Post on 29-Mar-2015
MGUS(interpreting the test you didn’t order)
Family Medicine Review Course 2011Christian Cable, MD, FACP
The Case
What is the laboratory abnormality?
• 10-3 = 7
• What’s in there?
What comprises the blood?
What’s in blood . . .
• Cellular (bone marrow)
– RBCs– Platelets– WBCs
• Plasma (liver)
– Water– Proteins
• Albumin• Antibodies• Clotting factors
Proteins in the Blood?
Brainstorm
• As many “globins” as you can think of . . .
Tell me more about antibodies
What is the correct test?
SPEP/SIEP
• SPEP qualitative (is it there?)• SIEP quantitative (how much, which one?)
Copyright ©2001 American Society of Hematology. Copyright restrictions may apply.
Lazarchick, J. ASH Image Bank 2001;2001:100185
Figure 8. Immunofixation electrophoresis showing a monoclonal IgA lambda light chain restricted band
Gammopa-what?
Greek to me (I) . . .
• Gamma - - region in electrophoretic mobility• Pathy - - disease or condition
Greek to me (II) . . .
• Clonal - - type• Mono - - one• Poly - - many (much)
Differentiate Polyclonal from Monoclonal
“M-spike”
What is normal?
How high?
Polyclonal gammopathy - -significance
• Think of an elevated ESR• What could cause that?
Is polyclonal gammopathy a plasma cell disorder?
Monoclonal gammopathy - -determined significance
New Myeloma Classification
Copyright ©2002 American Society of Hematology. Copyright restrictions may apply.
Schrier, S. ASH Image Bank 2002;2002:100514
Figure 2. This is a bone marrow aspirate from a patient with multiple myeloma showing the abnormal accumulation of malignant plasma cells
Copyright ©2001 American Society of Hematology. Copyright restrictions may apply.
Lazarchick, J. ASH Image Bank 2001;2001:100185
Figure 11. Skull x-ray showing multiple lytic areas
Monoclonal gammopathy - -undetermined significance
Common?
• 3% of population over 50• twice that prevalence African Americans
Defined
• M-spike < 3 g/dL• absence of CRAB symptoms (at least those
attributable to MM) - - tricky with pre-existing renal disease!
• Bone Marrow involvement <10% with clonal plasma cells
How to evaluate
• CBC, Creatinine, Calcium, SPEP/SIEP• Skeletal survey (plain films)
When to refer
Higher risk
• non-Ig G (IgA & Ig M)• African American• total M spike: >1.5 g/dL
Why follow?
• Over 20 years: 1% per year turn into either Multiple Myeloma or another blood cancer
• Double that risk for non-IgG subtypes and African American patients
How do you follow it?
• I’d like to help follow higher risk patients.• Lower risk:
– re-test in 6 months then annually
Our Patient
SPEP
SIEP
1.6 g/dL IgA kappa
Recommendations
• referral• bone marrow biopsy
ccable@swmail.sw.org