eMedicine Specialties > Orthopedic Surgery > Neoplasms

Myeloma: Differential Diagnoses & Workup

Author: Seema S Rizvi, MD, Associate Medical Director, Lutheran Care Center
Coauthor(s): Howard A Chansky, MD, Associate Professor, Department of Orthopedics and Sports Medicine, University of Washington Medical Center
Contributor Information and Disclosures

Updated: May 29, 2009

Differential Diagnoses

Malignant Lymphoma
Metastatic Carcinoma

Other Problems to Be Considered

MGUS
Smoldering MM
Primary amyloidosis
Heavy chain disease
Plasma cell leukemia

Workup

Laboratory Studies

  • The complete blood count (CBC) and differential may show pancytopenia, abnormal coagulation, and an increased erythrocyte sedimentation rate (ESR). The reticulocyte count is typically low.
  • Peripheral blood smears may show Rouleau formation.
  • Chemical screening, including calcium and creatinine SPEP, immunofixation, and immunoglobulin quantitation, may show azotemia, hypercalcemia, an elevated alkaline phosphatase level, and hypoalbuminemia. A high lactic dehydrogenase (LDH) level is predictive of an aggressive lymphomalike course.
  • SPEP is a useful screening test for detecting M proteins.
    • An M component is usually detected by means of high-resolution SPEP. The kappa-to-lambda ratio has been recommended as a screening tool for detecting M-component abnormalities.
    • An M-component serum concentration of 30 g/L is a minimal diagnostic criterion for MM.
    • In about 25% of patients, M protein cannot be detected by using SPEP.
  • Routine urinalysis may not indicate the presence of Bence Jones proteinuria. Therefore, a 24-hour urinalysis by means of UPEP or immunoelectrophoresis may be required.
    • UPEP or immunoelectrophoresis can also be used to detect an M component and kappa or lambda light chains.
    • The most important means of detecting multiple myeloma is electrophoretic measurement of immunoglobulins in both serum and urine.

Imaging Studies

  • Simple radiography is indicated for the evaluation of skeleton lesions, and a skeletal survey is performed when myeloma is in the differential diagnosis.
    • Conventional plain radiography can usually depict lytic lesions.
    • Plain radiographs can be supplemented by CT scanning to assess cortical involvement and risk of fracture.
    • Lytic bone lesions appear as multiple, rounded, punched-out areas found in the skull, vertebral column, ribs, and/or pelvis. Less common but not rare sites of involvement include the long bones.
  • MRI is useful in detecting thoracic and lumbar spine lesions, paraspinal involvement, and early cord compression. MRI can depict as many as 40% of spinal abnormalities in patients with asymptomatic gammopathies in whom radiographic studies are normal.
  • On technetium bone scanning, more than 50% of lesions can be missed.

Procedures

  • Bone marrow biopsy enables a more accurate evaluation of malignancies than does bone marrow aspiration.
  • Multiple myeloma (MM) is characterized by an increased number of bone marrow plasma cells.
  • Plasma cells show low proliferative activity, as measured by using the labeling index.
    • This index is a reliable parameter for the diagnosis of MM.
    • High values are strongly correlated with progression of the disease.

Histologic Findings

Analysis of bone biopsy specimens may reveal plasmacytic, mixed cellular, or plasmablastic histologic findings. With the plasmacytic type, median survival is approximately 39.7 months. With the mixed cellular type, survival is 16.1 months, and with the plasmablastic type, survival is 9.8 months.

Staging

The Durie and Salmon classification of multiple myeloma (MM) is based on 3 stages and additional subclassifications.

  • In stage I, the MM cell mass is less than 0.6 cells X 1012 m2, and all of the following are present:
    • Hemoglobin value greater than 10 g/100 mL
    • Serum calcium value less than 12 mg/100 mL (normal)
    • Normal bone structure (scale 0) or only a solitary bone plasmacytoma on radiographs
    • Low M-component production rates
      • IgG value less than 5 g/100 mL
      • IgA value less than 3 g/100 mL
      • Urine light-chain M component on electrophoresis less than 4 g/24 h
  • In stage II, the MM cell mass is 0.6-1.2 cells per 1012 m2. The other values fit neither those of stage I nor those of stage III.
  • In stage III, the MM cell mass is greater than 1.2 cells per 1012 m2, and all of the following are present:
    • Hemoglobin value equal to 8.5 g/100 mL
    • Serum calcium value greater than 12 mg/100 mL
    • Advanced lytic bone lesions (scale 3)
    • High M-component production rates
      • IgG value greater than 7 g/100 mL
      • IgA value greater than 5 g/100 mL
      • Urine light-chain M component on electrophoresis greater than 12 g/24 h
  • Subclassifications include the following:
    • Relatively normal renal function (serum creatinine value < 2 mg/100 mL)
    • Abnormal renal function (serum creatinine value > 2 mg/100 mL)

More on Myeloma

Overview: Myeloma
Differential Diagnoses & Workup: Myeloma
Treatment & Medication: Myeloma
Follow-up: Myeloma
References
Further Reading
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References

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Keywords

myeloma, multiple myeloma, MM, plasma cell dyscrasia, plasma cell proliferation, hematologic cancer, plasmacytoid lymphocytes, M proteins

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Contributor Information and Disclosures

Author

Seema S Rizvi, MD, Associate Medical Director, Lutheran Care Center
Seema S Rizvi, MD is a member of the following medical societies: American Academy of Family Physicians and American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Howard A Chansky, MD, Associate Professor, Department of Orthopedics and Sports Medicine, University of Washington Medical Center
Howard A Chansky, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons
Disclosure: Nothing to disclose.

Medical Editor

Miguel A Schmitz, MD, Consulting Surgeon, Department of Orthopedics, Klamath Orthopedic and Sports Medicine Clinic
Miguel A Schmitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Sean P Scully, MD, PhD, Professor, Department of Orthopedics, University of Miami
Sean P Scully, MD, PhD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, International Society on Thrombosis and Haemostasis, and Society of Surgical Oncology
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD, Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine
Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society
Disclosure: Nothing to disclose.

 
 
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