mgus (interpreting the test you didnt order) family medicine review course 2011 christian cable, md,...
TRANSCRIPT
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MGUS(interpreting the test you didn’t order)
Family Medicine Review Course 2011Christian Cable, MD, FACP
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The Case
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What is the laboratory abnormality?
• 10-3 = 7
• What’s in there?
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What comprises the blood?
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What’s in blood . . .
• Cellular (bone marrow)
– RBCs– Platelets– WBCs
• Plasma (liver)
– Water– Proteins
• Albumin• Antibodies• Clotting factors
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Proteins in the Blood?
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Brainstorm
• As many “globins” as you can think of . . .
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Tell me more about antibodies
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What is the correct test?
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SPEP/SIEP
• SPEP qualitative (is it there?)• SIEP quantitative (how much, which one?)
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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
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Gammopa-what?
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Greek to me (I) . . .
• Gamma - - region in electrophoretic mobility• Pathy - - disease or condition
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Greek to me (II) . . .
• Clonal - - type• Mono - - one• Poly - - many (much)
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Differentiate Polyclonal from Monoclonal
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“M-spike”
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What is normal?
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How high?
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Polyclonal gammopathy - -significance
• Think of an elevated ESR• What could cause that?
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Is polyclonal gammopathy a plasma cell disorder?
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Monoclonal gammopathy - -determined significance
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New Myeloma Classification
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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
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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
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Monoclonal gammopathy - -undetermined significance
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Common?
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• 3% of population over 50• twice that prevalence African Americans
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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
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How to evaluate
• CBC, Creatinine, Calcium, SPEP/SIEP• Skeletal survey (plain films)
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When to refer
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Higher risk
• non-Ig G (IgA & Ig M)• African American• total M spike: >1.5 g/dL
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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
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How do you follow it?
• I’d like to help follow higher risk patients.• Lower risk:
– re-test in 6 months then annually
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Our Patient
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SPEP
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SIEP
1.6 g/dL IgA kappa
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Recommendations
• referral• bone marrow biopsy
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