Do you have to have all "CRAB" symptoms for an official diagnosis of multiple myeloma?
I have all except (A)nemia. My 24-hour urine shows negative for Bence Jones proteins. However, I have serum viscosity at a 2.1 and 0.8 g/dL M-spike with osteolytic lesions in anterior calvarium. Hematologist noted on my chart multiple myeloma not having reached remission. Still have PET/CT to do tomorrow as well as upcoming bone marrow biopsy.
Any feedback is welcome.
Cee
Forums
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ApparentlyNot - Name: ApparentlyNot
- Who do you know with myeloma?: Me
- When were you/they diagnosed?: MGUS
- Age at diagnosis: 40
Re: Are all CRAB symptoms necessary for myeloma diagnosis?
Hi Cee,
Welcome to the forum.
I'm a bit confused by your post. You make mention of your "myeloma not having reached remission". The possibility of remission implies that you may have been receiving treatment for myeloma earlier. Were you?
To answer your questions about the "CRAB" criteria, all you have to do is meet any one of them to have a diagnosis of symptomatic myeloma. If the osteolytic lesions are found to be due to myeloma (the PET/CT scan will help confirm this), then you would technically have a diagnosis of myeloma and treatment would be considered by the doctor.
You also say you meet all the CRAB criteria, except the one for anemia. What are your serum calcium and creatinine levels, which are the two markers used to determine the "C" and "R" in CRAB?
It would also be good to know what your serum kappa and lambda free light chain numbers and IgG, IgA and IgM levels are.
Lastly, your doctor likely tested your serum viscosity level to check for hyperviscosity syndrome, which is not that typical of a test to do when first being diagnosed. Were there some specific symptoms that caused him to run this test? A person with a relatively small m-spike like yours wouldn't likely suffer from hyperviscosity syndrome, unless something else was causing a very significant rise in one of your IgA, IgG or IgM levels.
Note that it's also really helpful if you post the units of measure and the reference ranges when you post any of your lab numbers going forward.
Hope this helps a bit.
Welcome to the forum.
I'm a bit confused by your post. You make mention of your "myeloma not having reached remission". The possibility of remission implies that you may have been receiving treatment for myeloma earlier. Were you?
To answer your questions about the "CRAB" criteria, all you have to do is meet any one of them to have a diagnosis of symptomatic myeloma. If the osteolytic lesions are found to be due to myeloma (the PET/CT scan will help confirm this), then you would technically have a diagnosis of myeloma and treatment would be considered by the doctor.
You also say you meet all the CRAB criteria, except the one for anemia. What are your serum calcium and creatinine levels, which are the two markers used to determine the "C" and "R" in CRAB?
It would also be good to know what your serum kappa and lambda free light chain numbers and IgG, IgA and IgM levels are.
Lastly, your doctor likely tested your serum viscosity level to check for hyperviscosity syndrome, which is not that typical of a test to do when first being diagnosed. Were there some specific symptoms that caused him to run this test? A person with a relatively small m-spike like yours wouldn't likely suffer from hyperviscosity syndrome, unless something else was causing a very significant rise in one of your IgA, IgG or IgM levels.
Note that it's also really helpful if you post the units of measure and the reference ranges when you post any of your lab numbers going forward.
Hope this helps a bit.
Last edited by Multibilly on Mon May 21, 2018 8:28 am, edited 2 times in total.
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Multibilly - Name: Multibilly
- Who do you know with myeloma?: Me
- When were you/they diagnosed?: Smoldering, Nov, 2012
Re: Are all CRAB symptoms necessary for myeloma diagnosis?
Hello Cee,
I agree with everything that Multibilly has written in his (as usual) very helpful posting.
Perhaps these additional thoughts, which I started drafting prior to Multibilly's post, will help clarify your situation further.
You technically only need one "myeloma-defining event" (MDE) for a multiple myeloma diagnosis. One of the "CRAB" criteria would qualify as an MDE, for example, as would a very high free light chain ratio (100 or greater), or a very high bone marrow plasma cell percentage.
With the CRAB criteria, it's very important to understand that just having an elevated calcium ("C") level, for example, does not mean that you have multiple myeloma. It has to be clear that clonal plasma cells, or "myeloma cells", are the cause of the "CRAB" symptoms. So, for example, if there's a bone lesion or fracture, it needs to clear that myeloma is the cause of the lesion.
This is important when it comes to the sort of "lesions" that you mention. Possible skull lesions are often misinterpreted to be myeloma-related when they are not. Instead, they may be what are known as "venous lakes". Dr. Shain has raised this issue in a number of postings here in the forum; these are the ones that I was able to find quickly:
https://myelomabeacon.org/forum/can-a-skull-lesion-be-considered-benign-t221.html#p12134
https://myelomabeacon.org/forum/why-do-bone-marrow-biopsy-t3870.html#p21973
https://myelomabeacon.org/forum/solitary-bone-plasmacytoma-multiple-myeloma-t4684.html#p27299
This post in the forum, "Criteria for a multiple myeloma diagnosis," is very thorough in discussing the criteria for a myeloma diagnosis. It also references a useful article that summarizes the criteria:
SV Rajkumar, "New Criteria For The Diagnosis Of Multiple Myeloma And Related Disorders," The Myeloma Beacon, Oct 26, 2014
One final point I would make is that technically meeting the criteria for having multiple myeloma doesn't mean that all doctors will immediately start treatment. Doctor's will take into account how unequivocal the data are in regard to the diagnosis, and also factors such as whether or not the disease seems aggressive (based on lab results from the past), and how well the patient is likely to handle treatment.
Good luck, and let us know what you find out as you get further tests and feedback from your doctors.
I agree with everything that Multibilly has written in his (as usual) very helpful posting.
Perhaps these additional thoughts, which I started drafting prior to Multibilly's post, will help clarify your situation further.
You technically only need one "myeloma-defining event" (MDE) for a multiple myeloma diagnosis. One of the "CRAB" criteria would qualify as an MDE, for example, as would a very high free light chain ratio (100 or greater), or a very high bone marrow plasma cell percentage.
With the CRAB criteria, it's very important to understand that just having an elevated calcium ("C") level, for example, does not mean that you have multiple myeloma. It has to be clear that clonal plasma cells, or "myeloma cells", are the cause of the "CRAB" symptoms. So, for example, if there's a bone lesion or fracture, it needs to clear that myeloma is the cause of the lesion.
This is important when it comes to the sort of "lesions" that you mention. Possible skull lesions are often misinterpreted to be myeloma-related when they are not. Instead, they may be what are known as "venous lakes". Dr. Shain has raised this issue in a number of postings here in the forum; these are the ones that I was able to find quickly:
https://myelomabeacon.org/forum/can-a-skull-lesion-be-considered-benign-t221.html#p12134
https://myelomabeacon.org/forum/why-do-bone-marrow-biopsy-t3870.html#p21973
https://myelomabeacon.org/forum/solitary-bone-plasmacytoma-multiple-myeloma-t4684.html#p27299
This post in the forum, "Criteria for a multiple myeloma diagnosis," is very thorough in discussing the criteria for a myeloma diagnosis. It also references a useful article that summarizes the criteria:
SV Rajkumar, "New Criteria For The Diagnosis Of Multiple Myeloma And Related Disorders," The Myeloma Beacon, Oct 26, 2014
One final point I would make is that technically meeting the criteria for having multiple myeloma doesn't mean that all doctors will immediately start treatment. Doctor's will take into account how unequivocal the data are in regard to the diagnosis, and also factors such as whether or not the disease seems aggressive (based on lab results from the past), and how well the patient is likely to handle treatment.
Good luck, and let us know what you find out as you get further tests and feedback from your doctors.
Re: Are all CRAB symptoms necessary for myeloma diagnosis?
And, as usual, Cheryl makes some great points.
A skeletal survey (xray) can indeed produce ambiguous results when it comes to identifying lesions. In fact, I was originally thought to have an osteolytic lesion identified via a skeletal survey when I first being diagnosed. However, a PET/CT scan then later confirmed that no lesion existed at all. In fact, another radiologist also went back and looked at my original xray and couldn't understand why the fist radiologist had even suggested the possibility of a lesion.
In any case, if your suspected osteolytic lesions do in fact exist and are due to an active cancer such as myeloma, they will "light up" on the PET/CT scan, since the PET portion of the PET/CT scan is very good at detecting cancerous activity.
A skeletal survey (xray) can indeed produce ambiguous results when it comes to identifying lesions. In fact, I was originally thought to have an osteolytic lesion identified via a skeletal survey when I first being diagnosed. However, a PET/CT scan then later confirmed that no lesion existed at all. In fact, another radiologist also went back and looked at my original xray and couldn't understand why the fist radiologist had even suggested the possibility of a lesion.
In any case, if your suspected osteolytic lesions do in fact exist and are due to an active cancer such as myeloma, they will "light up" on the PET/CT scan, since the PET portion of the PET/CT scan is very good at detecting cancerous activity.
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Multibilly - Name: Multibilly
- Who do you know with myeloma?: Me
- When were you/they diagnosed?: Smoldering, Nov, 2012
Re: Are all CRAB symptoms necessary for myeloma diagnosis?
Hi all,
Thanks for the replies. I have not been officially diagnosed with multiple myeloma and so I was confused to see multiple myeloma not having reached remission on my chart. I have done bone scans and x-rays which showed uptake in anterior calvarium and pelvis. My complaints to doctor are always the same, pain in my upper back alongside spine and my thighs, both legs have a deep gnawing bone pain. I am 41 years and used to be very active. I can barely get up from sitting position because my legs are so weak.
Have had hypercalcemia, kidney issues, and bone lesions.
Here are my most recent labs from May 2. I am including ALL that are on my chart. Thank you all for taking time to even read my concerns.
Urea Nitrogen-Serum (BUN) 8 mg/dL 7.0-21.0
Creatinine-Serum 0.60 mg/dL 0.5-0.9
Creatinine Clearance (Est) 130.8000 mL/min 75.0-115.0 H
Protein (Total)-Serum 8.3 g/dL 6.0-8.3
Albumin-Serum 4.6 g/dL 3.5-5.2
Calcium-Serum 10.4 mg/dL 8.5-10.4
Bilirubin, Total 0.2 mg/dL 0.2-1.3
Alkaline Phosphatase 101 U/L 35.0-105.0
AST (SGOT) 14 U/L 0.0-32.0
ALT (SGPT) 19 U/L 0.0-33.0
GFR, Qt 110.12 ml/min/1.73m2
Protein (Total)-Serum 7.6 g/dL 6.0-8.5
Albumin-Serum 3.8 g/dL 2.9-4.4
Globulin 3.8 g/dL 2.2-3.9
A/G Ratio 1.1 0.7-1.7
WBC-Blood 8.4 x10^3uL 4.1-10.9
RBC Count-Blood 4.58 x10^6uL 4.2-6.3
Hgb-Blood 13.6 g/dL 12.0-16.0
Hematrocrit 40.5 % 37.0-51.0
MCV 88.4 fL 80.0-97.0
MCH 29.7 pg 26.0-32.0
MCHC 33.6 g/dL 31.0-36.0
Red Cell Dist Width 13.0 % 11.5-14.5
Platelet Count 319 x10^3uL 140.0-440.0
MPV (Mean Pltlt Vol) 9.5 fL 0.0-99.8
Granulocytes /
Bands-Blood 5.3 x10^3uL 2.0-6.9
Lymphocytes-Blood 2.3 x10^3uL 0.6-4.1
Monocytes-Blood 0.7 x10^3uL 0.1-0.6 H
Eosinophils-Blood 0.1 x10^3uL 0.0-0.7
Basophils-Blood 0.0 x10^3uL 0.0-0.2
Neutrophil % 63.5 % 37.0-80.0
Immature
Granulocytes # 0.0 0.0-0.2
Lymphocyte % 27.3 % 10.0-58.5
Monocyte % 7.8 % 0.0-10.0
Basophil % 0.2 % 0.0-2.5
Eosinophil % 1.1 % 0.0-7.0
Immature
Granulocytes % 0.1 % 0.0-0.5
ESR (Sed Rate) 24 mm/hr 0.0-20.0 H
Viscosity-Serum 2.1 rel.sal 1.6-1.9 H
CRP 8.1 mg/L 0.0-4.9 H
Kappa Free 15.6 mg/L 3.3-19.4
Lambda Free 19.9 mg/L 5.7-26.3
K/L Free Ratio 0.78 0.26-1.65
Alpha-1-globulin 0.2 g/dL 0.0-0.4
Alpha-2-globulin 0.7 g/dL 0.4-1.0
Beta Globulin 1.4 g/dL 0.7-1.3 H
Gamma Globulin 1.5 g/dL 0.4-1.8
M-Spike 0.8 g/dL 0.0-0.0 H
IgG 1429 mg/dL 700.0-1600.0
IgA 352 mg/dL 87.0-352.0
IgM 200 mg/dL 26.0-217.0
Immunofix Interp, Serum (T)
Comment Immunofixation shows IgG monoclonal protein with kappa light chain specificity.
PE Note
Comment Protein electrophoresis scan will follow via computer, mail, or courier delivery.
Thanks for the replies. I have not been officially diagnosed with multiple myeloma and so I was confused to see multiple myeloma not having reached remission on my chart. I have done bone scans and x-rays which showed uptake in anterior calvarium and pelvis. My complaints to doctor are always the same, pain in my upper back alongside spine and my thighs, both legs have a deep gnawing bone pain. I am 41 years and used to be very active. I can barely get up from sitting position because my legs are so weak.
Have had hypercalcemia, kidney issues, and bone lesions.
Here are my most recent labs from May 2. I am including ALL that are on my chart. Thank you all for taking time to even read my concerns.
Urea Nitrogen-Serum (BUN) 8 mg/dL 7.0-21.0
Creatinine-Serum 0.60 mg/dL 0.5-0.9
Creatinine Clearance (Est) 130.8000 mL/min 75.0-115.0 H
Protein (Total)-Serum 8.3 g/dL 6.0-8.3
Albumin-Serum 4.6 g/dL 3.5-5.2
Calcium-Serum 10.4 mg/dL 8.5-10.4
Bilirubin, Total 0.2 mg/dL 0.2-1.3
Alkaline Phosphatase 101 U/L 35.0-105.0
AST (SGOT) 14 U/L 0.0-32.0
ALT (SGPT) 19 U/L 0.0-33.0
GFR, Qt 110.12 ml/min/1.73m2
Protein (Total)-Serum 7.6 g/dL 6.0-8.5
Albumin-Serum 3.8 g/dL 2.9-4.4
Globulin 3.8 g/dL 2.2-3.9
A/G Ratio 1.1 0.7-1.7
WBC-Blood 8.4 x10^3uL 4.1-10.9
RBC Count-Blood 4.58 x10^6uL 4.2-6.3
Hgb-Blood 13.6 g/dL 12.0-16.0
Hematrocrit 40.5 % 37.0-51.0
MCV 88.4 fL 80.0-97.0
MCH 29.7 pg 26.0-32.0
MCHC 33.6 g/dL 31.0-36.0
Red Cell Dist Width 13.0 % 11.5-14.5
Platelet Count 319 x10^3uL 140.0-440.0
MPV (Mean Pltlt Vol) 9.5 fL 0.0-99.8
Granulocytes /
Bands-Blood 5.3 x10^3uL 2.0-6.9
Lymphocytes-Blood 2.3 x10^3uL 0.6-4.1
Monocytes-Blood 0.7 x10^3uL 0.1-0.6 H
Eosinophils-Blood 0.1 x10^3uL 0.0-0.7
Basophils-Blood 0.0 x10^3uL 0.0-0.2
Neutrophil % 63.5 % 37.0-80.0
Immature
Granulocytes # 0.0 0.0-0.2
Lymphocyte % 27.3 % 10.0-58.5
Monocyte % 7.8 % 0.0-10.0
Basophil % 0.2 % 0.0-2.5
Eosinophil % 1.1 % 0.0-7.0
Immature
Granulocytes % 0.1 % 0.0-0.5
ESR (Sed Rate) 24 mm/hr 0.0-20.0 H
Viscosity-Serum 2.1 rel.sal 1.6-1.9 H
CRP 8.1 mg/L 0.0-4.9 H
Kappa Free 15.6 mg/L 3.3-19.4
Lambda Free 19.9 mg/L 5.7-26.3
K/L Free Ratio 0.78 0.26-1.65
Alpha-1-globulin 0.2 g/dL 0.0-0.4
Alpha-2-globulin 0.7 g/dL 0.4-1.0
Beta Globulin 1.4 g/dL 0.7-1.3 H
Gamma Globulin 1.5 g/dL 0.4-1.8
M-Spike 0.8 g/dL 0.0-0.0 H
IgG 1429 mg/dL 700.0-1600.0
IgA 352 mg/dL 87.0-352.0
IgM 200 mg/dL 26.0-217.0
Immunofix Interp, Serum (T)
Comment Immunofixation shows IgG monoclonal protein with kappa light chain specificity.
PE Note
Comment Protein electrophoresis scan will follow via computer, mail, or courier delivery.
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ApparentlyNot - Name: ApparentlyNot
- Who do you know with myeloma?: Me
- When were you/they diagnosed?: MGUS
- Age at diagnosis: 40
Re: Are all CRAB symptoms necessary for myeloma diagnosis?
Hi Cee,
So, technically, you would need a calcium level > 11.5 mg/dL or a creatinine level > 2 mg/dL to meet the "C" and "R" thesholds in the CRAB criteria, respectively. So, that's good news that you don't meet these criteria.
I wouldn't know if a creatinine clearance level of 130 ml/min would be cause for any serious concern regarding your kidney function. Only your doctor can make that call.
It's also good that your free light chains are all in the normal range.
When you say that you had "bone scans" in the past, I assume that they were nuclear bone scans (i.e. skeletal scintigraphy)? Those types of scans are unfortunately not good at picking up lytic lesions. However, a PET/CT scan should easily find and greatly assist in confirming the presence of any myeloma-related damage in your pelvis and skull.
I am admittedly a little surprised that you would have much in the way of myeloma-related bone damage with your kind of relatively small m-spike and normal free light chain levels unless you have a form of partially secretory myeloma disease. This is where there is a greater burden of disease that is present in your bone marrow that isn't being fully expressed in your serum numbers, yet you can still experience CRAB organ damage damage such as lytic lesions. The bone marrow biopsy and the PET/CT should go a long ways to helping sort all this out.
Wishing you good luck and I hope that I haven't muddied the waters too much. Please let us know how things turn out.
So, technically, you would need a calcium level > 11.5 mg/dL or a creatinine level > 2 mg/dL to meet the "C" and "R" thesholds in the CRAB criteria, respectively. So, that's good news that you don't meet these criteria.
I wouldn't know if a creatinine clearance level of 130 ml/min would be cause for any serious concern regarding your kidney function. Only your doctor can make that call.
It's also good that your free light chains are all in the normal range.
When you say that you had "bone scans" in the past, I assume that they were nuclear bone scans (i.e. skeletal scintigraphy)? Those types of scans are unfortunately not good at picking up lytic lesions. However, a PET/CT scan should easily find and greatly assist in confirming the presence of any myeloma-related damage in your pelvis and skull.
I am admittedly a little surprised that you would have much in the way of myeloma-related bone damage with your kind of relatively small m-spike and normal free light chain levels unless you have a form of partially secretory myeloma disease. This is where there is a greater burden of disease that is present in your bone marrow that isn't being fully expressed in your serum numbers, yet you can still experience CRAB organ damage damage such as lytic lesions. The bone marrow biopsy and the PET/CT should go a long ways to helping sort all this out.
Wishing you good luck and I hope that I haven't muddied the waters too much. Please let us know how things turn out.
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Multibilly - Name: Multibilly
- Who do you know with myeloma?: Me
- When were you/they diagnosed?: Smoldering, Nov, 2012
Re: Are all CRAB symptoms necessary for myeloma diagnosis?
Thanks so much for the replies. It's a relief. I'm kind of at my wits end with all the testing and still no answers.
I will indeed let you all know what happens with the PET/CT.
Cheers.
I will indeed let you all know what happens with the PET/CT.
Cheers.
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ApparentlyNot - Name: ApparentlyNot
- Who do you know with myeloma?: Me
- When were you/they diagnosed?: MGUS
- Age at diagnosis: 40
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