Hello all,
Please bear with me while I present a brief clinical picture.
I am a 45 year old male who was diagnosed with renal insufficiency 1.5 years back. A stable creatinine of 1.6 since them. Had two kidney biopsies. Both the reports were "normal".
Recently, I saw another nephrologist and he suspected myeloma. He got SPEP test done which has an M-spike of 1.3.
The x rays of skull showed two well defined punched out lytic lesions. The free light chains were non existent. I went for the bone marrow aspiration and it was negative. The bone marrow biopsy report is due; however my oncologist already stated they may not find much in the report given the aspiration report is negative.
My RBCs and hemoglobin are normal. No hypercalcemia.
Any thoughts on what the next steps could be? Appreciate your insights.
TIA
Rao
Forums
5 posts
• Page 1 of 1
Re: Multiple myeloma or not?
Hi dolphinnose,
Welcome to the forum.
Having an M-spike and having kidney damage and evidence of bone damage would suggest that you have multiple myeloma. But you also have some potentially contradictory results.
First, a couple questions to clear things up.
What are the units of your M-spike – g/dL, or g/L? And did you have a serum immunofixation done and, if so, what did it say?
When you say "The free light chains were non existent", is this based on a urine or a blood test? It's important to have a blood (serum) FREE (not total) light chain test.
The finding of no free light chains whatsoever, if it is from a blood test, is odd because even healthy people have free light chains in their blood. If the test results were based on a serum free light chain test, can you share them with us (and, again, please provide the units of the test results)?
The results of your bone marrow biopsy will be important. If it shows no sign of myeloma cells (monoclonal plasma cells) in your bone marrow, that will be a good thing. However, it also will be at odds with the finding that you have an M-spike, since you have to have monoclonal plasma cells somewhere to generate the monoclonal protein found by the M-spike. So you will still want to investigate further to make absolutely certain that you do not have a significant number of myeloma cells somewhere.
One thing you should know is that x-rays of the skull can sometimes show areas that are misdiagnosed as lytic lesions when they are really something called "venous lakes". See, for example, this recent forum posting by myeloma specialist Dr. Ken Shain,
Also, myeloma cells are not uniformly present in the bone marrow of people with multiple myeloma. They can appear here and there, in "patches". In your cases, if your bone marrow biopsy comes up with no sign of the disease, and, if your skull x-ray on closer examination really seems to suggest the presence of lytic lesions there, you may want to have a biopsy of the skull lesions.
If you have not had it done yet, an MRI also would be useful to check further for signs of lesions in your bones.
Finally, if at all possible, you probably should be seeing a myeloma specialist at this point. A myeloma specialist is not just any haematologist-oncologist -- it's a haematologist-oncologist who focuses almost exclusively on seeing and treating patients with myeloma and related diseases. If you give us a general idea where you are located, there should be people here in the forum who can give you recommendations of myeloma specialists near you.
You also probably want to read this summary of the recently updated criteria for diagnosing multiple myeloma and related diseases:
SV Rajkumar, "New Criteria For The Diagnosis Of Multiple Myeloma And Related Disorders," The Myeloma Beacon," Oct 26, 2014.
To summarise: The bone marrow biopsy results are very important right now, as are serum free light chain test results. An MRI would be helpful. It would be good to be seeing a myeloma specialist.
Welcome to the forum.
Having an M-spike and having kidney damage and evidence of bone damage would suggest that you have multiple myeloma. But you also have some potentially contradictory results.
First, a couple questions to clear things up.
What are the units of your M-spike – g/dL, or g/L? And did you have a serum immunofixation done and, if so, what did it say?
When you say "The free light chains were non existent", is this based on a urine or a blood test? It's important to have a blood (serum) FREE (not total) light chain test.
The finding of no free light chains whatsoever, if it is from a blood test, is odd because even healthy people have free light chains in their blood. If the test results were based on a serum free light chain test, can you share them with us (and, again, please provide the units of the test results)?
The results of your bone marrow biopsy will be important. If it shows no sign of myeloma cells (monoclonal plasma cells) in your bone marrow, that will be a good thing. However, it also will be at odds with the finding that you have an M-spike, since you have to have monoclonal plasma cells somewhere to generate the monoclonal protein found by the M-spike. So you will still want to investigate further to make absolutely certain that you do not have a significant number of myeloma cells somewhere.
One thing you should know is that x-rays of the skull can sometimes show areas that are misdiagnosed as lytic lesions when they are really something called "venous lakes". See, for example, this recent forum posting by myeloma specialist Dr. Ken Shain,
Small, questionable calvarial (skull) lytic lesions on bone survey (skeletal) survey are also a questionable reason to start therapy, as naturally occurring venous formations ("venous lakes") are frequently over-called by radiologists in imaging from multiple myeloma or SBP patients."
Also, myeloma cells are not uniformly present in the bone marrow of people with multiple myeloma. They can appear here and there, in "patches". In your cases, if your bone marrow biopsy comes up with no sign of the disease, and, if your skull x-ray on closer examination really seems to suggest the presence of lytic lesions there, you may want to have a biopsy of the skull lesions.
If you have not had it done yet, an MRI also would be useful to check further for signs of lesions in your bones.
Finally, if at all possible, you probably should be seeing a myeloma specialist at this point. A myeloma specialist is not just any haematologist-oncologist -- it's a haematologist-oncologist who focuses almost exclusively on seeing and treating patients with myeloma and related diseases. If you give us a general idea where you are located, there should be people here in the forum who can give you recommendations of myeloma specialists near you.
You also probably want to read this summary of the recently updated criteria for diagnosing multiple myeloma and related diseases:
SV Rajkumar, "New Criteria For The Diagnosis Of Multiple Myeloma And Related Disorders," The Myeloma Beacon," Oct 26, 2014.
To summarise: The bone marrow biopsy results are very important right now, as are serum free light chain test results. An MRI would be helpful. It would be good to be seeing a myeloma specialist.
Re: Multiple myeloma or not?
Ian,
I appreciate your taking time to explain.
Here are the results for my serum free light chains (kappa & lambda):
Kappa Light Chain 9.46 mg/L (3.3-19.40)
Lambda Light Chain 13.26 mg/L (5.71-26.30)
Kappa Lambda Ratio 0.70 (0.26-1.65)
Electrophoresis of Serum Results:
-----------------------
Fractions % conc
-----------------------
Albumin 66.6 5.26
Alpha 1 2.0 0.16
Alpha 2 2.2 0.17
Beta 1 4.8 0.38
Beta 2 7.7 0.61
Gamma 16.7 1.32
T protein 7.9 g/DL
A/G Ratio 1.99
-----------------------
PEAKS % g/DL
-----------------------
16.5 1.30
-----------------------
Beta 2 microglobulin serum (ELFA) 2.17 mg/L (0.81-2.19)
IgG 2179 mg/DL (700-1600)
IgA 63 mg/DL (70-400)
My doctor just called and said my biopsy report came. There are 5% to 8% plasma cells present.
Thank You
I appreciate your taking time to explain.
Here are the results for my serum free light chains (kappa & lambda):
Kappa Light Chain 9.46 mg/L (3.3-19.40)
Lambda Light Chain 13.26 mg/L (5.71-26.30)
Kappa Lambda Ratio 0.70 (0.26-1.65)
Electrophoresis of Serum Results:
-----------------------
Fractions % conc
-----------------------
Albumin 66.6 5.26
Alpha 1 2.0 0.16
Alpha 2 2.2 0.17
Beta 1 4.8 0.38
Beta 2 7.7 0.61
Gamma 16.7 1.32
T protein 7.9 g/DL
A/G Ratio 1.99
-----------------------
PEAKS % g/DL
-----------------------
16.5 1.30
-----------------------
Beta 2 microglobulin serum (ELFA) 2.17 mg/L (0.81-2.19)
IgG 2179 mg/DL (700-1600)
IgA 63 mg/DL (70-400)
My doctor just called and said my biopsy report came. There are 5% to 8% plasma cells present.
Thank You
Re: Multiple myeloma or not?
Hello from sunny Seattle, dolphinnose.
Your case is somewhat hard to put together. Lytic lesions are always concerning for symptomatic multiple myeloma, but there are other diseases (benign and malignant) that can cause lytic lesions.
You do have a significant elevation in plasma cells in the bone marrow, but it is < 10% which meets the criterion for monoclonal gammopathy of undetermined significance (MGUS), but this degree of plasma cell elevation does not meet the criteria for myeloma. It should be noted, though, that there are a small number of patients with symptomatic myeloma whose plasmacytosis in the marrow is less than 10%.
The size of these lytic lesions is important. A few small lesions (less than 1 centimeter) are sometimes not considered to be significant. An MRI of the lytic lesions would be very helpful to determine if myelomatous invasion of the skull is causing them.
Overall, I recommend that you have a "bone marrow MRI," which is a special MRI designed to rule out myeloma lytic lesions and is more sensitive and informative than plain Xrays.
Overall, this sounds more like MGUS than symptomatic myeloma.
A multiple myeloma protocolled bone marrow MRI with attention to the lytic lesions in the skull would be very helpful.
I like your name, dolphinnose!
Your case is somewhat hard to put together. Lytic lesions are always concerning for symptomatic multiple myeloma, but there are other diseases (benign and malignant) that can cause lytic lesions.
You do have a significant elevation in plasma cells in the bone marrow, but it is < 10% which meets the criterion for monoclonal gammopathy of undetermined significance (MGUS), but this degree of plasma cell elevation does not meet the criteria for myeloma. It should be noted, though, that there are a small number of patients with symptomatic myeloma whose plasmacytosis in the marrow is less than 10%.
The size of these lytic lesions is important. A few small lesions (less than 1 centimeter) are sometimes not considered to be significant. An MRI of the lytic lesions would be very helpful to determine if myelomatous invasion of the skull is causing them.
Overall, I recommend that you have a "bone marrow MRI," which is a special MRI designed to rule out myeloma lytic lesions and is more sensitive and informative than plain Xrays.
Overall, this sounds more like MGUS than symptomatic myeloma.
A multiple myeloma protocolled bone marrow MRI with attention to the lytic lesions in the skull would be very helpful.
I like your name, dolphinnose!
-
Dr. Edward Libby - Name: Edward Libby, M.D.
Beacon Medical Advisor
Re: Multiple myeloma or not?
Dr. Libby,
Thank you for your valuable inputs. I will ask my doctor for a bone marrow MRI. Also, will check about the size of the lesions.
Re: "I like your name, dolphinnose!" - Thank You
Thank you for your valuable inputs. I will ask my doctor for a bone marrow MRI. Also, will check about the size of the lesions.
Re: "I like your name, dolphinnose!" - Thank You
5 posts
• Page 1 of 1