[Kay]

Questions on lab results

by Kay on Sat Oct 15, 2011 8:10 pm

I've had a diagnosis of MGUS for 8 years. For the previous 8 years, I was IgG Lambda, M spike of 0.2 g/dL. The SPEP and SIFE were the only tests I had done.

This fall I had a more comprehensive set of tests done. I now have an M spike of 0.4 g/dL, a Kappa/ Lambda ratio of 0.10. The other abnormal test results were:
LDH: 334 U/L [113-226]
B-2M: 4.5 mg/L [0.9-1.7]
Creatinine: 1.19 mg/dL [0.56-1.16]
Urea Nitrogen: 27mg/dL [8-22]
Uric Acid: 7.0 mg/dL [2.4-5.8]
eGFR: 45 -- indicating moderate Kidney dysfunction
BMB & Aspiration: normocellular marrow of 40-50% w/ trilineage hematopoiesis, plasma cells were 8-10% with Lambda restricted.
Flow Cytometry: 94% abnormal plasma cells.

I guess one of my questions is at what percentage point do the abnormal plasma cells indicate myeloma. Can one have 100% abnormal plasma cells and still be considered MGUS?

I was told that using the Mayo Clinic risk stratification: K/L ratio, IgG and M spike, that I have at 20 years a risk of progression of 21%.

In my previous readings, I understood that with MGUS the risk was 1%/year which I understood to be cummulative; IOW at 20 years the risk would be 20%, Is this wrong?

One test that I have not had done is a skeletal survey. If I have no bony lesions, does the MGUS dx hold even with 94% or more abnormal plasma cells?

Thanks, Kay

[suzierose]

Re: Questions on lab results

by suzierose on Sun Oct 16, 2011 8:45 am

Hi Kay,

You asked:
"at what percentage point do the abnormal plasma cells indicate myeloma. Can one have 100% abnormal plasma cells and still be considered MGUS?"

The criteria used to decide about MGUS is not based on plasma cells per se.

Deciding you have TREATABLE multiple myeloma means having end organ damage since the drugs used are very toxic and typically have not been shown to increase overall survival.

So they use this thing called CRAB...which assesses end organ damage.

C is for hypercalcemia, or amount of Calcium in blood

R is for renal function which is typically measured by creatinine numbers

A is for anemia typically measured by blood test and hemoglobin numbers

and

B is for bone, where they look for lytic bone lesions via x-ray skeletal survey

When any ONE of those CRAB tests are abnormal, you become eligible for treatment, even if you only have ONE.

Hope that helps

[Dr. Ken Shain]

Re: Questions on lab results

by Dr. Ken Shain on Mon Oct 17, 2011 7:20 pm

Be careful when you are interpreting the results from bone marrow biopsies, specifically to what percentages you are referring. In the data that you provided, your bone marrow had less than 10% plasma cells. The 94% by flow cytometry is likely only referring to the population of plasma cells, not the whole population of cells within your marrow. Your M-spike was only 0.4mg/dL and presumabley no end organ damage (no CRAB). So, you have MGUS.

For MGUS risk stratification, you are correct generally we quote progression rates at 1% per year. However, Dr. Rajkumar from Mayo identified several prognositic indicators of 20 year progression rates from MGUS to active disease. These include an abnormal serum free light chain, M-spike greater than 1.5gm/dL, and non-IgG paraprotein. For example, with no risk factors the 20 year progression rate is 5%, one risk factor is 21%, 2 is 37%, and 3 is 58%. Based on the information you listed IgG Lambda, 0.4mg/dL and an abnormal SFLC you have a single risk factor and would fall into the intermediated-low group (21%). These are guidelines based on a population of patients; therefore, these do not suggest that one should be any less maticulous in follow-up.

Treatment for multiple myeloma is generally based on the presentation of at least one of the CRAB"I" (I = infection) criteria, but it can be argued that patients with plamsa cell populations that encompass greater than 60% of there marrow cellularity should be treated as active disease even in the absence of signs of active myeloma. Also remember, hypercalcemia, renal insufficiency, anemia, boney lytic lesions and infection must also be attributed to the myeloma and not from another etiology for them to lead to treatment. As you can imaging that is not always easy. So please keep an eye on your calcium, hemoglobin, and creatinine.

Have a good evening.

[Kay]

Re: Questions on lab results

by Kay on Tue Oct 18, 2011 12:44 am

Thanks for your reply. I was aware of the CRAB"I" criteria. I have not read much on Flow Cytometry and was somewhat startled by the 94% figure; but I realize now that this sampling is also from just one area and as you stated is not representative of the whole population of cells in my bone marrow. I would assume that the flavor or phenotype of the abnormal cells would/could dictate treatment or not.

I also have Multiple Sclerosis (very stable) and have had chronic mild pancytopenia presumably from the interferon beta 1-B injections that I have done qod for 11.5 years. My neurologist sent me to a nephrologist because of my low eGFR and the recommendation was for me to d/c the Rx anti-inflammatory drug that I have taken for many years. I have done this just recently and once I level out on something else less toxic to the kidneys, we'll re-check the creatinine level & clearance. My UPEP was negative for proteins.

Thanks again for your response.

Kay