Oral; Aged; Antithrombins; Blood Coagulation Disorders; Humans; Hypercalcemia; Immunoglobulin A; Male; Melphalan; Multiple Myeloma; Phosphates

Topics: Bence Jones Protein; Bone Marrow Examination; Hemoglobinometry; Humans; Hypercalcemia; Melphalan; Multiple Myeloma; Neoplasm Proteins; Plasma Cells; Plasmacytoma; Prognosis

Topics: Adult; Aged; Amyloidosis; Anemia; Bence Jones Protein; Cyclophosphamide; Female; gamma-Globulins; Humans; Hypercalcemia; Immunochemistry; Immunoglobulin M; Male; Melphalan; Middle Aged; Multiple Myeloma; Uremia

Topics: Bence Jones Protein; Calcinosis; Calcium; Cyclophosphamide; Humans; Hypercalcemia; Kidney Tubules; Male; Melphalan; Multiple Myeloma; Perfusion; Phosphates; Pulmonary Alveoli

Topics: Anemia; Bence Jones Protein; Cyclophosphamide; Humans; Hypercalcemia; Immunoglobulin M; Kidney Failure, Chronic; Melphalan; Multiple Myeloma

Topics: Anemia; Humans; Hypercalcemia; Melphalan; Multiple Myeloma; Osteoporosis

Topics: Anemia; Bence Jones Protein; Female; Humans; Hypercalcemia; Male; Melphalan; Multiple Myeloma; Prognosis; Serum Globulins; Uremia; Urethane

Topics: Anti-Bacterial Agents; Antineoplastic Agents; Blood Cell Count; Blood Platelets; Cyclophosphamide; Humans; Hypercalcemia; Leukocyte Count; Melphalan; Multiple Myeloma; Prednisone

Topics: Anemia; Blood Protein Disorders; Chlorambucil; Humans; Hypercalcemia; Leukopenia; Melphalan; Plasmacytoma; Thrombocytopenia

Topics: Adult; Aged; Blood Platelets; Blood Proteins; Creatine; Female; Humans; Hypercalcemia; In Vitro Techniques; Leukocytes; Male; Melphalan; Middle Aged; Multiple Myeloma; Prednisone; Proteinuria

Topics: Cyclophosphamide; Humans; Hypercalcemia; Male; Melphalan; Middle Aged; Multiple Myeloma

Topics: Aged; Biopsy; Bone and Bones; Calcium; Female; Fluorides; Humans; Hypercalcemia; Male; Melphalan; Middle Aged; Multiple Myeloma; Radiography

Topics: Blood Cell Count; Blood Protein Electrophoresis; Blood Sedimentation; Bone Marrow Examination; Calcium; Drug Therapy; Electrophoresis; Geriatrics; Hemoglobinometry; Hemorrhagic Disorders; Humans; Hypercalcemia; Immunoelectrophoresis; Kidney Function Tests; Melphalan; Multiple Myeloma; Neoplasms; Radiography; Urethane; Urine