[dharsu]

Multiple myeloma, MGUS, or something else?

by dharsu on Thu Jun 11, 2015 2:32 pm

Hi,

Around 5 months back, my father-in-law used to slightly limp and walk with a little bit of pain in his left hip.The local doc suggested to do an x-ray after two months and gave some oral medication. Of late (30 days back), he came to my place and we had shown the doc. He is otherwise fine and limping remains the same and has not deteriorated. We are from India (Bangalore).

We did blood test, BMA/X from say Hospital A. They confirmed it's multiple myeloma and gave the treatment plan of chemo every week.

We repeat the similar test from say Hospital B. Biopsy report though is pending, but they said it's NOT multiple myeloma and suggested to show orthopaedic surgeon.

Need advice and opinion if anyone has faced similar cases.

Hospital A Details
------------------------

MRI = Lytic lesion in the left iliac lobe and acetabulum with multiple cortical breaks. To consider metastasis / multiple myeloma.

PET-CT scan = Consider possibility of plasmacytoma vs lymphoma, recommended histo­path­ology. No primary tumor detected

Aspiration report =
Differential count on 200 cells
Erythroid cells 24.0%, Myelocytes 9.0%, Metamyelocytes 6.0%, Neutrophils 25.0%, Lympho­cytes 18.0%, Eosinophils 6.0%, Plasma cell 12.0%.

Impression:
Hypercellular marrow showing trilineage hematopoiesis. 12% plasma cells seen . The possibility of a plasma cell dyscrasia - multiple myeloma needs to be ruled out.

Biopsy Report
Hypercellular marrow having increased number of plasma cells (12%) with nuclear pleomorphism.

Impression:
Consistent with plasma cell myeloma.

- Bone marrow trephine biopsy.

Total Protein (Biuret) 7.8 g/dL
Globulin 3.73 g/dL
Albumin:Globulin Ratio 1.09

Protein Electrophoresis

Protein Fractions (Electrophoresis)

Albumin 4.07 g/dL
Alpha 1 0.37 g/dL
Alpha 2 0.55 g/dL
Beta 1 0.48 g/dL
Beta 2 0.46 g/dL
Gamma 1.86 g/dL

Comments:
'M' spike seen in the gamma region . Conc of the 'M' Spike is 0.64 g/dL. Hypoalbuminemia seen.

Kappa free light = 1400 mg/l
Lambda = 37.2 mg/l
Ratio = 37.634

Hospital B Details
------------------------

We took the slides and blocks to this hospital and they did IHC and aspiration

Plasma cells 5% mature, Megakaryocytes is adequate, normocellular marrow with pre­dominantly erythroid series. Myeloid series appear normal. No increase in plasma cells.

Interpretation = No conclusive evidence.

Then we repeat the biopsy test:

Aspiration report = Fluid and imprint smear show normal erythroid and myeloid cells. 2% plasma cells seen. Please await biopsy. Please correlate clinically

Immunoglobulin A = 586.8 mg/dl
Immunoglobulin G = 1997.6 mg/dl
Immunoglobulin M = 90 mg/dl
Total Protein = 7.8 g/dl
Globulin = 3.60 g/dl
Albumin/Globulin Ratio = 1.17:1

M spike seen in gamma region and possible m spike in beta-gamma region

Protein Fractions (Electrophoresis)

Albumin 4.2 g/dL
Alpha 1 0.3 g/dL
Alpha 2 0.6 g/dL
Beta 0.8 g/dL
Gamma 2.0 g/dL
M Spike = 0.9 g/dL

Kappa free light = 1400mg/l
Lambda = 37.2mg/l
Ratio = 37.634

IgG kappa with IgA lambda monoclonal gammopathy

Please advise.

[Multibilly]

Re: Multiple myeloma, MGUS, or something else?

by Multibilly on Thu Jun 11, 2015 8:11 pm

Hi Dharsu,

Welcome to the forum. Sorry to hear that you are dealing with this situation and potential diag­nosis.

Bone marrow biopsies can yield quite different results from test to test since the disease is not evenly spread throughout one's bone marrow. But these tests suggest to me that some sort of monoclonal gammopathy may in fact be in play and you may possibly have symptomatic multiple myeloma by virtue of the MRI and PET/CT results.

The big items that jump out at me are the presence of an M-spike, elevated plasma cells in one of the bone marrow biopsies (normal is < 5%), abnormal free light chain ratio, and a lytic lesion detected via MRI that was followed by the suspicion of a plasmacytoma via a PET/CT.

Note that you also want to be looking at your calcium level, hemoglobin level and creatinine level to see if you may be hypercalcemic, anemic, and/or have any kidney involvement.

In any case, I would suggest seeking out a myeloma specialist to comment on the lab results and to certainly see one before undergoing any treatment. If you let us know what city you live in, folks on this forum can make a recommendation on where to find a top myeloma specialist.

[dharsu]

Re: Multiple myeloma, MGUS, or something else?

by dharsu on Thu Jun 11, 2015 11:46 pm

Thank you so much for replying. I live in Bangalore (India). It will be really really helpful if you suggest some name of myeloma doctors in Bangalore.

Below are the further readings

Hospital A
--------------
Haemoglobin = 9.7 gm/dl
Platelet count = 124
LDH = 293U/L
Globulin(liver) = 4.0 g/dl
SGOT = 59 U/L
Blood Urea Nitrogen = 2.8 mg/dl
Urea = 6.0 mg/dl
Serum Creatinine = 0.8mg/dl
Calcium = 8.4 mg/dl
Urine Immunofixation = Negative for light chains

Hospital B
--------------
Hgb = 10.4 gm/dl
Platelet count = 92
Blood Urea Nitrogen = 1.2 mg/dl
Serum Creatinine = 0.8mg/dl
Calcium = 9.1 mg/dl
LDH = 192U/L

[Multibilly]

Re: Multiple myeloma, MGUS, or something else?

by Multibilly on Fri Jun 12, 2015 8:03 am

I've been to Bengaluru (Bangalore) a couple of times. Great food there!

You will want to look at your standard reference ranges for your hemogloblin levels, but a level of 10.4 or 9.7 g/dL is quite low and technically qualifies you as being anemic by multiple myeloma standards, assuming the normal reference range is around 13.4 - 18.8 g/dL (anything that is 2 g/dL or more below the lower point of the reference range means you are anemic). Anemia is a classic symptom of symptomatic multiple myeloma and many people with symp­tomatic multiple myeloma present with anemia.

If you google on "Multiple Myeloma CRAB", you will find that you may actually meet the "A" and "B" in the CRAB criteria, so you should definitely be seeking out a specialist to confirm the diagnosis. If it is multiple myeloma and you meet either the "A" or "B" in the CRAB criteria, you definitely want to seek treatment, whether it be drug-only treatment or a stem cell transplant (which is not a simple decision to make, so take your time and ask for help on this forum). There are also other things a specialist may look for, including amyloidosis, etc.

As far as specialists in India, you may want to look at these threads:

https://myelomabeacon.org/forum/multiple-myeloma-specialist-india-t3168.html
https://myelomabeacon.org/forum/stem-cell-transplant-india-t3167.html

Hope this helps. Good luck.

[dharsu]

Re: Multiple myeloma, MGUS, or something else?

by dharsu on Fri Jun 12, 2015 9:14 am

Thank you Multibilly.

I was reading the PDF guide and I feel that the clinician has to make the best and conscious decision as my case sometimes looks like some criteria's are matching for each category.

In one way plasma cells of 2%, protein concentration of 0.64 g/dl in contrast to 1 lytic lesion and haemoglobin of 10 and below ...

Let me meet up with the doc and will post his reply. Thanks again.