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Multiple Myeloma

Multiple Myeloma. Dr. Edward Warren Chair, Geriatrics Carolinas Campus May 2012. Multiple Myeloma Case.

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Multiple Myeloma

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  1. Multiple Myeloma Dr. Edward Warren Chair, Geriatrics Carolinas Campus May 2012

  2. Multiple Myeloma Case • A 62 old man presents to you for yearly screening. Generally he has been doing well, but does note some fatigue which he describes as minimal and due to not sleeping well. He denies any weight loss or fevers. • Current problems • Hypercholesterolemia • Mild osteoarthritis knees • Medicines • Aspirin 81 mg • Zocor 40mg • ROS no weight loss, fever, cough, or musculoskeletal pain. Positive for fatigue.

  3. Multiple Myeloma Case • Physical exam is positive for mild mitral insufficiency. • Past medical history update unchanged • Family history update brother 72 died heart attack. • You take labs for his cholesterol which include a • Comprehensive metabolic profile • Cholesterol profile ( Fasting lipids) • Labs for fatigue • Complete blood count (CBC) • Thyroid function test (TSH)

  4. Follow up • You instruct the patient that you will send a letter with his labs and appropriate follow up. • Instruct him that if his fatigue is not better in 1 month or worsens (including new symptoms) to set up a return appointment sooner than 2 months (or 2 weeks for changes).

  5. TEST result Normals • Serum TSH 2.5 0.5-6 uU/ml

  6. His labs return with a moderate anemia (hemoglobin 7.8g/dl ) and elevated globulin 5.2 g/dl

  7. Question 1 With the above lab values what other tests would you now order. • Bone scan to evaluate possible skeletal involvement. • Iron studies to evaluate his anemia for possible iron deficiency. • Serum and urine protein electrophoresis to evaluate the high globulin. • MRI to evaluate possible spinal involvement. • Blood cultures to access infection.

  8. Multiple Myeloma Case • You bring back the patient and obtain a comprehensive metabolic profile and a serum and urine protein electrophoresis. • The results are as follows.

  9. Urine protein electrophoresis

  10. The serum protein electrophoresis (SPE)

  11. Serum Protein Electrophoresis The interpretation of this SPE was decreased prealbumin, albumin, alpha-2, and gamma globulins; and a paraprotein spike of approximately 4.3 g/dL detected in the beta region.

  12. Comprehensive Metabolic Profile

  13. Serum immunofixation electrophoresis identified the beta region paraprotein as a monoclonal IgD/lambda.

  14. Question 2 With the above studies what tests would be inappropriate to order. • Bone marrow biopsy. • Skeletal survey • Cytogenetic analysis of the bone marrow • EKG to evaluate electrolyte abnormalities on the heart.

  15. Bone Marrow Evaluation

  16. Bone Marrow Evaluation • Given the presence of 13% blasts in the peripheral blood smear, and new evidence of a significant IgDparaprotein, a bone marrow biopsy and aspirate were performed to evaluate the patient's hematopoietic status. • The bone marrow aspirate showed numerous blastic appearing plasmacytoid cells with prominent nucleoli and variable amounts of basophilic cytoplasm. Overall, the bone marrow biopsy was hypercellular and almost completely replaced by a diffuse proliferation of large cells.

  17. Skeletal Survey Skeletal survey reveals generalized osteopenia and a questionable lytic lesion in the femur.

  18. Question 3 With the above material your diagnosis would be: • Waldenstrom’smacroglobulinemia • Monoclonal gammopathy of unknown significance • Plasmacytoma • Multiple myeloma IgD

  19. Staging of Myeloma

  20. Question 4 Your classification of this disease would be. • Stage I • Stage II subclass B • Stage IIIsubclass A • Stage IIsubclass A

  21. Answers • C: Serum and urine electrophoresis. The bone scan is ineffective and it is too early for an MRI. The others have no indication. • A, B, & C: Bone marrow biopsy, cytology and skeletal survey. There is no indication for an EKG. • D: Multiple Myeloma IgD. IgM is needed for Waldenstrom’s, there is no plasmacytoma, and 4.3 gm/dl of IgD is too much for MGUS. There are more than 10% plasma cells. • C: Stage III subclass A. It is not Stage I because the Hgb is too low. It meets one criterion for Stage III (low Hgb), so it is not Stage II.

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