44 year old male (on no medications) developed severe back pain in July 2011.The pain had significant musculoskeletal features and associated with severe back spasm. After a month of this, an MRI of the back was obtained that showed djd and possibly some spinal stenosis.
A neurosurgeon who eyeballed the MRI recommended myeloma workup. The bones looked abnormal to him. The radiologist did not flag anything of this nature on the report and another neurosurgeon did not comment on this on reviewing the MRI.
An SPEP and UPEP were ordered amongst other tests
There was an M-spike in the serum 1.1 gm/ dl and the serum and urine IFE confirmed the monoclonal nature (lambda)
ESR is 1. cr was normal at. 0.65
Bone marrow was done.The following are some labs done over the last 11 months.
No symptoms present.
Note higher free light chains.
Does this fit with smoldering myeloma ?
What treatment options are available at this time and what might be recommended ?
Thank you.
Result Nov 2011 Apr 2012 Sep 2012
Bone Marrow 15-20% plasma 11-13% xxxx (13q- and + 17)
M-spike 1.1 gm/dl 1.93gm/dl 1.8gm/dl
FLC Kappa Not done 5.3 g/L 6.7 g/L
FLC Lambda Not done 465 g/L 871 g/L
FLC Ratio Not done 0.01 0.01
Albumin 4.4
Hgb 13.9
PET CT neg
Beta2 micro normal
LDH normal
Creatinine 0.7
IgG 2273 mg/dl (Sep 2011) and 2303 (Nov 2011)
IgA 105 mg/dl (Sep 2011) and 95 (Nov 2011)
IgM 21 mg/dl (Sep 2011) and 26 (Nov 2011)
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Is it smoldering multiple myeloma?
Last edited by yrz1955 on Tue Oct 02, 2012 3:34 pm, edited 1 time in total.
Re: Is it smoldering multiple myeloma?
From your numbers, it looks like you do have multiple myeloma, IgG variety, which is what my husband has. The norm for IgG is 700-1600, so your IgG is elevated and your M-spike, which is the amount of tumor or cancer burden. so I would get a specialist in this field and start treatment.
My husband Igg 3800 range when he was diagnosed in February of 2011. It was shocking, but I read and what you need to concentrate on is this is becoming a chronic treatable disease with all the new therapies and treatments. My husband had stem cell transplants in November of 2011 and the second one in May of 2012 and he is now in complete remission.
Wish you luck and here to lend support and help if i can.
Good luck. Biggest thing is having a multiple myeloma specialist who can recommend a course of treatment to fight this cancer.
Tamster2
My husband Igg 3800 range when he was diagnosed in February of 2011. It was shocking, but I read and what you need to concentrate on is this is becoming a chronic treatable disease with all the new therapies and treatments. My husband had stem cell transplants in November of 2011 and the second one in May of 2012 and he is now in complete remission.
Wish you luck and here to lend support and help if i can.
Good luck. Biggest thing is having a multiple myeloma specialist who can recommend a course of treatment to fight this cancer. Tamster2
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tamster2
Re: Is it smoldering multiple myeloma?
From what is posted you are correct. Your burden of disease as measured by percent plasma in the bone marrow (>10%) puts you in the myeloma category even though your monoclonal paraprotein (M-spike) is less than 3 gm/dl. IgG lambda standard risk.
The next step is to define your status as smoldering vs active (in need of treatment). The key to this are the classic symptoms of myeloma – the CRAB-I criteria: high Calcium, Renal (kidney) insufficiency, Anemia (low hemoglobin / RBC), Boney lytic lesions (Ii am assuming there are no lesions on bone survey), and increased rate of serious Infections.
From you description – good hgb, good kidney, good bones, no infections, and calcium is likely normal (I would add that to your spreadsheet).
You should be monitored every three months with myeloma labs with an annual bone survey. I don't generally recommend annual bone marrow biopsies unless there are concerns about progression to active disease.
Treatment is generally not recommended for patients with smoldering / inactive myeloma. Potential options would be a clinical trial. For higher risk smoldering myeloma, a nice study out of Spain suggested that patients benefited from Revlimid / dexamethasone therapy. However, I have not adopted this for smoldering patients, especially patients with low risk to progression.
Risk of progression is often calculated based on risk factors described in Dispenzieri et al Blood- 2008:
1) M-spike > 3 gm/dL,
2) Plasma cell percent >10, and
3) Kappa/lambda ratio >8 or <0.125.
You have only one risk factor, consistent with lower risk smoldering multiple myeloma, with a "median time to progression of 10 years." However, everyone is unique and you need continual monitoring as above.
Best of luck and keep us updated.
The next step is to define your status as smoldering vs active (in need of treatment). The key to this are the classic symptoms of myeloma – the CRAB-I criteria: high Calcium, Renal (kidney) insufficiency, Anemia (low hemoglobin / RBC), Boney lytic lesions (Ii am assuming there are no lesions on bone survey), and increased rate of serious Infections.
From you description – good hgb, good kidney, good bones, no infections, and calcium is likely normal (I would add that to your spreadsheet).
You should be monitored every three months with myeloma labs with an annual bone survey. I don't generally recommend annual bone marrow biopsies unless there are concerns about progression to active disease.
Treatment is generally not recommended for patients with smoldering / inactive myeloma. Potential options would be a clinical trial. For higher risk smoldering myeloma, a nice study out of Spain suggested that patients benefited from Revlimid / dexamethasone therapy. However, I have not adopted this for smoldering patients, especially patients with low risk to progression.
Risk of progression is often calculated based on risk factors described in Dispenzieri et al Blood- 2008:
1) M-spike > 3 gm/dL,
2) Plasma cell percent >10, and
3) Kappa/lambda ratio >8 or <0.125.
You have only one risk factor, consistent with lower risk smoldering multiple myeloma, with a "median time to progression of 10 years." However, everyone is unique and you need continual monitoring as above.
Best of luck and keep us updated.
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Dr. Ken Shain - Name: Ken Shain, M.D., Ph.D.
Beacon Medical Advisor
Re: Is it smoldering multiple myeloma?
Friends: Update
So I elected to observe and have been getting labs done every few months.
Date Lambda Kappa FLC M-spike
FLC FLC Ratio
Apr 2012 465 5.3 87 1.9
Sep 2012 871 6.7 130 1.8
Dec 2013 705 4.3 164 1.8
Sep 2014 1193 8 149 1.7
Feb 2015 921 7.2 127 1.4
Oct 2015 953 5 190 1.6
Jun 2016 780 8.7 89 1.9
Oct 2016 600 10.9 55 1.8 (different lab)
Feb 2017 871 7.8 112 1.6
Also Feb 2017:
IgA 80 (low)
IgM 13 (low)
IgG 2094
Gamma glob 2.2
Albumin 3.6 (on spep)
Calcium is normal as is the hemoglobin and renal function.
WBC 4.7
Hgb 13.2
Platelets 240
I suspect most would have recommended treatment?
With revised criteria, the involved to uninvolved ratio being over 100, this could be considered multiple myeloma, but not behaving as multiple myeloma thus far it appears. Do you agree?
The immunoglobulin levels were not checked regularly, but 2 are low (another high risk feature?)
I plan to get another bone marrow biopsy and repeat PET/CT or MRI to look at the bones.
M-spike being stable thus far is kind of interesting.
Please feel free to opine. Thanks!
So I elected to observe and have been getting labs done every few months.
Date Lambda Kappa FLC M-spike
FLC FLC Ratio
Apr 2012 465 5.3 87 1.9
Sep 2012 871 6.7 130 1.8
Dec 2013 705 4.3 164 1.8
Sep 2014 1193 8 149 1.7
Feb 2015 921 7.2 127 1.4
Oct 2015 953 5 190 1.6
Jun 2016 780 8.7 89 1.9
Oct 2016 600 10.9 55 1.8 (different lab)
Feb 2017 871 7.8 112 1.6
Also Feb 2017:
IgA 80 (low)
IgM 13 (low)
IgG 2094
Gamma glob 2.2
Albumin 3.6 (on spep)
Calcium is normal as is the hemoglobin and renal function.
WBC 4.7
Hgb 13.2
Platelets 240
I suspect most would have recommended treatment?
With revised criteria, the involved to uninvolved ratio being over 100, this could be considered multiple myeloma, but not behaving as multiple myeloma thus far it appears. Do you agree?
The immunoglobulin levels were not checked regularly, but 2 are low (another high risk feature?)
I plan to get another bone marrow biopsy and repeat PET/CT or MRI to look at the bones.
M-spike being stable thus far is kind of interesting.
Please feel free to opine. Thanks!
Re: Is it smoldering multiple myeloma?
Hello,
I also have IgG lambda myeloma and my numbers look like yours, with a stable M-spike, 20-30% in the marrow with the exception that my free light chain ratio was normal due to a biclonal process. I started treatment after smoldering for 3 years.
My local oncologist wanted me to continue to watch and wait, but my myeloma specialist came off this year's ASH meeting suggesting treatment. There are enough studies now that indicate the earlier you treat the longer the remission, and that if you wait for CRAB symptoms your quality of life is diminished. He helped me make this decision based on quality of life issues, since I had experienced a few pathological fractures.
If my free light chain ratio was abnormal, I would have treated earlier. Immunoparesis and an abnormal free light chain ratio are two very high-risk indicators. It is a very personal decision and not an easy one when you are otherwise feeling good. I hadn't felt good at all during my waiting years because I was either fighting infection or IVIG dependent.
I hope this helps.
J
I also have IgG lambda myeloma and my numbers look like yours, with a stable M-spike, 20-30% in the marrow with the exception that my free light chain ratio was normal due to a biclonal process. I started treatment after smoldering for 3 years.
My local oncologist wanted me to continue to watch and wait, but my myeloma specialist came off this year's ASH meeting suggesting treatment. There are enough studies now that indicate the earlier you treat the longer the remission, and that if you wait for CRAB symptoms your quality of life is diminished. He helped me make this decision based on quality of life issues, since I had experienced a few pathological fractures.
If my free light chain ratio was abnormal, I would have treated earlier. Immunoparesis and an abnormal free light chain ratio are two very high-risk indicators. It is a very personal decision and not an easy one when you are otherwise feeling good. I hadn't felt good at all during my waiting years because I was either fighting infection or IVIG dependent.
I hope this helps.
J
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jhorner - Name: Magpie
- Who do you know with myeloma?: Myself
- When were you/they diagnosed?: 2013
- Age at diagnosis: 49
Re: Is it smoldering multiple myeloma?
2018 update:
I underwent another bone marrow biopsy in February 2017 that showed 20-25 % of the cellularity on the bone marrow biopsy with plasma cells and 20% on the aspirate.
PET/CT done last February was negative.
The latest free light chain levels are:
Lambda - 1300
Kappa - 11
No anemia, renal impairment, bone pain, or abnormal calcium level.
No immunoparesis, although both IgM and IgA are at the bottom end of the range (20 and 91) (19 and 89 would be low for both, for example).
IgG 2412
B2 microglobulin is normal at 1.7.
So it seems to boil down as before to the abnormal FLC ratio mostly (and if you consider the bone marrow with an increase to 25%, although that could be subject to some sampling variances as well, as I understand it).
I suspect many would have treated in the past. I chose to observe and still am on the fence, although I recognize that the time is likely approaching. It has been over 6 years since diagnosis.
I meet with a transplant specialist this coming week.
If I go for treatment, it seems that it likely will be Revlimid, Velcade, and dexamethasone for induction.
Happy to hear opinions. Thank you.
I underwent another bone marrow biopsy in February 2017 that showed 20-25 % of the cellularity on the bone marrow biopsy with plasma cells and 20% on the aspirate.
PET/CT done last February was negative.
The latest free light chain levels are:
Lambda - 1300
Kappa - 11
No anemia, renal impairment, bone pain, or abnormal calcium level.
No immunoparesis, although both IgM and IgA are at the bottom end of the range (20 and 91) (19 and 89 would be low for both, for example).
IgG 2412
B2 microglobulin is normal at 1.7.
So it seems to boil down as before to the abnormal FLC ratio mostly (and if you consider the bone marrow with an increase to 25%, although that could be subject to some sampling variances as well, as I understand it).
I suspect many would have treated in the past. I chose to observe and still am on the fence, although I recognize that the time is likely approaching. It has been over 6 years since diagnosis.
I meet with a transplant specialist this coming week.
If I go for treatment, it seems that it likely will be Revlimid, Velcade, and dexamethasone for induction.
Happy to hear opinions. Thank you.
Re: Is it smoldering multiple myeloma?
Hello,
Well, in my opinion, your M-spike and free light chain ratio are stable, and that's a good thing.
Given that you are asymptomatic and feeling ok, and the only factor that suggests starting treatment is the free light chain ratio ((lambda divided by kappa in your case) being greater than 100, I would not start treatment, if that is ok with your doctor.
In my opinion, the longer you can stay away from treatment, the better. Of course, it's just an opinion.
Well, in my opinion, your M-spike and free light chain ratio are stable, and that's a good thing.
Given that you are asymptomatic and feeling ok, and the only factor that suggests starting treatment is the free light chain ratio ((lambda divided by kappa in your case) being greater than 100, I would not start treatment, if that is ok with your doctor.
In my opinion, the longer you can stay away from treatment, the better. Of course, it's just an opinion.
-
Dimamar - When were you/they diagnosed?: June, 2016
- Age at diagnosis: 54
7 posts
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