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Diagnostic Workup for Multiple Myeloma

Patricia Mangan, RN, MSN, APRN-BC, from Abramson Cancer Center, University of Pennsylvania, provides background information on typical diagnostic tests performed in patients with multiple myeloma.

Tip Sheet about this topic

Hello. I’m Patricia Mangan, and welcome to the Multiple Myeloma Center for Nurses video: Diagnostic Workup for Multiple Myeloma. In this video, we’ll discuss the diagnostic workup for multiple myeloma.

Before making a diagnosis of multiple myeloma, the physician will typically assess a patient’s medical history and conduct a physical exam. The patient’s medical history is useful to identify comorbid conditions that may affect treatment decisions, including coronary artery disease, congestive heart failure, hypertension, renal disorders, liver disorders, lung diseases, and infection.

The National Comprehensive Cancer Network, or NCCN, guidelines recommend several serum assays to confirm the diagnosis of multiple myeloma. Specifically, the recommendations for the initial diagnostic workup are a complete blood count with differential to assess for cytopenias; and a full metabolic panel with blood urea nitrogen, creatinine, and electrolytes including calcium to assess for renal insufficiency and hypercalcemia. Albumin, lactate dehydrogenase, and beta-2 microglobulin are recommended to assess tumor burden and for prognostic staging of the disease.

NCCN recommends other serum tests, which are often referred to as a myeloma panel. This panel typically includes serum protein electrophoresis, also called SPEP. SPEP detects the presence of a monoclonal protein, or M-protein. Additional tests in a myeloma panel may include quantitative immunoglobulins and serum immunofixation electrophoresis, also called SIFE. SIFE detects which immunoglobulins are being overproduced: IgG, IgA, IgM, IgE, or IgD. Quantified immunoglobulin results provide the level of immunoglobulins present. These tests are recommended for use when monitoring patient response to treatment and tracking disease progression.

The final test recommended as part of the myeloma panel is the serum free light chain assay. The serum free light chain assay, in combination with SPEP and SIFE, produces highly sensitive results. These tests measure the number of light chains that are not matched to heavy chains. Free light chains can be a marker of early response to treatment or myeloma activity if outside the normal range. Specific urine testing is also recommended by NCCN as part of the initial diagnostic workup. Twenty-four hour urine is used to assess for total protein (which measures the amount and type of protein in urine over a 24-hour period), urine protein electrophoresis, or UPEP (which measures the amount of M-protein in the urine), and urine immunofixation electrophoresis, or UIFE (which measures the type of M-protein for light chains).

NCCN guidelines recommend a full skeleton radiographic survey to confirm the presence of lytic bone lesions. Other tests currently used, under specific circumstances, include magnetic resonance imaging, or MRI; a computed tomography, or CT, scan; or a positron emission tomography, or PET/CT, scan. If no abnormality is detected on routine radiographs, a PET/CT and/or MRI scan may be indicated because these are more sensitive tests. A tissue biopsy may also be necessary to confirm the presence of plasmacytomas. To evaluate bone marrow plasma cell infiltration, bone marrow aspiration and biopsy is recommended to detect quantitative and or qualitative abnormalities of bone marrow plasma cells. Bone marrow studies at initial diagnosis should include chromosomal analysis by conventional karyotyping (cytogenetics) and fluorescence in situ hybridization, or FISH, performed with the plasma cells obtained from bone marrow aspiration. Stratification of patients into various risk groups based on the chromosomal markers is being utilized by some centers for prognostic counseling, selection, and sequencing of therapy approaches.

NCCN guidelines also recommend cytogenetic testing during the initial workup. The cells used to perform this testing are obtained during a bone marrow aspiration. Cytogenetic testing can be performed either by conventional karyotyping or by fluorescence in situ hybridization, or FISH.

This concludes the Multiple Myeloma Center for Nurses Diagnostic Workup for Multiple Myeloma video. To find out more on this and other topics related to multiple myeloma, please see additional videos and resources on this site. Here you will find a number of educational tools, including tip sheets to help you discuss these topics with your patients, answers to common questions, and other downloadable materials. Thank you.