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GET THE CORRECT DIAGNOSIS
07.12.11

WHAT IS MYELOMA?

KNOW WHAT YOU’RE DEALING WITH: GET THE CORRECT DIAGNOSIS

FEATURES WHICH RAISE SUSPICION OF POSSIBLE MYELOMA

  • Symptoms
    • Persistent or worsening tiredness due to anemia or reduced kidney function
    • Sudden pain due to a broken bone in the spine, ribs, or elsewhere
    • Recurrent unexplained infections, such as pneumonia, sinus, or urinary infection

  • Signs
    • Pain with movement and/or at night/rest
    • Pain tenderness/swelling of bone areas
    • Swelling, shortness of breath or evidence of heart or kidney failure

  • Lab test findings
    • Anemia
    • Possible low white blood cells or blood platelets
    • Increased blood calcium
    • Increased blood creatinine and/or blood urea nitrogen (BUN)
    • Increased protein level in the blood and/or urine

KEY FINDING

  • Presence of monoclonal protein in the blood and/or urine (M-SPIKE)
  • Detected on:
  • The M-SPIKE is produced by the cancerous myeloma cells present in the bone marrow.
  • In general, the amount of M-SPIKE reflects the amount of myeloma. However, in some cases, a small amount of protein is produced or occasionally none (non-secretory [1%])

HOW TO ESTABLISH THE CORRECT DIAGNOSIS IF A MONOCLONAL PROTEIN (M-SPIKE) IS PRESENT

  1. Exclude some other acute or chronic medical condition causing production of a monoclonal protein. Many conditions associated with inflammation, autoimmune, and/or allergic reactions and even other types of cancer can be associated with monoclonal protein production in a “reactive” fashion.
  2. If careful evaluation reveals no other obvious cause, then definitive direct diagnosis is required.
  3. The presence of 1 or more “CRAB” features is needed to confirm the diagnosis of active (“symptomatic”) myeloma requiring systemic anti-myeloma therapy.

    Table 1 - Multiple Myeloma Diagnostic Criteria: All Three Required

    1. Monoclonal plasma cells in the bone marrow > 10% and/or presence of a biopsy-proven plasmacytoma
    2. Monoclonal protein present in the serum and/or urinea
    3. Myeloma-related organ dysfunction (1 or more)b
    • [C] Calcium elevation in the blood (serum calcium > 10.5 mg/l or upper limit of normal)
    • [R] Renal insufficiency (serum creatinine > 2 mg/dl)
    • [A] Anemia (hemoglobin < 10 g/dl or 2 g < normal)
    • [B] Lytic bone lesions or osteoporosisc

    *Note: These criteria identify Stage IB and Stages II and III A/B myeloma by Durie/Salmon stage. Stage IA becomes smoldering or indolent myeloma.
    a If no monoclonal protein is detected (non-secretory disease), then > 30% monoclonal bone marrow plasma cells and/or a biopsy-proven plasmacytoma required.
    b A variety of other types of end organ dusfunction can occationally occur and lead to a need for therapy. Such dysfunction is sufficient to support classification as myeloma if proven to be myeloma related.
    c If a solitary (biopsy-proven plasmacytoma or osteoporosis alone (without fractures) are the sole defining criteria, then > 30% plasma cells are required in the bone marrow.
  1. If the CRAB criteria are absent, patients most likely have a precursor state (a “pre-myeloma”). There are 3 categories:

    • MGUS- monoclonal gammopathy of undetermined significance More>>
    • Smoldering myeloma (low risk) More>>

    • Smoldering myeloma (high risk) More>>
  1. Another entity is solitary plasmacytoma of bone. More>>

ASH 2011 Presentations that address STEP 1

REFERENCES

©2011 International Myeloma Foundation

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