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Dr. Andrew Rynne
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Dr. Andrew Rynne

Family Physician

Exp 50 years

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Suggest treatment for plasma cell neoplasms

Answered by
Dr.
Dr. Deepak Sundriyal

Oncologist

Practicing since :2005

Answered : 1546 Questions

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Posted on Fri, 15 Jul 2016 in Cancer
Question: I would like to know why the pathologist feels highly suspicious for plasma cell neoplasm in a background of normal plasma cells? The marrow is mildly hypo cellular (30%) and contains all 3 hematopoietic lines. Immunoperoxidase staining for CD138(performed on the biopsy) demonstrates approximately 15% plasma cells while in situ hybridization for kappa and lama light chains (performed on the the biopsy) demonstrates a kappa:lama ratio of approximately 2.5:1. Immunoperoxidase for CD56 does not demonstrate reactivity with these cell populations. The myeloid:erythroid ratio is within normal limits(2.5:1) and the maturation of both cell lines proceeds normally with no increase of blast or maturational arrest. Adequate number of megakaryocytes are present and are morphologically unremarkable. Special stain for iron( performed on the biopsy, clot section and pirate smear) demonstrate 1-2+ iron; occasional siderblasts are seen but no increase of ringed sideroblast is identified.
Flow cytometry performed demonstrates a kappa light chain excess among polytypic plasma cells with a subset demonstrating immunophenotypic aberrancy. These findings are reported as highly suspicious for plasma cell neoplasm in a background of normal plasma cells. This population cannot be definitely identified by light microscope methods.

HISTORY OF PRESENT ILLNESS: The patient is a 47 YO with no past medical history. noted to
have low bone density five years ago and repeat one again showed low bone density. SPEP show 09 g/dL M spike. White count ls 4.3. hemoglobin 14 3. and platelets 265.000. Creatinine 1.1 and IgG of 1468.
lgA 93. IgM 114 UPEP. urine protein lmmunoflxation negative and serum immunoflxation shows 196
kappa and kappa chain is 13. lambda is 8.69. kappa to lambda 1.50. We will order a skeletal survey and also bone marrow aspiration and biopsy and regroup in 10 days. However. i do not see any end-organ damage at this point, He probably has MGUS. No significant other symptoms,
WBC 3.7, RBC 4.56, HGB 13.9, HCT 41.4, MCV 90.8, MCH 30.4, MCHC 33.5, RDW 13.3, PLT 217 ,MVP 217 ANC 0
PAST MEDICAL HISTORY: No diabeles or hypertension, No heart problems.
SURGERIES:
1. Vasectomy.
2. Wisdom teeth extraction.
MEDICATIONS: Vyvanse and vitamin D and calcium.
SOCIAL HISTORY: No smoking. Drlnks alcohol almost 5 days a week. Married. Has three children and Lives In XXXXXXX Self-employed.
FAMILY HISTORY: Mother had heart valve replacement. She is on Coumadin. Father has stroke.
hypertension. diabetes. and has almost 14 half siblings. one half brother died of leukemia. Paternal
grandfather has skin cancer. Grand father liver cancer.
ALLERGIES: No known drug allergies.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: No fever. chills. or night sweats. No loss ofweight or appetite.
CARDIOVASCULAR: No shortness of breath, chest pain. PND. orthopnea. palpitations.
RESPIRATORY: No lever. cough, or mucoid sputum
GASTROINTESTINAL: No abdominal pain. nausea. vomiting. homelemeels. or mslena.
NEUROLOGICAL: No headaches. dlplopia. seizures. loss ofconsciousness.
ENDOCRINE: No heat or cold intolerance.
PHYSICAL EXAMINATION:
HEENT: There is no pallor icterus.
LUNGS: Clear. No palpable adenopathy.
HEART: SI and S2 heard, No murmur or gallop.
ABDOMEN: Soft. non-tender. Bowel Bounds positive,
EXTREMITIES: No edema.
LABORATORY RESULTS: White count 5.9, hemoglobin 14.8, and platelets 277,000. Creatinine 1.1,
Sodium 138. potassium 4.3. chloride 101, calcium 9.4.
IMPRESSION AND RECOMMENDATIONS: A 47 YO M with no past medical history. has M-protein of 1gIdL CBC normal. Calcium and creatlnin is normal. SPEP shows a g/dL lgG kappa. UPEp and urine immunofixation is negative. Quantitative Immunoglohulins are normal. At this point. no end-organ damage noted. We will check a bone marrow aspiration and biopsy and skeletal survey and will see him back within 10 days. Most likely he has MGUS.
doctor
Answered by Dr. Deepak Sundriyal 14 hours later
Brief Answer:
Hello dear. The patient has smoldering myeloma.

Detailed Answer:
Hello dear. Welcome to HCM. I have gone through the details. The patient is suffering from plasma cell neoplasm and fits into the category of smoldering myeloma(plasma cells in marrow more than 10 percent defines myeloma).
However , i donot see any indication for the treatment as he does not fullfil(CRAB) criteria except that bony lesion require evaluation by atleast a skeletal survey( a PETscan or MRI would be better choice). Moreover the pathologist is right in saying , it is a plasma cell neoplasm and not MGUS.
He however require skeletal evaluation. Repeat marrow is not indicated.
Thanks and regards

Above answer was peer-reviewed by : Dr. Yogesh D
doctor
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Follow up: Dr. Deepak Sundriyal 2 hours later
Ok there was a skeletal evaluation included in the attachment. I am not sure if you were able to review the attached reports which included the bone scan survey. There were no focal lytic lesions. There was some mild acromioclavicular joint hypertrophy. (Please review the report for additional Impression Summary). Do you feel that smoldering myeloma patients with normal MRIs have a lower rate of progression to active, symptomatic disease? Please share with your success with prevention of progression of to MM.
doctor
Answered by Dr. Deepak Sundriyal 8 minutes later
Brief Answer:
Hello dear. Skeletal survey is normal.

Detailed Answer:
Hello dear. Your skeletal survey is normal. The rate of conversion of smoldering myeloma to active disease is 10 percent per year. Means 10 out of 100 patient will turn to active er year. At present no treatment is recommended at your stage so actually i have no data of such patients getting prevented from development of active disease.
Thanks
Above answer was peer-reviewed by : Dr. Naveen Kumar
doctor
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Follow up: Dr. Deepak Sundriyal 28 hours later
Ok I provided your diagnostic opinion during the review of the reports today and was told that it before we are able consider this Smoldering Myeloma we must first look at the FLC report because this patient does not meet CRAB and even though there is a slight M-Spike, it is not nominal. Also the because of the CD138 shows 15% of Plasma Cells from the biopsy is considered vague until I review the Clonal Cell Type percentage. I was told told that the age and symptoms are another factor to consider MGUS rather than SMM. They said MGUS cases requiring staining for lambda/kappa/CD138 and look at plasma cells clonality. In most cases one can see that there are both normal PC and monoclonal population present , which results in s.c. clonal excess i.e. pathological kappa/lambda ratio. The difference with myeloma would be that the normal plasma cells are not there any more. Then I was told to go back over the lab reports. I looked at todays blood report again and the {WBC =3.4 (low) rng 4.8 -10.8} {RBC= 4.8(normal) rng 4.7-6.1}{LY#= 1.0(low) rng 1.2 -3.4}. I have gone over the reports and blood/urine/scans since March and reviewed old records with first report of osteopenia reported 4 yrs ago by PCP. I requested a MRI or PET/CT and now I must provide a reason why I want the imaging and explain why. I guess the role of PET scan (or spine and pelvic MRI ) for monitoring or following high risk SMM patients has not been studied to my knowledge. Also, I should avoid performing additional imaging during surveillance of SMM, particularly if the pertinent blood work is stable and the patient is asymptomatic. Really this is very frustrating seems like everything I present it challenged. I almost want to tell them I am speaking with a seasoned Oncologist who agrees with my findings. Yet I am unable to share this information with further objections. Please tell me how you would address this matter. I will wait to get the FCL report as suggested and then provide my final opinion report. As for the imagining I will request the MRI first. Because according to Dr. Kappor "Doctors are still learning to integrate these modalities into their practice. For example, MRI findings in smoldering myeloma patients (who by definition have no detectable areas of bone destruction on X-rays) can be predictive of outcomes as they provide additional information about the rate of progression to active myeloma. Smoldering myeloma patients with normal MRIs have a lower rate of progression to active, symptomatic disease. If more than 1 focal lesion is noted on MRI of smoldering myeloma patient, the chances of progression to active myeloma are greater. If the pattern of marrow involvement on MRI is similar to that seen in monoclonal gammopathy of undetermined significance (MGUS) patients, the chances to progressing into symptomatic multiple myeloma are lower. Importantly, areas with bone marrow abnormalities detected on MRI may not necessarily suggest increased threat to bone destruction. However, closer monitoring may be required due to higher risk of progression to active disease. So please tell me how I should present this without offending others opinions. I need to defend my opinion and request for additional testing.
doctor
Answered by Dr. Deepak Sundriyal 18 hours later
Brief Answer:
Hello dear. It is smoldering myeloma by definition. and not MGUS

Detailed Answer:
HEllo dear. By definition, you have a smoldering myeloma. Any plasma cells beyond 10 percent in marrow in the absence of CRAB CRITERIA is either a smoldering myeloma or a high risk smoldering myeloma but definitely not MGUS.
Moreover, a FLC ratio has nothing to do with the diagnosis of MGUS
However, an abnormal flc ratio (involved/uninvolved more than 60)qualifies for the diagnosis of high risk smoldering myeloma. So by looking at FLC ratio we can decide whether you have smoldering type or not. IF it is even higher , more than 100 then you have active myeloma.
Similarly if a PET or MRI shows active lesions, as they are more sensitive than skeletal survey, you require treatment as active active myeloma.
But for all practical purposes you donot have MGUS.
clonality has nothing to do to differentiate between MGUS and Smoldering myeloma.
Now the crux is
you require treatment only if
1. you fullfill any of CRAB
2. you have an abnormal flc of 100 or more
3. you have high viscosity
4. repeated pulmonary infections
5. amyloidosis
6. 2 or more lesions on petct.
If you donot have any of these, you have smoldering myeloma and just require observation till you develop any of these.
Thanks and regards
I dnt want to argue with your physician, but this is all what is evidence based and i can guarantee this.
Thanks
Above answer was peer-reviewed by : Dr. Yogesh D
doctor
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Follow up: Dr. Deepak Sundriyal 13 hours later
I know you are correct and I appreciate your time. Dont worry there is no need for me to argue with the her. I will present these FACTS that I trust valid. Thank you and Be Blessed!
doctor
Answered by Dr. Deepak Sundriyal 5 minutes later
Brief Answer:
Hello. Thanks and regards

Detailed Answer:
Feel free to ask further. Thanks and regards
Above answer was peer-reviewed by : Dr. Sonia Raina
doctor
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Follow up: Dr. Deepak Sundriyal 15 days later
Dr. Juvvadi {http://www.texasoncology.com/doctors/sridevi-juvvadi} is unclear of how Smoldering Myeloma could be the diagnosis. According to her she says that when you look at the number of poly vs. mono plasma cells in the FISH report (it is the last 2 pages of the attached report). There is not enough of a significant difference of mono cells. However she says that she will order a PET CT if that help us see that Smoldering Myeloma is a premature diagnosis. I said no to PET CT because I feel that an MRI who be less radiation an would show a good whole body scope also. It really is frustrating to me because I have reviewed the Immunophenotypic analysis and based on a few things I wonder if it is "ALL". Please review and tell what you think.
doctor
Answered by Dr. Deepak Sundriyal 4 hours later
Brief Answer:
Hello dear. I have confirmed. It is smoldering myeloma.

Detailed Answer:
Hello dear. Welcome once again. I am referring you to the latest guidelines of NCCN(NAtional cancer cooperative network) which I follow in my clinical practice. As per these guidelines, it fits into the category of smoldering myeloma.
Nothing to do with monoclonal or polyclonal for determining smoldering versus MGUS and FISH is not used to diagnose MGUS vs smoldering myeloma. Moreover myeloma is always monoclonal for all practical purposes, rarely it can be polyclonal.
It is for certain not ALL. Mark my words.
Rest assured. and relax. You do not need treatment as of now.
Thanks
Above answer was peer-reviewed by : Dr. Sonia Raina
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