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    ESR of 120, granulomatous inflammation, tuberculosis, multiple myeloma. Treatment ?

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Posted on Sun, 27 May 2012 in Cancer
Question: Last year around the same time my father had an ESR of around 120.. On protein electrophoresis found an M-spike of 2.23 g/dl.. then immunofixation report revealed beta 2 microglobulin of 2.34 mg/L and IgG value 3040 mg/dl.. all other readings of calcium,free light chains,IgA were within normal range.. malignancy and reported mildly hypercellular for age with an impression of granulomatous inflammation suggestive to tuberculosis.. All X-rays were normal.. it has been a year but he has not reported any symptoms or concerns regarding health.. he is pretty healthy... can it be a case of multiple myeloma.. what can certainly rule it out as a case of multiple myeloma.. Thanks
doctor
Answered by Dr. Robert Galamaga 3 hours later
Hello and thanks for the query.

This looks like a picture of MGUS or monoclonal gammopathy of undetermined significance with borderline features of myeloma. With that being said, the M protein spike is high enough to be concerning for him. It is possible that at some point in the future he will need to be treated for this. This is especially true in light of the anemia which he has going on.

The best medicine from a hematology standpoint for him, will be to have serial lab studies done to monitor the protein levels, calcium level, kidney function as well as his blood counts. If there is any evidence of progression of these lab studies in a negative direction then it is more supportive of treatment.

The fact that the marrow shows no evidence of disease is reassuring and more predictive that he should be stable enough to just observe for now. Myeloma can not necessarily be ruled out until he has serial labs performed in the coming months.

I thank you again for submitting your query and hope my response has proven to be adequate and helpful. I am available if you have any additional concerns regarding this.

Sincerely,

Dr. Galamaga
Above answer was peer-reviewed by : Dr. Prasad
doctor
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Follow up: Dr. Robert Galamaga 2 hours later
Thanks a lot Doctor for your response. If at all he happens to have Myeloma what should be the best course of treatment if it is at an initial stage. And how good is the outlook or life expectancy for an initial stage.
doctor
Answered by Dr. Robert Galamaga 9 hours later
Hi,
Thanks for the follow up.

If it progresses to myeloma there are very good drugs available which can keep the disease in remission for a long time. Sometimes a bone marrow transplant is performed to provide an even longer term response.

What he has is very early stage and is certainly not life threatening right now.

Close followup and interval lab testing is really key to determining overall prognosis.

Life expectancy is over 10 years at minimum and likely much longer than that.

Thanks again for the query. Please let me know if I can help with anything else.

Wishing you good health.

Regards,

Dr. Galamaga
Above answer was peer-reviewed by : Dr. Radhika
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Follow up: Dr. Robert Galamaga 2 hours later
Thanks a lot Doctor XXXXXXX Your answers gave a lot of confidence. Hope I could reach you later if we found out something and need value opinions. Thanks Again.

Soumyo XXXXXXX
doctor
Answered by Dr. Robert Galamaga 5 hours later
Hello again,

You can always reach me by submitting a query to my attention at YYYY@YYYY

I wish you all the best.

Dr. Galamaga
Above answer was peer-reviewed by : Dr. Ashwin Bhandari
doctor
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Follow up: Dr. Robert Galamaga 12 days later
Hi Doctor,

Following up on the above a week back we had retests.. The CBC showed Haemoglobin at 11.9.. SPEP showed albumin 3.8 g/dl, Gamma globulin 2.8 and A/G ratio 0.82.. the myelocyte -7% , metamylocyte - 1%,
band forms - 2%, neutrophil - 43%, lymhpocyte - 31%, eosihophil - 1% and plasma cell - 2%.. Also there is an observation of erythroid precursors - 13% and
iron stain grade -3+

The impression in the report says 'Mildly hypocellular marrow with normoblastic erythroid maturation'

considering the lab reports I had presented earlier to you in my past.. could you please advise on if the diseaes is progressing to Myeloma.. or if you could provide any indicators as to when can it be expected to progress to myeloma..

Thanks for your help
doctor
Answered by Dr. Robert Galamaga 4 hours later
Hello and thanks for the followup.

On review of the results you submitted there is a very mild anemiain this case and this is more certainly a monoclonal gammopathy. There is no indication for treatment with chemotherapy at all because the percentage of plasma cells (myeloma cells) in the bone marrow is so very small at 2%.

We generally consider treatment if the anemia is more severe or if there is evidence of kidney dysfunction or bone disease. It is really impossible to predict if and when this might progress so it is very important that close followup every 3 months is observed with repeat SPEP studies to evaluate the extent of the M-Protein and blood counts/metabolic panels to evaluate the anemia and survey for anything like kidney dysfunction. Sometimes we will do a baseline bone mineral density study as well as a skeletal survey which is basically an xray of the whole skeleton to rule out any evidence of plasma cells ausing problems in the bones.

Sometimes this MGUS will smolder for many years requiring no treatment. It is better to observe rather than treat at this point because we know from large randomized studies that treating at this point provides no benefit over observation.

I thank you again for the query and hope you find this reply to be helpful and informative. If you have any additional concerns I would be happy to address them.

Sincerely,

Dr. Galamaga
Above answer was peer-reviewed by : Dr. Raju A.T
doctor
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Follow up: Dr. Robert Galamaga 4 hours later
Thank you doctor... we will definitely not consider chemo treatment now.. what criteria is considered good enough for treatment in terms of plasma cell percentage.. and if the plasma cell goes up but symptoms do not occur should we consider treatment at that point or wait till symptoms show up.. does the erythroid precursors of 13 % indicate anything.. thank you
doctor
Answered by Dr. Robert Galamaga 15 hours later
Hello and thanks for the followup.

Generally plasma cells greater than 10% meets criteria for treatment but every patient must be considered individually. Sometimes if percentage is 10-20 percent observation is possible.

I would only consider treatment if significant anemia or kidney failure or hypercalcemia develops.

I would not worry about the erythroid precursor percentage.

Thanks again for the query. I hope this continues to be a healthy experience for you. I am here if you have any followups also.

Sincerely,

Dr. Galamaga

Above answer was peer-reviewed by : Dr. Raju A.T
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Dr. Robert Galamaga

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