[Brittanie]

Is it really smoldering multiple myeloma?

by Brittanie on Wed May 11, 2016 12:09 pm

My mother in law was recently diagnosed with smoldering myeloma by an oncologist and was told to follow-up with blood work every three months. Her primary is referring her to the Moffitt Cancer Center in Tampa, Florida and we are trying to get her in there soon for a second opinion.

I've been looking through all of her labs and I'm having a hard time trying to figure out what's important and what's not and how to decipher the results. You all may be much more help in determining what else is relevant, but this is what I'm seeing so far:

(Sorry for such a long post of results; I'm not sure what to look for and don't understand some of the reports at all. I'm completely new to this)

Immunoglobulin G is high and has significantly increased (A and M have stayed in lower end of the range):

JUL 15 2015 - 1779
SEP 21 2015 - 1589
MAR 14 2016 - 2435

Note on Immunofixation Result Serum states - "igG monoclonal protein with lambda light chain specificity"

Albumin has been decreasing

MAY 27 2015 - 4.3
SEP 21 2015 - 3.8
MAR 14 2016 - 3.7

M-spike

SEP 23 2015 - .9
MAR 15 2016 - .6

Gamma Globulin

SEP 23 2015 - 1.3
MAR 15 2016 - 2.0

24 hr UR (UPEP?) on JUL 15 2015

Free Kappa Lt Chains - 27.80 H (normal 1.36-24.19)
Free Lambda Lt Chains - 5.98 (normal .24-6.66)
Kappa/Lambda Ratio - 4.65 (normal 2.04-10.37)

Kappa/Lambda Serum Testing (SPEP?)

SEP 21 2015
Free Kappa Lt Chains - 8.11 (normal 3.30-19.40)
Free Lambda Lt Chains - 34.80 H (normal 5.71-26.30)
Kappa/Lambda Ratio - .23 L (normal .26-1.65)

MAR 14 2016
Free Kappa Lt Chains - 12.55
Free Lambda Lt Chains - 57.85 H
Kappa/Lambda Ratio - .22 L

(I was confused about why the kappa would be high on the UPEP but the lambda was high on the SPEP and everywhere else?)

Flow Cytometry Report:

"Abnormal plasma cell population identified, representing 3.7% of the viable leukocytes after lysis of the erythroid elements; No abnormal B cell, T cell or NK cell populations identified"

"abnormal plasma cell population expressed lambda-restricted cytoplasmic light chains, slightly decreased CD38, abnormally decreased CD45 and CD19, aberrant intermediate-level CD56, and no CD20. The abnormal population represents 95% of the plasma cells and 3.7% of the total viable leukocytes, which will likely be an underestimate compared with the pending morphologic evaluation of the specimen"

"Flow cytrometric immunophenotyping after lysis of the eruthroid cells shows that the viable leukocytes include 26% lymphocytes, 3.7% monocytes, 64.1% maturing granulocytes, 2.3% blasts/basophils (.9% CD34+ blasts), and 3.9% plasma cells. The lymphocytes consist of 6.2% B cells (CD19+), 85.5% T cells (CD5+), and 8.3% NK cells (CD5-, CD38+, CD56). The mature B cells have a kappa:lambda ratio of 50:31. The T cells have a CD4:CD8 ratio of 64:32. The NK cells have a normal immunophenotype. The plasma cells have a cytoplasmic kappa:lambda ratio of 2:93."

Bone Marrow Consultation Report

Diagnosis: "Limited bone marrow with diffuse involvement by plasma cell neoplasm; Abnormal plasma cell population identified representing 3.7% of the viable leukocytes by flow cytometry."

"By morphologic differential of a hemodilute aspirate smear, 11.5% of the marrow elements are plasma cells, while by immunohistochemistry 40-50% of the cells appear to be plasma cells with lambda light chain restriction"

"Bone Marrow Aspirate: The bone marrow aspirate smears are aparticulate and paucicellular reflecting some element of hemodilution...Plasma cells are increased with a marked increase in atypical forms including large forms of prominent central nucleoli. A 200 cell differential demonstrates 62% myeloids, 13% erythoids, 10% lymphocytes, 11.5% plasma cells, 2.5% monocytes, and 1% blasts."

"Bone Marrow Biopsy and Clot: The H&E stained sections of the bone marrow biopsy and clot section show virtually no trabecular bone and only scant small fragments of intact marrow particle. Given the disruption and paucicellular nature of the speciment, a definitive marrow cellularity estimation cannot be performed. Among the limited fragments of marrow, the vast majority of cells appear to be plasmacytoid in appearance. The remaining hematopoietic elements appear unremarkable; although the fragments are of such limited size that no megakaryocytes are seen."

"Immunophenotype: By immunohistochemistry... CD138+ plasma cells account for an estimated 40-50% of the cellular elements both within the marrow particles and within the clot sections. These plasma cells appear larger with occasional central nucleoli compared to the surrounding lymphocytes and granulocytes. The majority of these plasma cells are lambda light chain expression with virtually no kappa light chain expressing cells seen" (summary of the clot shows CD 138 uniformly positive, polyclonal kappa light chains negative and polyclonal lambda light chains uniformly positive; summary of the bone marrow core shows CD138 uniformly positive 40-50% of cellularity, polyclonal kappa light chains rare cells positive and polyclonal lambda light chains variably positive"

(What is the percentage of plasma cells? 11.5% or 40-50%?)

Cytogenetics Report

"Karyotype: 46,XX[20]... This individual has a constitutional pericentric inversion in one homologue of chromosome 9 [inv(9)(p12q13)]"

FISH study was performed and was negative for t(11;14), t(4;14) and t(14;16)... They didn't examine 13q14, or 17p13.1 because of the type of material tested (formalin-fixed paraffin embedded material v. fresh bone marrow?) - Should this be tested as well right now? I'm assuming she would need another biopsy for that right?

B12 level of 1579; normal range is 184-958 (I didn't see this talked about much other than the possible connection of a low B12 level with multiple myeloma, but I thought it was interesting and should be noted just in case)

HGB has been normal around 11.5-12
BUN is normal at 15
CREAT is normal at 1.0

I apologize for the long post. I'm completely new to this and after spending a few hours trying to decipher all of this, I figured you all might be more help to point me in the right direction. I feel completely lost. I'm trying to figure out whether she really has smoldering multiple myeloma and whether she's high-risk and what we should be watching.

Thank you all so much for your help!

[Multibilly]

Re: Is it really smoldering multiple myeloma?

by Multibilly on Wed May 11, 2016 2:42 pm

Brittanie,

Welcome to the forum. The key lab values you need to consider are:

M-spike
Creatinine
Hemoglobin
Calcium
Involved Free Light Chain Value (Lambda)
Free Light Chain Ratio
Bone Marrow Plasma (BMPC) %

If you could re-post the values for these figures along with their units of measure and their normal ranges from the lab report, that would be helpful.

You want to check with your doc on this, but I believe the 40-50% BMPC measurement is the most accurate value for the bone marrow plasma cell % figure. I say this because of this article:

"Myeloma Morning: Bence Jones Protein & Smoldering Multiple Myeloma, Plasma Cell Percentage Measurement, And TJP1," The Myeloma Beacon, May 4, 2016

At first blush, this does appear to be smoldering multiple myeloma regardless of which BMPC figure you use (both are > than 10%). But in order to say that more definitively, you would need to also know her calcium level and the results of a whole body MRI or PET/CT scan (or at least a whole-body skeletal XRAY survey) to know if she has any focal or lytic bone lesions due to her condition.

B12 can become elevated in patients with hematological malignancies:

Arendt, JFB, et al, "Elevated Plasma Vitamin B12 Levels as a Marker for Cancer: A Population-Based Cohort Study," The Journal of the National Cancer Institute, Nov 2013 (full text)

But, you would be best advised to discuss this with her specialist.

I'm going to guess that a doc would not order another biopsy unless some of the above markers were to change significantly. But, then again, I'm not a doctor.

Moffitt in Tampa is a great facility for multiple myeloma patients. Note that Dr. Ken Shain, who is a regular contributor on this forum, is based there.

Hope this helps.

[Brittanie]

Re: Is it really smoldering multiple myeloma?

by Brittanie on Wed May 11, 2016 10:37 pm

Thank you for your response and thank you for providing those articles. I'm slowly learning a little bit more, but this is all still very confusing for someone with no medical experience.

I've read that albumin can be an indication of the risk of progression and I've noticed that her albumin has been decreasing from 4.3 g/dL in May 2015 to 3.7 g/dL in March 2016.. This seems worrying to me as one of the indications for high risk is an albumin level < 3.5 g/dL and it seems that she could be on her way there soon. Also, it appears that her numbers below (M-spike, Lambda) are rising. Maybe they aren't significant right now, but it seems a little worrying for us when she hasn't been able to see a myeloma specialist yet and we don't have clear answers.

The following are the results from the lab reports (most of the labs that we have don't list the units of measure for some reason):

M-spike (I noticed that I made a mistake on my initial post)

SEP 23 2015 - 0.9
MAR 14 2016 - 1.6

Creatinine - Reference Range (0.7-1.4 mg/dL)

JUL 15 2015 - 0.7
APR 13 2016 - 1.0

Hemoglobin - Reference Range (11.0-16.0 g/dL)

SEP 21 2015 - 11.5
MAR 14 2016 - 11.5
APR 13 2016 - 12

Calcium - Reference Range (8.4-9.7 mg/dL)

APR 13 2016 - 8.6

Free Light Chain Values

UR - JUL 15 2015

Kappa Lt Chains - 27.80 H (Reference Range: 1.35-24.19)
Lambda Lt Chains - 5.98 (Reference Range: 0.24-6.66)
Kappa/Lambda Ratio - 4.65 (Reference Range: 2.04-10.37)

Serum Testing (seems to be the opposite of UR; is there a good explanation for this?)

Kappa Lt Chains - Reference Range: 3.30-19.40
SEP 21 2015 - 8.11
MAR 14 2016 - 12.55

Lambda Lt Chains - Reference Range: 5.71-26.30
SEP 21 2015 - 34.80
MAR 14 2016 - 57.85

Kappa/Lambda Ratio - Reference Range 0.26-1.65
SEP 21 2015 - 0.23
MAR 14 2016 - 0.22

Bone Marrow Plasma (BMPC) %40-50?

She's had bone scans that did not show any lesions. She is going for an MRI of her spine soon because of frequent back pain (the pain could be entirely unrelated because she has other health issues as well).

Hopefully we will be able to get her into Moffitt soon. She has several other health issues and has not been working for a couple years. She has no insurance right now and is trying to apply for disability. We are trying to see if she'll qualify for charity assistance at Moffitt. If not we will have to figure out how we can get her insurance to cover everything. I know that it's early to tell right now how aggressive it will be and if she will be smoldering for the rest of her life, but all of this is a little overwhelming right now. And, by the way, she's 59.

Another thing that I think I forgot to mention is that my mother-in-law's sister actually died from multiple myeloma several years ago as well. I know they technically say it's not supposed to be hereditary, there has to be some genetic association where there's so many instances of such a "rare disease" occurring in more than one member of the family.

Thank you so much for your help.

[Multibilly]

Re: Is it really smoldering multiple myeloma?

by Multibilly on Thu May 12, 2016 6:06 am

I wouldn't necessarily assume that her albumin level is going down based on the disease itself. Hydration can also have a pretty big impact on albumin and BUN levels, so it's important to drink lots of fluids. I am smoldering and my albumin level has been all over the map in the past 3 1/2 years, as you can see from the values below (taken about every two months):

3.80
3.90
4.0
4.2
4.0
3.7
3.5
4.1
3.4
3.7
3.3
3.7
3.4
3.6
3.7
4.2
4.1
4.2
4.3
4.2
4.4
4.4
4.5

Also, you mentioned "bone scans". Were these PET/CT scans, xrays, MRIs or actually nuclear "bone scans" (bone scintigraphy)? Some non-specialists mistakenly order nuclear bone scans to screen for multiple myeloma problems. Unfortunately, bone scans cannot usually pick up on the types of bone problems caused by multiple myeloma. But an MRI is an excellent means of screening and it is good that she is getting one of her spine if she does indeed have pain there.