Baseline testing

The presence of abnormal chromosomes generally suggests poor prognosis, but this is a trend and not a guaranteed outcome. Approximately one third of patients with any of the high-risk abnormalities can do well and have normal outcomes with standard current approaches to treatment, including induction therapy followed by autologous stem cell transplant (ASCT).

Baseline testing Bone marrow biopsy:

This is the single most critical test to determine both the presence and the percentage of myeloma cells in the bone marrow, and to assess prognosis. In stage I myeloma or for a solitary plasmacytoma, direct biopsy of the tumor mass may be necessary. Cytogenetic analysis can reveal good or poor chromosomal features, but a fresh bone marrow sample is needed for this type of testing.

Figure 7. Blood composition

Blood tests:

¡ Complete blood count (CBC) is used to assess presence and severity of anemia, low white cell count, and low blood platelet count. ¡ Chemistry panel is used to assess kidney function (creatinine and

BUN), liver functions, albumin, calcium level, and LDH. ¡ Serum protein electrophoresis (SPEP) assesses amount of the abnormal myeloma heavy chain protein, and shows the presence of the M-spike. ¡ Immunofixation electrophoresis (IFE) shows the heavy chain (G, A, D, E, and M) and light chain (kappa [κ], lambda [λ]) types of the myeloma protein. ¡ Freelite® assay measures the amount of free kappa or lambda light chains, and the kappa-to-lambda ratio, if no SPEP or UPEP abnormality is discovered. ¡ Hevylite® assay measures normal and abnormal levels of intact immunoglobulins.

Plasma

Platelets Red blood cells White blood cells

2015 Slaybaugh Studios ©

albumin albumin albumin albumin

beta-2 beta-2

alpha-1 alpha-1 alpha-2alpha-2 beta-1 beta-2 beta-1 gammabeta-2 gamma alpha-1 alpha-1 alpha-2alpha-2 beta-1 beta-1 gamma gamma

Normal SPEP result Abnormal result with myeloma cells producing the M-protein, creating an M-spike in the beta-2 zone

Urine tests:

Urine protein electrophoresis (UPEP) shows the amount of M-protein in the urine. Immunofixation shows the type of M-protein.

Bone testing:

The presence, severity, and location of bone damage can be assessed using the following: ¡ X-rays show characteristic myeloma bone disease in the majority of patients, but X-rays can be negative in approximately 25% of patients with active myeloma. Further imaging with whole-body MRI, wholebody low-dose CT, or PET/CT is needed to rule out possible bone involvement. A full skeletal survey for myeloma using a series of X-rays is needed to show loss (osteoporosis) or thinning (osteopenia) of bone caused by myeloma bone destruction, lytic lesions, or any fracture or collapse of bone. ¡ Magnetic resonance imaging (MRI) can reveal the presence and distribution of disease in the bone marrow when X-rays show no bone damage or for more detailed testing of particular areas such as spine and/or brain. Can also reveal disease outside of bone, which may be pressing on nerves and/or the spinal cord. ¡ Computed tomography (CT) scans are used when X-rays are negative or for more detailed testing of particular areas. Especially useful for detailed evaluation of small areas of possible bone damage or nerve pressure. ¡ Positron emission tomography (PET) scanning is a much more sensitive whole-body scanning technique. FDG/PET or PET/CT scanning is useful for disease monitoring, especially for non-secretory myeloma.

CT is used to assess sites of PET-positive disease.