Consensus recommendations for standard investigative workup: report of the International Myeloma Workshop Consensus Panel 3

Abstract

IntroductionThe plasma cell proliferative disorders are characterized by the proliferation of a single clone of plasma cells in the bone marrow and by the production of monoclonal immunoglobulins. These disorders may range from a phenotypically benign entity, monoclonal gammopathy of undetermined significance, to symptomatic myeloma with bone destruction, suppression of bone marrow function, and renal damage. The International Myeloma Working Group has established criteria for the diagnosis of plasma cell proliferative disorders. These test criteria have been adopted and/or slightly modified by other groups and are shown in Table 1. [1][2][3] In everyday practice, there is still some confusion regarding the use of standard laboratory tests that evaluate serum and urine monoclonal proteins. Furthermore, a new test, serum-free light measurement, has emerged. Over the last decade, newer imaging techniques, such as magnetic resonance imaging (MRI) and positron emission tomography-computed tomography (PET-CT), are increasingly used in the assessment of patients with multiple myeloma. In this paper, we report International Myeloma Working Group Consensus Panel recommendations for the minimal diagnostic and prognostic tests, the follow-up investigation after therapy, and the tests to be performed at relapse for patients with multiple myeloma. The Consensus Panel consisted of several physicians with a research interest in plasma cell dyscrasias who held several teleconferences, and their recommendations were presented during the 2009 International Myeloma Workshop. Minimal diagnostic and prognostic testsInitial investigation of a patient with suspected multiple myeloma should include the tests shown in Table 2. Family history should focus on first-degree relatives with the diagnosis of hematologic malignancies, especially lymphoma, chronic lymphocytic leukemia, and plasma cell dyscrasias. Past medical history should focus on comorbid conditions that may affect treatment decisions, such as coronary artery disease, congestive heart failure, hypertension, renal disorders, liver disorders, and lung diseases. A complete blood count with differential should be ordered, and a peripheral blood smear should be evaluated in search of specific findings, such as rouleaux formation and circulating plasma cells. A complete biochemistry screen should be ordered, which includes liver function tests, renal function tests, electrolytes, calcium, and albumin.Both serum and urine should be assessed for monoclonal protein. Agarose gel electrophoresis or capillary zone electrophoresis of serum and urine is preferred to screen for the presence of monoclonal protein. However, quantitation of serum immunoglobulins by nephelometry should also be performed. Measurement of monoclonal protein both by densitometer tracing and by nephelometric quantitation is recommended. These 2 tests are complementary, and nephelometric quantitation may be particularly useful for low levels of uninvolved immunoglobulins. 4 However, it should be

Prognostic significance of bone marrow abnormalities in the appendicular skeleton of patients with multiple myeloma

“…Baseline laboratory studies and bone marrow studies were performed according to the recommendations of the IMWG. 10 Circulating PCs were quantified using 6-color flow cytometry after August 2014, as previously reported. 11 Five patients were excluded from the analysis due to the unavailability of MDCT.…”

Combined light chain immunofixation to detect monoclonal gammopathy: a comparison to standard electrophoresis in serum and urine

“…This was consistent in both serum and urine specimens and in both new patients investigated de novo and in known patients whose therapeutic responses were monitored. This was expected as CLIF is a modified immunofixation procedure which has a superior detection limit for monoclonal immunoglobulins [1,2,7]. Our finding that 22.1% ± 6.7% (95% CI) of monoclonal immunoglobulins were not detected with a standard PE in the serum of newly investigated patients were similar to the report by Eisele et al (27.3% ± 6.8%) who used a screening immunofixation procedure with antisera directed against a mixture of both heavy and light chains [7].…”

“…Brought to you by | University of Queensland -UQ Library Authenticated Download Date | 9/21/15 2:58 AM required at least a subsequent IFE to assist in classifying the therapeutic response [1,2]. The reduction in IFE procedures in this patient group after implementation of CLIF partially explained the improved TATs and decreased usage of IFE consumables.…”

“…The laboratory contribution to the diagnosis and monitoring of plasma cell proliferative disorders largely depends on the electrophoretic demonstration of a monoclonal immunoglobulin in serum and/or urine [1,2]. Protein electrophoresis (PE) separates the constituent proteins according to charge with most immunoglobulins migrating to the anodal or γ-region on agarose gel or capillary zone electrophoresis.…”

“…The mere presence of a monoclonal immunoglobulin is also not diagnostic of malignancy as implied by the aptly named monoclonal gammopathy of uncertain significance (MGUS) which constitutes the majority of newly identified cases with a monoclonal immunoglobulin in serum [5,6]. Thus the detection of small bands below the detection limit of PE with an analytically more sensitive technique such as IFE is not routinely performed in new patients unless there is a specific clinical suspicion of multiple myeloma or a related disorder [1,2,7].…”