Hello everyone,
New member (who's been lurking since early May)!
A brief overview: At a trip to my ortho (badly damaged neck from a 20 year old sports injury), he suggested seeing a neurologist for new symptoms, and she in turn did labs among other tests which found an M-spike, thus sending me to a hematologist-oncologist. I had a month wait for my first appointment and in that time he did more labs and a 24-hour urine. He was prepared to diagnose me with straightforward MGUS until a new back pain sent me to my primary who sent me for a chest and a thoracic spine x-ray, which showed a small compression fracture at T7.
When I finally saw the oncologist, he said the game may have changed and sent me for a metastatic x-ray series, a DEXA scan, an MRI and a bone marrow biopsy.
The second x-ray showed a 15 millimeter lytic lesion at T7 and an 8 millimeter lucent lesion on my left wrist. The MRI then showed not only no lesion in my spine but also no fracture.
He says he isn't sure about my wrist and wants to wait and see. He did no further imaging of this possible lesion. His thinking is that, since my labs are mostly normal, my M-spike small, my bone marrow biopsy shows few abnormal cells, and my DEXA shows only some osteopenia in my hips, that we watch it and see.
My concern is that, having done my homework, a single lesion with an M-spike, even with low to no level plasmas and proteins, can be a plasmacytoma. But as the larger lesion seen in the x-ray proved nonexistent, this may be as well.
I return to him the first week of November, which will be the six month mark since first labs were done (it took two months of waiting to see him twice to get definitive a MGUS diagnosis).
So my question is: Do I wait four months and readdress my wrist then, or seek a second opinion now?
As my diagnosis seemed pretty straightforward, I figured I could use a small break from 10 weeks of endless hospital visits/tests and wait til fall to visit Dana Farber, but now I'm uncertain. Is this matter super pressing, or can it safely wait just under four months? Opinions, please?
In an attempt to keep my posts manageably short, I'll post my initial lab results separately.
Thank you very much!
Victoria
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4 posts
• Page 1 of 1
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lonely artist - Name: Victoria Adams
- Who do you know with myeloma?: myself with MGUS
- When were you/they diagnosed?: June 2017
- Age at diagnosis: 53
Re: Possible plasmacytoma on wrist: can it wait?
Here are my labs. I really don't know if I should wait on the possible wrist lesion or not based on these results. Thank you SO much in advance!
M-spike 0.65 g/dL 0 g/dL
PEP Interp: An abnormal band is seen in the gamma region.
IgG 1356 mg/dL 751 - 1560 mg/dL
IgA 140 mg/dL 82 - 453 mg/dL
IgM 146 mg/dL 46 - 304 mg/dL
Kappa Free Light Chain 11.5 mg/L 3.3 - 19.4 mg/L
Lambda Free Light Chain 17.4 mg/L 5.7 - 26.3 mg/L
Kappa-Lambda FLC Ratio 0.66 0.26 - 1.65
Interpretation: M component of IgG lambda
Protein, timed urine (mg/24hr) 75 mg/24 h <167 mg/24 h
Collection Duration: 24 h h
Urine Volume: 2500 mL mL
Protein, Timed Ur (mg/dL) 3 mg/dL mg/dL
Albumin 100 % %
A1 Globulin (%), Timed Urine Test component not applicable or not reported.
Alpha 2-Globulin Test component not applicable or not reported.
Beta-Globulin Test component not applicable or not reported.
Gamma-Globulin Test component not applicable or not reported.
A/G Ratio Test component not applicable or not reported.
M Spike Test component not applicable or not reported.
M Spike Test component not applicable or not reported.
NOTE: Albumin is the only protein detected.
IMMUNOFIXATION, U No monoclonal protein detected.
Specimen Type: Bone Marrow:
NO DEFINITE EVIDENCE FOR MYELOMA DETECTED
Comments:
Cytoplasmic light chain studies demonstrate polytypic light chain expression. Sampling is not excluded. Please correlate with a good aspirate smear, marrow histology and clinicoradiologic findings.
Flow Differential (%) and Population Analysis:Lymphocytes: 17.5%T cells in this region are 72%. CD4 to CD8 ratio is 3. NK cells are 15% and large granular lymphocytes are 1%. B cells are 6%, polytypic. Monocytes: 3.2% Immunoreactivity for CD56 is detected. Granulocytes: 77.2% Findings are suggestive of peripheral dilution. CD45 Dim: 0.7% 0.2% are CD34 positive blasts. CD45 Neg: 1.4% Plasma Cells: 0.06% Cytoplasmic light chain studies demonstrate an overall kappa to lambda ratio of 1.2. Markers Performed:CD2, CD3, CD4, CD5, CD7, CD8, CD10, CD11c, CD13, CD14, CD16, CD19, CD20, CD23, CD33, CD34, CD38, CD45, CD56, CD64, CD117, CD138, cKappa, cLambda, HLA-DR, Kappa, Lambda (27 Markers)
Surgical Pathology Report
FINAL PATHOLOGIC DIAGNOSIS:
A, B, C. BONE MARROW CORE BIOPSY, CLOT SECTION AND ASPIRATE SMEAR:
Normocellular marrow with complete erythroid and myeloid maturation.
Unremarkable megakaryocytes present.
Markedly decreased to absent iron stores.
NOTE: The bone marrow biopsy is adequate for evaluation. The marrow cellularity is overall approximately 40%. The myeloid to erythroid ratio is normal. Myeloid maturation is complete. Erythroid maturation is complete. Megakaryocytes are adequate in number with overall normal morphology. No lymphoid aggregates or plasma cell infiltrates are seen in the routine stained sections. A reticulin stain (with a control showing appropriate reactivity) shows normal to mildly increased but thin reticulin fibers with no evidence of fibrosis or focal lesions seen. Immunostains show few, scattered CD20 positive small B-cells and slightly more numerous but also scattered CD3 positive small T-cells. A CD138 immunostain shows only few, scattered positive staining plasma cells (less than 5%).
The clot sections are scant but adequate for evaluation, and show similar findings. The myeloid to erythroid ratio is normal. Myeloid maturation is complete. Erythroid maturation is complete. Megakaryocytes are adequate in number with overall normal morphology. No lymphoid aggregates or plasma cell infiltrates are seen in the routine stained sections. Immunostains show few, scattered CD20 positive small B-cells and slightly more numerous but also scattered CD3 positive small T-cells. A CD138 immunostain shows only few, scattered positive staining plasma cells (less than 5%).
The aspirate smear and touch prep slides are adequate for evaluation. A 500 cell count reveals: 56.3% neutrophils and precursors; 23.1% erythroid precursors; 13.9% lymphocytes; 1.3% monocytes; 2.6% eosinophils; 0% basophils; 0% promyelocytes; 0.9% blasts; and 1.9% plasma cells. Myeloid maturation is normal. Erythroid maturation is normal. Megakaryocytes are present and appear normal. An iron stain (with a control showing appropriate reactivity) shows markedly
decreased to absent iron stores. Ring sideroblasts are absent.
Flow cytometric immunophenotyping studies performed on a sample of bone marrow at NeoGeomics laboratories are reported as showing no definite evidence for myeloma detected with cytoplasmic light chain studies demonstrating polytypic light chain expression. Cytogenetic studies and FISH molecular studies sent to NeoGeomics are pending and will be reported separately.
In summary, no specific pathologic changes are seen in the histologic sections, immunostained sections, aspirate smear or flow cytometry studies. Follow-up with cytogenetic and FISH studies is recommended.
IHC Summary: Immunostains performed on block A1 for CD138, CD20, CD3. Immunostains performed on block B1 for CD138, CD20, CD3.
M-spike 0.65 g/dL 0 g/dL
PEP Interp: An abnormal band is seen in the gamma region.
IgG 1356 mg/dL 751 - 1560 mg/dL
IgA 140 mg/dL 82 - 453 mg/dL
IgM 146 mg/dL 46 - 304 mg/dL
Kappa Free Light Chain 11.5 mg/L 3.3 - 19.4 mg/L
Lambda Free Light Chain 17.4 mg/L 5.7 - 26.3 mg/L
Kappa-Lambda FLC Ratio 0.66 0.26 - 1.65
Interpretation: M component of IgG lambda
Protein, timed urine (mg/24hr) 75 mg/24 h <167 mg/24 h
Collection Duration: 24 h h
Urine Volume: 2500 mL mL
Protein, Timed Ur (mg/dL) 3 mg/dL mg/dL
Albumin 100 % %
A1 Globulin (%), Timed Urine Test component not applicable or not reported.
Alpha 2-Globulin Test component not applicable or not reported.
Beta-Globulin Test component not applicable or not reported.
Gamma-Globulin Test component not applicable or not reported.
A/G Ratio Test component not applicable or not reported.
M Spike Test component not applicable or not reported.
M Spike Test component not applicable or not reported.
NOTE: Albumin is the only protein detected.
IMMUNOFIXATION, U No monoclonal protein detected.
Specimen Type: Bone Marrow:
NO DEFINITE EVIDENCE FOR MYELOMA DETECTED
Comments:
Cytoplasmic light chain studies demonstrate polytypic light chain expression. Sampling is not excluded. Please correlate with a good aspirate smear, marrow histology and clinicoradiologic findings.
Flow Differential (%) and Population Analysis:Lymphocytes: 17.5%T cells in this region are 72%. CD4 to CD8 ratio is 3. NK cells are 15% and large granular lymphocytes are 1%. B cells are 6%, polytypic. Monocytes: 3.2% Immunoreactivity for CD56 is detected. Granulocytes: 77.2% Findings are suggestive of peripheral dilution. CD45 Dim: 0.7% 0.2% are CD34 positive blasts. CD45 Neg: 1.4% Plasma Cells: 0.06% Cytoplasmic light chain studies demonstrate an overall kappa to lambda ratio of 1.2. Markers Performed:CD2, CD3, CD4, CD5, CD7, CD8, CD10, CD11c, CD13, CD14, CD16, CD19, CD20, CD23, CD33, CD34, CD38, CD45, CD56, CD64, CD117, CD138, cKappa, cLambda, HLA-DR, Kappa, Lambda (27 Markers)
Surgical Pathology Report
FINAL PATHOLOGIC DIAGNOSIS:
A, B, C. BONE MARROW CORE BIOPSY, CLOT SECTION AND ASPIRATE SMEAR:
Normocellular marrow with complete erythroid and myeloid maturation.
Unremarkable megakaryocytes present.
Markedly decreased to absent iron stores.
NOTE: The bone marrow biopsy is adequate for evaluation. The marrow cellularity is overall approximately 40%. The myeloid to erythroid ratio is normal. Myeloid maturation is complete. Erythroid maturation is complete. Megakaryocytes are adequate in number with overall normal morphology. No lymphoid aggregates or plasma cell infiltrates are seen in the routine stained sections. A reticulin stain (with a control showing appropriate reactivity) shows normal to mildly increased but thin reticulin fibers with no evidence of fibrosis or focal lesions seen. Immunostains show few, scattered CD20 positive small B-cells and slightly more numerous but also scattered CD3 positive small T-cells. A CD138 immunostain shows only few, scattered positive staining plasma cells (less than 5%).
The clot sections are scant but adequate for evaluation, and show similar findings. The myeloid to erythroid ratio is normal. Myeloid maturation is complete. Erythroid maturation is complete. Megakaryocytes are adequate in number with overall normal morphology. No lymphoid aggregates or plasma cell infiltrates are seen in the routine stained sections. Immunostains show few, scattered CD20 positive small B-cells and slightly more numerous but also scattered CD3 positive small T-cells. A CD138 immunostain shows only few, scattered positive staining plasma cells (less than 5%).
The aspirate smear and touch prep slides are adequate for evaluation. A 500 cell count reveals: 56.3% neutrophils and precursors; 23.1% erythroid precursors; 13.9% lymphocytes; 1.3% monocytes; 2.6% eosinophils; 0% basophils; 0% promyelocytes; 0.9% blasts; and 1.9% plasma cells. Myeloid maturation is normal. Erythroid maturation is normal. Megakaryocytes are present and appear normal. An iron stain (with a control showing appropriate reactivity) shows markedly
decreased to absent iron stores. Ring sideroblasts are absent.
Flow cytometric immunophenotyping studies performed on a sample of bone marrow at NeoGeomics laboratories are reported as showing no definite evidence for myeloma detected with cytoplasmic light chain studies demonstrating polytypic light chain expression. Cytogenetic studies and FISH molecular studies sent to NeoGeomics are pending and will be reported separately.
In summary, no specific pathologic changes are seen in the histologic sections, immunostained sections, aspirate smear or flow cytometry studies. Follow-up with cytogenetic and FISH studies is recommended.
IHC Summary: Immunostains performed on block A1 for CD138, CD20, CD3. Immunostains performed on block B1 for CD138, CD20, CD3.
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lonely artist - Name: Victoria Adams
- Who do you know with myeloma?: myself with MGUS
- When were you/they diagnosed?: June 2017
- Age at diagnosis: 53
Re: Possible plasmacytoma on wrist: can it wait?
Hi Victoria,
I don't think you need to be too nervous about waiting until your appointment in four months (which will be with a myeloma specialist, right?)
I'm not a doctor, but if I recall correctly, it's unusual for myeloma-related lesions to occur in places like hands and feet. They tend to occur more centrally in the body. It's not impossible for lesions to be in the hands and feet; but it's less likely.
Also, your M-spike is not high, and your free light chain ratio is within the normal range, suggesting you do not have much of a disease burden.
What is are your hemoglobin and calcium levels? They might give you additional information about what sort of disease burden you have.
The one thing I would suggest doing in your situation is to have one or two more sets of myeloma-related blood tests prior to your appointment in four months. I would want to track things like your M-spike, free light chain levels and ratio, hemoglobin, and calcium levels to make sure they are staying reasonably constant.
If you do have additional testing done in the next few months, it would be a good idea to have it done at the same lab(s) where you had your original testing done, just to ensure the results are comparable. There can be differences between laboratories, and you don't want that sort of variation stressing you in the lead up to your appointment in four months.
Best of luck to you, and please keep us posted on what you find out.
I don't think you need to be too nervous about waiting until your appointment in four months (which will be with a myeloma specialist, right?)
I'm not a doctor, but if I recall correctly, it's unusual for myeloma-related lesions to occur in places like hands and feet. They tend to occur more centrally in the body. It's not impossible for lesions to be in the hands and feet; but it's less likely.
Also, your M-spike is not high, and your free light chain ratio is within the normal range, suggesting you do not have much of a disease burden.
What is are your hemoglobin and calcium levels? They might give you additional information about what sort of disease burden you have.
The one thing I would suggest doing in your situation is to have one or two more sets of myeloma-related blood tests prior to your appointment in four months. I would want to track things like your M-spike, free light chain levels and ratio, hemoglobin, and calcium levels to make sure they are staying reasonably constant.
If you do have additional testing done in the next few months, it would be a good idea to have it done at the same lab(s) where you had your original testing done, just to ensure the results are comparable. There can be differences between laboratories, and you don't want that sort of variation stressing you in the lead up to your appointment in four months.
Best of luck to you, and please keep us posted on what you find out.
-
JimNY
Re: Possible plasmacytoma on wrist: can it wait?
Thank you for the wise words, JimNY.
My oncologist isn't a multiple myeloma specialist, though he has coauthored a paper on Waldenstrom's. He's the hematology oncologist my neurologist sent me to when the M-spike was discovered in labs in May. I had planned, if diagnosed with multiple myeloma, to make a lateral move to specialists here in Boston. I also thought that perhaps I would move there sooner for a second opinion, but your advice to have back to back test results from the same lab makes a lot of sense. That hadn't occurred to me. I go in the week before my next appointment to redo my labs, so he'll have them already reviewed for that meeting.
Here are my CBC and metabolic panel results from June.
WBC 6.25 K/uL 4.0-11.0 K/uL
RBC 4.87 M/uL 3.9-5.03 M/uL
HGB 14.2 g/dL 12-15.5 g/dL
HCT 41.0 % 34.9-44.5 %
PLT 250 K/uL 135-400 K/uL
MCV 84.2 fL 80-100 fL
MCH 29.2 pg 27-34 pg
MCHC 34.6 g/dL 31.5-36.5 g/dL
RDW 12.4 % 11.9-14.8 %
MPV 9.8 fl 9.6-12 fl
NRBC 0/100 WBCs 0/100 WBCs
DIFF METHOD Auto
NEUTS 60.3 % %
LYMPHS 32.5 % %
MONOS 5.4 % %
EOS 1.0 % %
BASOS 0.6 % %
Gran, immature 0.2 % 0-0.9 %
ABSOLUTE NEUTS 3.77 K/uL 1.8-7.5 K/uL
ABSOLUTE LYMPHS 2.03 K/uL 1-4.8 K/uL
ABSOLUTE MONOS 0.34 K/uL 0.1-0.9 K/uL
ABSOLUTE EOS 0.06 K/uL 0-0.4 K/uL
ABSOLUTE BASOS 0.04 K/uL 0-0.2 K/uL
Gran, immature 0.01 K/uL 0-0.1 K/uL
SODIUM 140 mmol/L 136-145 mmol/L
POTASSIUM 4.2 mmol/L 3.5-5.2 mmol/L
CHLORIDE 98 mmol/L 95-106 mmol/L
CO2 28 mmol/L 20-31 mmol/L
BUN 11 mg/dL 9-23 mg/dL
CREATININE 0.67 mg/dL 0.50-1.30 mg/dL
GLUCOSE 78 mg/dL 74-106 mg/dL
ALBUMIN 4.2 g/dL 3.5-4.8 g/dL
TOTAL PROTEIN 7.0 g/dL 5.7-8.2 g/dL
CALCIUM 9.4 mg/dL 8.7-10.4 mg/dL
ALK. PHOS. 89 U/L 27-129 U/L
TOTAL BILIRUBIN 0.4 mg/dL 0.0-1.0 mg/dL
AST 14 U/L 6-40 U/L
ALT (U/L) 13 U/L 10-49 U/L
GLOBULIN 2.8 g/dL 1.9-4.1 g/dL
EGFR >60 mL/min/1.73m2 (>60)
ANION GAP 14 mmol/L 3-17 mmol/L
Thank you again for your thoughts on this. I very much appreciate it! Take care,
Victoria
My oncologist isn't a multiple myeloma specialist, though he has coauthored a paper on Waldenstrom's. He's the hematology oncologist my neurologist sent me to when the M-spike was discovered in labs in May. I had planned, if diagnosed with multiple myeloma, to make a lateral move to specialists here in Boston. I also thought that perhaps I would move there sooner for a second opinion, but your advice to have back to back test results from the same lab makes a lot of sense. That hadn't occurred to me. I go in the week before my next appointment to redo my labs, so he'll have them already reviewed for that meeting.
Here are my CBC and metabolic panel results from June.
WBC 6.25 K/uL 4.0-11.0 K/uL
RBC 4.87 M/uL 3.9-5.03 M/uL
HGB 14.2 g/dL 12-15.5 g/dL
HCT 41.0 % 34.9-44.5 %
PLT 250 K/uL 135-400 K/uL
MCV 84.2 fL 80-100 fL
MCH 29.2 pg 27-34 pg
MCHC 34.6 g/dL 31.5-36.5 g/dL
RDW 12.4 % 11.9-14.8 %
MPV 9.8 fl 9.6-12 fl
NRBC 0/100 WBCs 0/100 WBCs
DIFF METHOD Auto
NEUTS 60.3 % %
LYMPHS 32.5 % %
MONOS 5.4 % %
EOS 1.0 % %
BASOS 0.6 % %
Gran, immature 0.2 % 0-0.9 %
ABSOLUTE NEUTS 3.77 K/uL 1.8-7.5 K/uL
ABSOLUTE LYMPHS 2.03 K/uL 1-4.8 K/uL
ABSOLUTE MONOS 0.34 K/uL 0.1-0.9 K/uL
ABSOLUTE EOS 0.06 K/uL 0-0.4 K/uL
ABSOLUTE BASOS 0.04 K/uL 0-0.2 K/uL
Gran, immature 0.01 K/uL 0-0.1 K/uL
SODIUM 140 mmol/L 136-145 mmol/L
POTASSIUM 4.2 mmol/L 3.5-5.2 mmol/L
CHLORIDE 98 mmol/L 95-106 mmol/L
CO2 28 mmol/L 20-31 mmol/L
BUN 11 mg/dL 9-23 mg/dL
CREATININE 0.67 mg/dL 0.50-1.30 mg/dL
GLUCOSE 78 mg/dL 74-106 mg/dL
ALBUMIN 4.2 g/dL 3.5-4.8 g/dL
TOTAL PROTEIN 7.0 g/dL 5.7-8.2 g/dL
CALCIUM 9.4 mg/dL 8.7-10.4 mg/dL
ALK. PHOS. 89 U/L 27-129 U/L
TOTAL BILIRUBIN 0.4 mg/dL 0.0-1.0 mg/dL
AST 14 U/L 6-40 U/L
ALT (U/L) 13 U/L 10-49 U/L
GLOBULIN 2.8 g/dL 1.9-4.1 g/dL
EGFR >60 mL/min/1.73m2 (>60)
ANION GAP 14 mmol/L 3-17 mmol/L
Thank you again for your thoughts on this. I very much appreciate it! Take care,
Victoria
-
lonely artist - Name: Victoria Adams
- Who do you know with myeloma?: myself with MGUS
- When were you/they diagnosed?: June 2017
- Age at diagnosis: 53
4 posts
• Page 1 of 1