Outcomes of Patients with Multiple Myeloma in Middle Euphrates Region of Iraq: Data from Developing Country

  1. Ahmed Mjali ,
  2. Safaa Ayad Jawad ,
  3. Nareen Tawfeeq Abbas

Vol 6 No 2 (2021)

DOI 10.31557/apjcb.2021.6.2.99-103


Background: Multiple myeloma (MM) is a B cells neoplasm characterized by plasma cells clonal proliferation.
Aims: The aim of this study was to evaluate incidence, prevalence and pattern of multiple myeloma (MM) in Middle Euphrates region of Iraq. Materials and Methods: A retrospective descriptive conducted at Al-Hussein center in Karbala province of Iraq between February 2012 and February 2020.
Results: A total of 78 patients with MM were included in this study, median age at presentation was 59.8 years, M:F ratio was 0.85:1. The most frequent presenting complain was bony lesions in 87.18% of patients, IgG was the most frequent paraprotient in 61.53% and VRD was the most common used protocol in 37.18% . Survival rate was higher in younger & female patients, while there was no correlation between myeloma defining events and early death in our study.
Conclusion: MM presenting age in our region was close to other parts of Iraq and neighboring countries but younger than western countries with female predominance. Giving that the majority of the patients presented with advance stage disease, therefore raising awareness of early symptoms is recommended for early diagnosis and proper management.


Multiple myeloma (MM) is a malignant hematological disease characterized by the irregular proliferation of clonal plasma cells in the bone marrow [1]. These clonal plasma cells secrete large quantities of monoclonal immunoglobulin into the serum and/or urine, leading to significant morbidity due to end-organ destruction [2]. The etiology of MM is unclear but it commonly occur among farmers, wood workers, leather workers, petroleum products exposed workers and occupations associated with radiation. Several studies suggested that various etiological factors may have played a role in MM etiology such as viral infections, inflammatory disorders, autoimmune diseases, allergic diseases & family history [3-4]. Early recognition of clinical symptoms is an important factor for early management and preventing irreversible complications. Several criteria have been used to diagnose MM & distinguish it from other plasma cell diseases [5].

The following criteria must be fulfilled:

A. Clonal bone marrow plasma cells ≥ 10% or biopsy-proven bony or extramedullary plasmacytoma

B. Any one or more of the following myeloma- defining events:

1. Hypercalcemia: Serum calcium > 0.25 mmol/L (>1 mg/dL) higher than the upper limit of normal or >2.75 mmol/L (> 11 mg/dL).

2. Renal insufficiency: Creatinine clearance < 40 mL/ min or serum creatinine > 177 mmol/L (> 2 mg/dL).

3. Anemia: Hemoglobin value <10 g/dL or hemoglobin > 2 g/dL below the lowest limits of normal hemoglobin levels.

4. Bone lesions: One or more osteolytic lesions on skeletal radiography, CT or PET/CT.

5. Clonal bone marrow plasma cell ≥ 60%.

6. Involved: uninvolved serum free light chain (FLC) ratio ≥ 100 and the involved FLC level must be 10 mg/dL or higher.

7. More than one focal lesion on MRI studies (≥5 mmin size) [6].

Until 2000, the mainstays of MM therapy were alkylating agents, corticosteroids and high-dose chemotherapy with autologous stem cell transplantation (ASCT). Recently, thalidomide, bortezomib, lenalidomide, carfilzomib and pomalidomide are emerged as effective agents that dramatically improved clinical outcomes [7].

This was the first statistical study of MM in Middle Euphrates region of Iraq, it can help provide basic information, assess progress in recent years and develop future myeloma treatment strategies in this area of our county.

Materials and Methods

This was a retrospective, descriptive study conducted in Al-Hussein cancer center in Karbala province of Iraq on MM patients diagnosed between February 2012 to February 2020. This center was established in November 2011 with oncology & hematology wards. It covers not only Karbala population but other patients from Middle Euphrates region of Iraq who are referred to this center for solid & hematological malignancies treatment [8-9]. All patients had full blood & biochemistry profile especially complete blood count, renal functions tests, serum and urine electrophoresis, serum calcium, skeletal survey and bone marrow aspirate with biopsy. Data also provide information about sex, age, occupational history and treatment plan. Patients with inconclusive results were excluded from the study. The study protocol was approved by Ethical Committee of Teaching Hospital in Karbala , Iraq.

The statistical package for social sciences (SPSS) for windows, version 24 was used for entering, managing and analysis of data. Findings were presented in Tables and figures using MS-office software version 2013. P-values of 0.05 or less were regarded as statistically significant.


Seventy eight patients were enrolled in the study. Median age at presentation was 59.8 years ( range 33-91 years). Thirty six patients (46.15%) were males and 42 (53.85%) were females with M:F ratio 0.85:1.

Regarding myeloma-defining events, bony lesions presented in 68 patients (87.18%) followed by anemia in 58 patients (74.36%), renal impairment in 19 patients (24.36%) and hypercalcemia in 14 patients (17.95%).

The most common treatment protocol in our center was VRD protocol in 29 patients (37.18%) followed by VD protocol in 21 patients (26.92%), VCD protocol in 12 patients (15.38%), VTP protocol in 9 patients (11.54%), melphalan & prednisolone in 4 patients (5.13%), supportive treatment in 2 patients (2.57%) and VAD protocol in one patient (1.28%) as shown in (Table 1).

Table 1. Baseline Characteristics of MM Patients in Middle Euphrates Region of Iraq (N=78).

Characteristics N (%)
Age in years  
Median 59.8
Range 33-91
Male 36 (46.15)
Female 42 (53.85)
Myeloma-defining events  
Anemia 58 (74.36)
Bony lesions 68 (87.18)
Hypercalcemia 14 (17.95)
Renal impairment 19 (24.36)
Treatment protocols  
VRD 29 (37.18)
VD 21 (26.92)
VCD 12 (15.38)
VTP 9 (11.54)
Melphalan & prednisolone 4 (5.13)
VAD 1 (1.28)
Supportive 2 (2.57)

VRD, bortezomib; lenalidomide; dexamethasone; VD, bortezomib; dexamethasone; VTP, bortezomib; thalidomide; prednisone; VCD, bortezomib, cyclophosphamide, dexamethasone; VAD, vincristine; doxorubicin; dexamethasone.

The paraprotein types of MM patients showed that the most common type was IgG in 48 patients (61.53%) followed by IgA in 15 patients (19.24%). Regarding Immunofixation, 45 patients (57.70%) had kappa chain, 29 (37.17%) had lambda chain and 4 (5.13%) were non secretary as shown in Figure 1.

Figure 1. Types of Paraproteins.

The mean duration of follow-up was 24.67 months. A total of 16 patients (20.51%) died during the study period as shown in Figures 2 and 3.

Figure 2. Survival and Death Rates.

Figure 3. Mean Survival Time.

Survival rate was higher in patients < 50 years 83.33% versus 66.67% in patients > 70 years and among females (83.33% versus 75.00% in males) , and these differences were statistically significant (P value = 0.013 and 0.031, respectively). On the other hand, there was no correlation between myeloma defining events and treatment protocols on survival (P value > 0.05 each) (Table 2).

Table 2. Survival Rate Based on the Clinical Characteristics and Treatment Protocols.

Characteristic N (62) N (16) P value
Survive Died
Age in years
<50 10 (83.33%) 2 (16.67%) 0.013*
50-59 22 (81.48%) 5 (18.52%)
60-69 20 (83.33%) 4 (16.67%)
≥70 10 (66.67%) 5 (33.33%)
Male 27 (75.00%) 9 (25.00%) 0.031*
Female 35 (83.33%) 7 (16.67%)
Myeloma-defining events
Anemia 0.249
Yes 44 (75.86%) 14 (24.14%)
No 18 (90.00%) 2 (10.00%)
Bony lesions 0.435
Yes 54 (79.41%) 14 (20.59%)
No 8 (80.00%) 2 (20.00%)
Hypercalcemia 0.381
Yes 11 (78.57%) 3 (21.43%)
No 51 (79.69%) 13 (20.31%)
Renal impairment 0.27
Yes 17 (89.47%) 2 (10.53%)
No 45 (76.27%) 14 (23.73%)
Treatment protocols
VD 18 (85.71%) 3 (14.29%) 0.143
VTP 3 (33.33%) 6 (66.67%)
VRD 29 (100.00%) 0 (0.00%)
Melphalan & prednisolone 2 (50.00%) 2 (50.00%)
VCD 9 (75.00%) 3 (25.00%)
VAD 1 (100%) 0 (0.00%)
Supportive 0 (0.00%) 2 (100%)

* significant differences (P ≤ 0.05); VD, bortezomib, dexamethasone; VTP, bortezomib, thalidomide, prednisone ;VRD, bortezomib, lenalidomide and dexamethasone; VCD, bortezomib, cyclophosphamide, dexamethasone; VAD, vincristine, doxorubicin, dexamethasone.


MM accounts for about 1% of all cancers and approximately 10% of all hematologic malignancies. More than 30,000 new cases are diagnosed in the US per year and more than 12,000 patients have died from the disease, while in Iraq MM accounts for around 1.08 % of cancer patients [10-11]. It is generally more common in men & among African-Americans and median age of patients was around 65 years [12].

In the present study, the median age at presentation was 59.8 years which was close to median age in other parts of Iraq, India, China and Turkey [12-15]. While mean age in US was a decade older than ours[16]. Interestingly, in our center MM was more common in females than males, that was inconsistent with previous studies conducted in north Iraq, Turkey,China and US [12,14,16,17].

Clinical presentations can be highly varied among patients, in our region bony lesions were the most common myeloma-defining event , same results in India, Iran and Turkey while in Africa & US anemia was the most common one [14,16,18-20].The most frequent monoclonal protein in our patients was IgG, which was consistent with previous studies in north Iraq, US, China and Turkey [12,14,16,17,21].

During the past decade, the survival rate of MM patients was significantly increased. But the median overall survival was less than five years [22]. In the present study, overall survival rate was high 79.49%, this may be explained by short follow-up period and a small sample size. Survival rate was greater in young patients, same results were obtained from a study conducted at 17 institutions from North America, Europe and Japan where younger myeloma patients were more favorable features and showed better survival [23]. On the other hand, in our study survival was better in female, same results were obtained from a study done by Derman et al., but disagreed with previously published data suggesting no difference in survival outcomes by sex [24-25].

There was no correlation between myeloma defining events and survival in our patients, which was inconsistent with previous studies conducted in China, Japan, Greece and Africa where survival rate was decreased in patients with myeloma defining events [12, 26-28].

Cancer patients tend to present with heterogonous presentations and complications making treatment of those patients as a major concern. Detection of the disease in its early stages before the appearance of signs & symptoms can significantly improve outcomes [29-35]. Treatment of MM is a great challenge to the health system with different treatment protocols. The advent of thalidomide, lenalidomide, and bortezomib changed the standard of treatment and improved the survival of MM patients [36]. In our center VRD protocol (bortezomib, lenalidomide and dexamethasone) was the commonly used regimen. This protocol became as standard of care in many centers with successful results [37]. In the present study, survival rate improved in patients used VRD protocol compared to other protocols , but this result was statistically not significant.

In conclusion, the results of this study showed that Iraqi patients with multiple myeloma were younger than patients in western countries. Most of patients presented with bony lesions in the late stages. IgG was the most frequent paraprotein in the patients. VRD protocol was the most commonly used protocol with good outcomes. Survival rate was higher in younger & female patients, while there was no correlation between myeloma defining events and early death in our study. Future studies in other parts of Iraq with a larger sample size & longer follow up period are recommended to understand MM pattern in our war- torn country.


  1. The Diagnosis and Investigation of Multiple Myeloma in 2018 Alant J, Pool R, Thomson J, et al . Arch Clin Pathol J. 1:1. of. 2018; 6:2..
  2. Multiple myeloma epidemiology and survival: A unique malignancy Kazandjian Dickran. Seminars in Oncology.2016;43(6). CrossRef
  3. Multiple myeloma: the disease and its treatment Gupta M, Pal RA, Tikoo D. Int J Basic. Clin Pharmacol. 2013 Mar.;2(0):103-121.
  4. Multiple myeloma: A review of the epidemiologic literature Alexander Dominik D., Mink Pamela J., Adami Hans-Olov, Cole Philip, Mandel Jack S., Oken Martin M., Trichopoulos Dimitrios. International Journal of Cancer.2007;120(S12). CrossRef
  5. Treatment of Multiple Myeloma: ASCO and CCO Joint Clinical Practice Guideline Mikhael Joseph, Ismaila Nofisat, Cheung Matthew C., Costello Caitlin, Dhodapkar Madhav V., Kumar Shaji, et al . Journal of Clinical Oncology.2019;37(14). CrossRef
  6. How I treat the young patient with multiple myeloma Gandolfi Sara, Prada Claudia Paba, Richardson Paul G.. Blood.2018;132(11). CrossRef
  7. Multiple Myeloma: Diagnosis and Treatment Rajkumar S. Vincent, Kumar Shaji. Mayo Clinic Proceedings.2016;91(1). CrossRef
  8. Gynecological Cancer in Middle Euphrates Region of Iraq , 2012-2020 Mjali Ahmed, Jawad Safaa Ayad, Al Baroodi Bushra Najeh Hasan. Asian Pacific Journal of Environment and Cancer.2020;3(1). CrossRef
  9. Imatinib Mesylate Adherence in Chronic Myeloid Leukemia Patients: Data from Middle Euphrates Region of Iraq Mjali A, Abbas SK. Sys Rev Pharm.2021;12(1):83-87.
  10. Multiple myeloma: 2018 update on diagnosis, risk-stratification, and management Rajkumar S. Vincent. American Journal of Hematology.2018;93(8). CrossRef
  11. Some Facts About Cancers in Karbala province of Iraq, 2012-2020 Mjali Ahmed, Najeh Hasan Al Baroodi Bushra. Asian Pacific Journal of Cancer Care.2020;5(2). CrossRef
  12. Clinical features and treatment outcome in newly diagnosed Chinese patients with multiple myeloma: results of a multicenter analysis Lu J, Lu J, Chen W, Huo Y, Huang X, Hou J. Blood Cancer Journal.2014;4(8). CrossRef
  13. Recent advances in the management of multiple myeloma Kumar L, Vikram P, Kochupillai V. Natl Med J India.2006;19(2):80.
  14. Multiple myeloma in the region of Bursa, Turkey: a retrospective analysis Ozkalemkas F, Ali R, Tunali A, et al . J Environ Pathol Toxicol Oncol.1996;15(2-4):267-270.
  15. Frontline therapy of multiple myeloma Moreau Philippe, Attal Michel, Facon Thierry. Blood.2015;125(20). CrossRef
  16. Review of 1027 Patients With Newly Diagnosed Multiple Myeloma Kyle Robert A., Gertz Morie A., Witzig Thomas E., Lust John A., Lacy Martha Q., Dispenzieri Angela, Fonseca Rafael, Rajkumar S. Vincent, Offord Janice R., Larson Dirk R., Plevak Matthew E., Therneau Terry M., Greipp Philip R.. Mayo Clinic Proceedings.2003;78(1). CrossRef
  17. Clinical Outcomes of Patients with Plasma Cell Neoplasm in Sulaymaniyah Province of Iraq Abbas NT, Sheikha A, Mjali A. Sys Rev Pharm.2020;11(6):1142-1144.
  18. Multiple myeloma: from diagnosis to treatment Eslick R, Talaulikar D. Aust Fam Physician.2013;42(10):684.
  19. Multiple myeloma in Nigeria: An insight to the clinical, laboratory features, and outcomes Madu AJ, Ocheni S, Nwagha TA, Ibegbulam OG, Anike US. Nigerian Journal of Clinical Practice.2014;17(2). CrossRef
  20. Clinical profile of the spectrum of multiple myeloma in a teaching hospital Diwan ArundhatiG, Gandhi SushilA, Krishna Kavita, Shinde VineetP. Medical Journal of Dr. D.Y. Patil University.2014;7(2). CrossRef
  21. Clinical and Laboratory Profiles of 109 Patients diagnosed as Multiple Myeloma in Erbil City Yassin AK. J R Fac Med Iraq.2013;55(2):121-124.
  22. Long‐term survival in multiple myeloma João Cristina, Costa Carlos, Coelho Inês, Vergueiro Maria João, Ferreira Mafalda, Silva Maria Gomes. Clinical Case Reports.2014;2(5). CrossRef
  23. Myeloma in patients younger than age 50 years presents with more favorable features and shows better survival: an analysis of 10 549 patients from the International Myeloma Working Group Ludwig Heinz, Durie Brian G. M., Bolejack Vanessa, Turesson Ingemar, Kyle Robert A., Blade Joan, et al . Blood.2008;111(8). CrossRef
  24. Sex differences in outcomes in multiple myeloma Derman Benjamin A., Langerman Spencer S., Maric Maya, Jakubowiak Andrzej, Zhang Wei, Chiu Brian C.‐H.. British Journal of Haematology.2020;192(3). CrossRef
  25. Sex Differences in Multiple Myeloma Biology and Clinical Outcomes: Results from 3894 Patients in the Myeloma XI Trial Bird Sarah Anne, Cairns David, Davies Faith E., Boyd Kevin, Cook Gordon, Drayson Mark T, et al . Blood.2019;134(Supplement_1). CrossRef
  26. Impact of CRAB symptoms in survival of patients with symptomatic myeloma in novel agent era Nakaya Aya, Fujita Shinya, Satake Atsushi, Nakanishi Takahisa, Azuma Yoshiko, Tsubokura Yukie, Hotta Masaaki, Yoshimura Hideaki, Ishii Kazuyoshi, Ito Tomoki, Nomura Shosaku. Hematology Reports.2017;9(1). CrossRef
  27. Renal failure in multiple myeloma: Incidence, correlations, and prognostic significance Eleutherakis-Papaiakovou V., Bamias A., Gika D., Simeonidis A., Pouli A., Anagnostopoulos A., Michali E., Economopoulos T., Zervas K., Dimopoulos on behalf of the Greek M M. A.. Leukemia & Lymphoma.2007;48(2). CrossRef
  28. Presentation and survival of multiple myeloma patients in Ghana: a review of 9 cases Acquah Michael E, Hsing Ann W, McGuire Valerie, Wang Sophia, Birmann Brenda, Dei-Adomakoh Yvonne. Ghana Medical Journal.2019;53(1). CrossRef
  29. Chronic myeloid leukemia patient with isolated central nervous system blast crisis Mjali A, Kareem YA, Al–Shammari HH, et al . World J Pharm Pharm Sci.2019;8(9):111-117.
  30. Myeloid sarcoma as the presenting symptom of chronic myeloid leukemia chronic phase: A case report Mjali A, Hasan DM, Al-Anssari MJ, et al . World J Pharm Res.2017;6(13):10-15.
  31. Primary Cutaneous Aspergillosis in Acute Myeloid Leukemia Patient: A Case Report Mjali A, Kehiosh HJ, Al-Ansari MJ, et al . World J Pharm Res.2017;6(15):105-111.
  32. Skin Reaction at Site of Intrathecal Methotrexate Mjali A, Al Baroodi BN, Al–Shammari HH, et al . World J Pharm Res.2019;8(10):170-173.
  33. Acute Promyelocytic Leukemia in Third Trimester Pregnant Women Treated with All-Trans-Retinoic Acid Mjali A, Abbas SK, Mutlag JH, et al . World J Pharm Pharm Sci.2019;8(9):146-151.
  34. Vincristine Induced Vocal Cord Paralysis in Patient with Diffuse Large B-cell Lymphoma: A Case Report Mjali A, Al-Anssari MJ, Al-Shammari HH. World J Pharm Res.2017;6(12):11-15.
  35. Proliferating Trichilemmal Tumor: Case Report Mjali A, Alshami MA, Metib NJ, et al . Karbala J Med.2017;10(2):2800-2803.
  36. Multiple Myeloma : Recent Progress in Diagnosis and Treatment Chou Takaaki. Journal of Clinical and Experimental Hematopathology.2012;52(3). CrossRef
  37. Bortezomib, lenalidomide, and dexamethasone as induction therapy prior to autologous transplant in multiple myeloma Rosiñol Laura, Oriol Albert, Rios Rafael, Sureda Anna, Blanchard María Jesús, Hernández Miguel Teodoro, et al . Blood.2019;134(16). CrossRef


© Asian Pacific Journal of Cancer Biology , 2021

Author Details

Ahmed Mjali
Department of Hematology /Oncology, Al- Hussein Medical City, Karbala, Iraq

Safaa Ayad Jawad
Department of Hematology /Oncology, Al- Hussein Medical City, Karbala, Iraq

Nareen Tawfeeq Abbas
Department of Hematology, Hiwa Hematology/ Oncology Hospital, Sulaymaniyah, Iraq.

How to Cite

Mjali A, Jawad S, Abbas N. Outcomes of Patients with Multiple Myeloma in Middle Euphrates Region of Iraq: Data from Developing Country. apjcb [Internet]. 6May2021 [cited 28May2024];6(2):99-03. Available from: http://waocp.com/journal/index.php/apjcb/article/view/622
  • Abstract viewed - 2569 times
  • PDF (FULL TEXT) downloaded - 1284 times
  • Xml downloaded - 281 times