In preparation for the XII International Myeloma Workshop (IMW), physicians have compiled a standardized set of guidelines for diagnosing suspected new or recurrent multiple myeloma. The event will be held in Washington D.C. at the end of February.

Initial investigation of a patient with suspected multiple myeloma should include family and past medical history, blood tests, urine analysis, and bone marrow extraction. Physicians should inquire about any first degree relatives with blood disorders or cancers. Documenting a patient's medical history is important for evaluating which treatments and side effects the patient will best tolerate if multiple myeloma diagnosis is confirmed.

The guidelines advocate that physicians perform a number of blood tests, including but not limited to, complete blood count (CBC) with differential, electrolytes, calcium, and albumin. These tests may reveal irregularities like high numbers of circulating bone marrow plasma cells or abnormal reading levels, which are valuable both in confirming multiple myeloma diagnosis and in staging the disease's severity.

The standard work-up should also include screening for abnormal monoclonal protein levels in the patient's blood serum and urine. This protein, also called "M-protein," is produced by plasma cells in the bone marrow. High M-protein levels in the serum and blood may indicate that these plasma cells have proliferated out of control, as occurs in multiple myeloma. Furthermore, through a process called immunofixation electrophoresis (IFE), laboratories can identify the specific type of elevated M-protein. This information can enable physicians to determine the variant of multiple myeloma present, the severity of disease, and treatment response. In particular, the guidelines recommend that even asymptomatic myeloma patients should undergo serum testing for "light chain" M-proteins because elevated levels may predict those cases that will progress to symptomatic disease.
Suspected multiple myeloma patients should undergo both a bone marrow aspirate and biopsy, which involves extracting samples of the marrow fluid and tissue. High numbers of clonal plasma cells in the aspirate and tissue can verify a suspected multiple myeloma diagnosis. Where physicians highly suspect multiple myeloma, they should also perform a genetic analysis of the abnormal plasma cells. The procedures, known as cytogenetics and FISH, can identify the specific mutations present, which is an important prognostic indicator and can influence treatment decisions.

Where laboratory results indicate or suggest multiple myeloma, full-body X-rays remain the standard for determining bone lesion location and fracture-risk areas, a frequent myeloma complication. In bones harboring the myeloma, lesions of decreased bone density -- often appearing as "punched out" holes -- will frequently appear. The guidelines explicitly require follow-up MRIs, or magnetic resonance imaging, for patients who possess localized, painful skeletal areas. Nevertheless, they strongly recommend MRI for all patients, even those who are currently asymptomatic. Presently, the role of PET-CT scans, which provide a detailed picture of cancer location and activity, remains unproven in the general multiple myeloma patient population.

For confirmed myeloma patients who are undergoing treatment, the guidelines recommend that blood and urine tests continue to monitor for decreases in abnormal protein levels, which can indicate treatment response. Where such tests are unhelpful or inconclusive, MRI may reveal the extent of bone lesion progression or regression. Repeat bone marrow biopsy is usually unnecessary, unless physicians suspect and want to document a "complete response" to treatment. Studies have indicated that complete response may predict longer duration of progression-free and overall survival. In relapsed patients, most of the tests performed at initial diagnosis remain relevant and bear repeating.

A physician panel will present these guidelines at the IMW on February 28, from 8:15 to 10:15 a.m. in the Marriot Wardman Park Hotel Ballroom. For more information about the symposium, visit the International Myeloma Workshop Web site. A copy of the full diagnosis guidelines can be found here (pdf).