Wednesday, 4 December 2013

Multiple myeloma- The Diagnosis

Multiple myeloma, also known as plasma cell myeloma or Kahler’s disease, is a type of abnormal growth of plasma cells collected in the bone marrow where they grow and multiple to interfere with the production of normal blood cells. Paraprotein, an abnormal antibody produced by the plasma cell myeloma not only can cause kidney problem but also interference with the Roche automated total bilirubin assay by precipitate formation of that can lead to clinical confusion, according to the study by the Harvard Medical School, Boston(1). Other study indicated that the production of paraproteins caused spurious results on individual analytes including total bilirubin (TBIL), direct bilirubin (DBIL), or HDL-cholesterol (HDL-C)(b). There is also a report of a 50 years old
chloride resistant metabolic alkalosis in a patient with hypercalcemia related to Multiple Myeloma (MM)(c).
B. Diagnosis
If you are experience some of the above symptoms, after recording the complete family history and physical examination, the test which your doctor orders may include
1. Standard Blood and urine tests
The aim of the tests are to detect the presence of M proteins of which may be an indication of Multiple myeloma. If M protein is found in the test, additional boold test for beta-2-microglobulin may be necessary for the comfirmation of outcome.
2. Serum Free Light Chain Assays
Free light chain (FLC) assays are important in the diagnosis and monitoring of patients with multiple myeloma (MM). Elevated immunoglobulin free light chain (FLC) level and abnormal FLC ratio are commonly seen in multiple myeloma (MM) and have prognostic implications, accosing to the study by the Division of Hematology, Mayo Clinic, a combination of the risk factors; either abnormal FLC estimate and/or the presence of high-risk IgH translocation, achieved better prognostic stratification. We conclude that patients with IgH translocations have higher FLC levels and abnormal ratios, but the prognostic effect of FLC is only partially explained by translocation status. A system including both these risk factors allows better prediction of outcome(35).
3. Imaging
In multiple myeloma, imaging is required to determine the stage of disease and to anticipate impending bone fractures. According to the study by the Department of Radiology, German Cancer Research Center, modern systems include
a. MRI findings. MRI is most sensitive to both diffuse bone marrow involvement as well as solid plasma cell tumors.
b. Whole-body low-dose CT (WBCT) may replace plain films in the near future, since it is quicker, more sensitive, and is better tolerated by patients. Intramedullary lesions are well seen as long as they are located in long bones where they are surrounded by fat. Diffuse bone marrow infiltration as well as intravertebral lesions, however, are difficult to detect with WBCT in the absence of frank destruction of cancellous bone.
c. PET or PET-CT with 18-fluoro-deoxyglucose (FDG) are insensitive to diffuse bone marrow infiltration, but may help to assess treatment response in solitary or multiple solid plasma cell tumors which have a high FDG uptake before treatment(36).
4. Bone marrow examination
There have been suggestions to eliminate the need for BM examinations as a result of a bone marrow (BM) examination showing less than 5% plasma cells in addition to negative serum and urine immunofixation. In the study to evaluate of patients with multiple myeloma who achieved negative immunofixation in the serum and urine after therapy and found that 14% had BM plasma cells more than or equal to 5%. Adding a requirement for normalization of the serum-free light chain ratio to negative immunofixation studies did not negate the need for BM studies; 10% with a normal serum-free light chain ratio had BM plasma cells more than or equal to 5%. We also found that, on achieving immunofixation-negative status, patients with less than 5% plasma cells in the BM had improved overall survival compared with those with 5% or more BM plasma cells (6.2 years vs 2.3 years, respectively; P = .01)(37).
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