Hello everyone,
While doing research on multiple myeloma, I came across this statement on the UAMS [University of Arkansas] website:
"It is important to remember that myeloma often is a focal disease, meaning that there can be areas in the bone with large numbers of myeloma cells and areas with small numbers of myeloma cells or none at all. The aspirate or biopsy may hit a pocket of myeloma cells and overestimate the overall amount of myeloma cells. It may also hit a spot with no myeloma cells, while there is still myeloma present in other areas of the bone marrow."
My question is, then why do a bone marrow biopsy if it's not always accurate? If your IGs point to multiple myeloma as well as your light chains & you have lytic bone lesions, but a biopsy comes out with a low percentage of plasma cells, do you have to keep repeating the biopsy or just start your treatment?
Thanks for your comments.
Forums
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Lillyput189 - Who do you know with myeloma?: Self
- When were you/they diagnosed?: MGUS 2011, multiple myeloma 2014
- Age at diagnosis: 54
Re: Why do bone marrow biopsy?
I don't think that you would do another biopsy (or keep doing one) until you get some sort of satisfactory results.
It's my understanding that while there is always the disclaimer that BM biopsies may not representative of the overall condition, they are nevertheless very helpful, in that they do allow one to assess the status of the bone marrow compartment. If you do collect BM cells, they are useful in cytogenetic studies, not just getting you an estimate of myeloma cell counts, as well as giving you a glimpse into the rest of the bone marrow compartment.
The disclaimer is more for when you don't see much going on, because it may still mean there is still something going on elsewhere. However, this doesn't mean that the test is not useful. When used in conjunction with PET/MRI/skeletal survey as well as blood/urine analyses, they together do give a very comprehensive look into disease status, or lack thereof.
It's my understanding that while there is always the disclaimer that BM biopsies may not representative of the overall condition, they are nevertheless very helpful, in that they do allow one to assess the status of the bone marrow compartment. If you do collect BM cells, they are useful in cytogenetic studies, not just getting you an estimate of myeloma cell counts, as well as giving you a glimpse into the rest of the bone marrow compartment.
The disclaimer is more for when you don't see much going on, because it may still mean there is still something going on elsewhere. However, this doesn't mean that the test is not useful. When used in conjunction with PET/MRI/skeletal survey as well as blood/urine analyses, they together do give a very comprehensive look into disease status, or lack thereof.
Last edited by dnalex on Wed Aug 13, 2014 2:19 pm, edited 1 time in total.
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dnalex - Name: Alex N.
- Who do you know with myeloma?: mother
- When were you/they diagnosed?: 2007
- Age at diagnosis: 56
Re: Why do bone marrow biopsy?
Lillyput,
If you have multiple lytic lesions, you are symptomatic and require treatment. It doesn't matter what your plasma cell % is if you have one or more CRAB symptoms.
But keep in mind that the various tests you get when you have a bone marrow biopsy also tells you a lot more info about the disease than just the plasma cell percentage. You also get key information about your cytogenetics, immunophenotype, etc. This is all key information to know wrt prognosis and the selection of drugs for treatment.
If you have multiple lytic lesions, you are symptomatic and require treatment. It doesn't matter what your plasma cell % is if you have one or more CRAB symptoms.
But keep in mind that the various tests you get when you have a bone marrow biopsy also tells you a lot more info about the disease than just the plasma cell percentage. You also get key information about your cytogenetics, immunophenotype, etc. This is all key information to know wrt prognosis and the selection of drugs for treatment.
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Multibilly - Name: Multibilly
- Who do you know with myeloma?: Me
- When were you/they diagnosed?: Smoldering, Nov, 2012
Re: Why do bone marrow biopsy?
I asked this question on behalf of a woman I met in the doctor's office, who is now a friend.
She was very upset at what the doc had told her.
She is 60 years old and had SPEP, Freelite tests, skeletal survey - all the usual tests one would have. Then she was told she needed a bone marrow biopsy. On the day I met her, she had received her biopsy results with the doctor telling her she only had 5% cells and didn't need treatment.
I was confused along with her because she has a high IgM, abnormal light chains, and her skeletal survey showed the lytic lesions. When she asked him why the biopsy was "normal" when she had all the other symptoms, he told her maybe the lytic lesions were something else and/or the blood tests were wrong. She is in the process of having her blood redone.
Seems strange to me.
She was very upset at what the doc had told her.
She is 60 years old and had SPEP, Freelite tests, skeletal survey - all the usual tests one would have. Then she was told she needed a bone marrow biopsy. On the day I met her, she had received her biopsy results with the doctor telling her she only had 5% cells and didn't need treatment.
I was confused along with her because she has a high IgM, abnormal light chains, and her skeletal survey showed the lytic lesions. When she asked him why the biopsy was "normal" when she had all the other symptoms, he told her maybe the lytic lesions were something else and/or the blood tests were wrong. She is in the process of having her blood redone.
Seems strange to me.
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Lillyput189 - Who do you know with myeloma?: Self
- When were you/they diagnosed?: MGUS 2011, multiple myeloma 2014
- Age at diagnosis: 54
Re: Why do bone marrow biopsy?
Sounds like she needs a new doctor.
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kjpoppit - Name: Kim Nelson
- Who do you know with myeloma?: Me
- When were you/they diagnosed?: Sept. 19th, 2013
- Age at diagnosis: 47
Re: Why do bone marrow biopsy?
Thanks everyone for your replies.
MB, I don't think she'll redo the biopsy as she had a lot of pain (so did I even with 5 vials of lidocaine & tramadol on board). Perhaps the other info gleaned from the biopsy will be enough for a new doc (cytogenics?). I agree she needs to get started with treatment. Thanks as always for your input.
MB, I don't think she'll redo the biopsy as she had a lot of pain (so did I even with 5 vials of lidocaine & tramadol on board). Perhaps the other info gleaned from the biopsy will be enough for a new doc (cytogenics?). I agree she needs to get started with treatment. Thanks as always for your input.
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Lillyput189 - Who do you know with myeloma?: Self
- When were you/they diagnosed?: MGUS 2011, multiple myeloma 2014
- Age at diagnosis: 54
Re: Why do bone marrow biopsy?
My bone marrow biopsies never really showed anything abnormal. Nevertheless, I have multiple myeloma and have undergone treatment including a SCT. The results of my light chain assay were the key to my diagnosis. In my opinion, it's time for her to find another doctor that is either a myeloma specialist or is much more familiar with this disease than the one that made her diagnosis.
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Blackbird - Name: Rick Crow
- Who do you know with myeloma?: Me
- When were you/they diagnosed?: Feb, 2013
- Age at diagnosis: 53
Re: Why do bone marrow biopsy?
This is an excellent question. The statement from the UAMS is correct - myeloma can be focal disease. So, bone marrows are not perfect.
However, bone marrow biopsies are critical for a number reasons:
1) They do give the best representative look into the bone marrow (site of disease) and percent bone marrow plasmacytosis. As you all know, the percent plasma cells has bearing on initial diagnosis (MGUS, smoldering myeloma, and evolving definitions such as ultra high risk smoldering myeloma with >60% PCs (or maybe >50%)).
2) In patients with non-secretory or oligosecretory disease, it may be the only (or best) marker of disease burden and therefore response.
3) Important risk stratifying information is garnered from the BMPCs:
i) Metaphase cytogenetics,
ii) FISH
iii) GEP (MyPRS)
Moreover, as technology continues to expand, more information will be gathered (for example, genome sequencing, targeted or whole).
4) Follow-up bone marrows are required to assess response (to have a CR or stringent CR, the bone marrow biopsy must be "clear" of clonal plasma cells).
5) With relapse, the reasons above are still important, plus biopsies give us an idea of how the disease may be changing over time (evolving so to speak). Though at relapse, the merits of a bone marrow biopsy must be weighed against the need for therapy (acuity), and patient and MD factors (i.e. not every relapse requires a marrow biopsy).
Personally, we hope that we can use this and additional information to create better algorithms for personalized care. For instance, at Moffitt (and I am sure elsewhere), we are working with our mathematical colleagues in capturing subsequent bone marrows to quantify the evolution of drug response using different aspects of the bone marrow (looking at the myeloma cells as well as the change in the other cells as well, or tumor microenvironment). We are not yet making clinical decisions based on these findings, but will hopefully open a clinical trial soon to ask the question: Can we?
So there is a lot of information to be collected from a marrow. Easy for me to say - I am not being stuck in the butt (posterior superior iliac spine).
However, bone marrow biopsies are critical for a number reasons:
1) They do give the best representative look into the bone marrow (site of disease) and percent bone marrow plasmacytosis. As you all know, the percent plasma cells has bearing on initial diagnosis (MGUS, smoldering myeloma, and evolving definitions such as ultra high risk smoldering myeloma with >60% PCs (or maybe >50%)).
2) In patients with non-secretory or oligosecretory disease, it may be the only (or best) marker of disease burden and therefore response.
3) Important risk stratifying information is garnered from the BMPCs:
i) Metaphase cytogenetics,
ii) FISH
iii) GEP (MyPRS)
Moreover, as technology continues to expand, more information will be gathered (for example, genome sequencing, targeted or whole).
4) Follow-up bone marrows are required to assess response (to have a CR or stringent CR, the bone marrow biopsy must be "clear" of clonal plasma cells).
5) With relapse, the reasons above are still important, plus biopsies give us an idea of how the disease may be changing over time (evolving so to speak). Though at relapse, the merits of a bone marrow biopsy must be weighed against the need for therapy (acuity), and patient and MD factors (i.e. not every relapse requires a marrow biopsy).
Personally, we hope that we can use this and additional information to create better algorithms for personalized care. For instance, at Moffitt (and I am sure elsewhere), we are working with our mathematical colleagues in capturing subsequent bone marrows to quantify the evolution of drug response using different aspects of the bone marrow (looking at the myeloma cells as well as the change in the other cells as well, or tumor microenvironment). We are not yet making clinical decisions based on these findings, but will hopefully open a clinical trial soon to ask the question: Can we?
So there is a lot of information to be collected from a marrow. Easy for me to say - I am not being stuck in the butt (posterior superior iliac spine).
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Dr. Ken Shain - Name: Ken Shain, M.D., Ph.D.
Beacon Medical Advisor
Re: Why do bone marrow biopsy?
To the question about your friend and no treatment. Depending on the nature of the single lytic lesion, some surveys identify venous lakes within the calvarium [upper skull] or bone cysts that are not related to multiple myeloma and, therefore, she would not be defined as active multiple myeloma from the perspective of a skeletal event. It sounds like IgM MGUS. She will be followed every 6 (at least) and annual bone surveys to assess for changes.
If there is a question, seeing a multiple myeloma expert is always the correct answer, but she sounds safe at this point.
If there is a question, seeing a multiple myeloma expert is always the correct answer, but she sounds safe at this point.
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Dr. Ken Shain - Name: Ken Shain, M.D., Ph.D.
Beacon Medical Advisor
Re: Why do bone marrow biopsy?
Dr Shain,
Thank you for your replies. I just wanted to clarify that my friend has multiple lytic lesions - spine, femur & ribs. You mentioned a single lytic lesion, so I wanted to be sure we are clear on that subject.
Thanks again!
Thank you for your replies. I just wanted to clarify that my friend has multiple lytic lesions - spine, femur & ribs. You mentioned a single lytic lesion, so I wanted to be sure we are clear on that subject.
Thanks again!
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Lillyput189 - Who do you know with myeloma?: Self
- When were you/they diagnosed?: MGUS 2011, multiple myeloma 2014
- Age at diagnosis: 54
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