1. MGUS (interpreting the test you didnt order) Family Medicine Review Course 2011 Christian Cable, MD, FACP

2. The Case

3. What is the laboratory abnormality? 10-3 = 7 Whats in there?

4. What comprises the blood?

6. Whats in blood... Cellular (bone marrow) – RBCs – Platelets – WBCs Plasma (liver) – Water – Proteins Albumin Antibodies Clotting factors

9. Proteins in the Blood?

10. Brainstorm As many globins as you can think of...

11. Tell me more about antibodies

12. What is the correct test?

14. SPEP/SIEP SPEP qualitative (is it there?) SIEP quantitative (how much, which one?)

15. 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

16. Gammopa-what?

17. Greek to me (I)... Gamma - - region in electrophoretic mobility Pathy - - disease or condition

18. Greek to me (II)... Clonal - - type Mono - - one Poly - - many (much)

19. Differentiate Polyclonal from Monoclonal

20. M-spike

21. What is normal?

22. How high?

23. Polyclonal gammopathy - -significance Think of an elevated ESR What could cause that?

25. Is polyclonal gammopathy a plasma cell disorder?

26. Monoclonal gammopathy - - determined significance

27. New Myeloma Classification

28. 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

29. 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

30. Monoclonal gammopathy - - undetermined significance

31. Common?

32. 3% of population over 50 twice that prevalence African Americans

33. 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

34. How to evaluate CBC, Creatinine, Calcium, SPEP/SIEP Skeletal survey (plain films)

35. When to refer

37. Higher risk non-Ig G (IgA & Ig M) African American total M spike: >1.5 g/dL

38. 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

39. How do you follow it? Id like to help follow higher risk patients. Lower risk: – re-test in 6 months then annually

40. Our Patient

41. SPEP

42. SIEP 1.6 g/dL IgA kappa

44. Recommendations referral bone marrow biopsy

45. ccable@swmail.sw.org