Case study: Diagnosing Myeloma
Read through the case studies below and think about how you would manage this patient presenting to your surgery
new cases of myeloma diagnosed in the UK per year
There are 5,500 new cases of myeloma diagnosed in the UK per year, which account for 10-15% of all haematological malignancies.
- Incidence increases with age, and the average age at diagnosis is 70
- 40% of patients who present are under 60 years old
- More common in men than women
- Twice as common in those of black origin compared with caucasian
- Less common in those of Asian origin.
Case study 1
A 76 year old man presents to your surgery with no concerning symptoms.
His routine blood tests revealed a high total protein level, prompting a further set of blood tests which included serum protein electrophoresis.
His results are:
- <<<Hb 136 g/L
- MCV 99
- WBC, Plt normal
- U+E, calcium normal
- IgG kappa paraprotein of 17 g/L
- sFCL: kappa 18 mg/L, lambda 10 mg/L, ratio 1.8
What would you do?
- Refer to the haematologist under the 2 week rule
- Standard referral to haematology
- Repeat blood tests in 12 weeks
- Write to Haematologist for advice
The correct answer is 2.
The indices are not especially suggestive of myeloma as a diagnosis, but the level of paraprotein fulfils referral guidelines.
The likely diagnosis is Monoclonal gammopathy of undetermined significance (MGUS). Unless there are any concerning symptoms the Haematologist would be unlikely to perform any invasive investigations such as bone marrow biopsy. The risk of progression to myeloma can be stratified based on the paraprotein isotype, level of paraprotein and light chain ratio.
In this case the patient would fall into the low-intermediate Mayo risk group, estimating a 20 year risk of progression to myeloma at 21%, or 10% when taking death as a competing factor into account.
The detection of a high total protein is one of the most common ways that MGUS is identified. The correct follow up is dependent on the risk of progressing to myeloma.In this case the risk is relatively low, so this case could be followed up in primary care.
It is advised to repeat the original tests in 3/12, and then if stable, in 6/12 and ongoing every 6 - 12 months. Blood tests should include FBC, U+E, Calcium, SPE and sFLC. A re-referral would be precipitated by a significant rise in paraprotein (usually >10 g/l) or anything else suggestive of myeloma e.g. anaemia.
Case study 2
A 49 year old man presents to your surgery with lumbar back pain. He previously saw a colleague with the same problem 6 weeks ago, and was advised to take ibuprofen and return if symptoms did not settle.
He has taken ibuprofen and paracetamol in combination with some relief but the pain is increasing.
There are no concerning neurological symptoms and nothing to find on examination.
You request some blood tests which show:
- Hb 106 g/L
- WBC 4.5 x10^9/L
- Plt 160 x 10^9/L
- corrected calcium 3.15 mmol/L
- Creatinine 160 umol/L
- ESR 90
- Total protein 102 g/L (normal 60 – 78 g/L) Albumin 26 g/L (normal 30-50)
What would you do?
- Refer to haematology under 2 week rule
- Do a standard referral to haematology
- Advise him to stop ibuprofen
- Request Serum protein electrophoresis and serum freelite chains
- Arrange admission to hospital
The correct answer is 5.
This is highly suggestive of myeloma. The high calcium will be contributing to the renal failure.
A delay of 2 weeks could result in dialysis-dependent renal failure so this should be considered a medical emergency that requires admission, primarily to correct the calcium and monitor renal function and also to confirm the diagnosis of myeloma.
There are five key symptoms of myeloma to look out for:
- Bone marrow failure (anaemia most common)
- Bone pain / fracture (usually back)
- Recurrent infections
- Renal impairment
Presentation of any of these symptoms should prompt referral to your haematologist where full blood counts can confirm a diagnosis.