Introduction Multiple myeloma is cancer of monoclonal plasma cells produces large amounts of IgG (55%) or IgA (25%) high levels of IL-6 may be present Epidemiology most common primary tumor arising within bone in the elderly If asymptomatic called monoclonal gammopathy of undetermined significance (MGUS) increased gamma globulin on serum electrophoresis but no symptoms of multiple myeloma are present Presentation Symptoms bone pain sequelae associated with hypercalcemia sequelae associated with renal failure Evaluation Serum protein electrophoresis monoclonal immunoglobulin spike (M protein) Urinalysis Ig light chains (Bence Jones protein) Peripheral blood smear Russell bodies Ig containing inclusion bodies seen in plasma cells RBC rouleaux formation Igs coat RBC and neutralize the ionic charge than normally repels RBCs Bone marrow aspiration proliferation of large monoclonal plasma cells "fried-egg" appearance Serology hypercalcemia result of bone degradation due to cytokine production that activates RANK receptor on osteoclasts prolonged bleeding time Imaging punched-out lytic bone lesions on x-ray Prognosis, Prevention, and Complications May lead to renal insufficiency ↑ susceptibility to infection anemia primary amyloidosis (AL) Poor prognosis
QUESTIONS 1 of 5 1 2 3 4 5 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI Blood, Plasma, Serum Reference Range ALT 8-20 U/L Amylase, serum 25-125 U/L AST 8-20 U/L Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL Calcium, serum (Ca2+) 8.4-10.2 mg/dL Cholesterol, serum Rec: < 200 mg/dL Cortisol, serum 0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h Creatine kinase, serum Male: 25-90 U/LFemale: 10-70 U/L Creatinine, serum 0.6-1.2 mg/dL Electrolytes, serum Sodium (Na+) 136-145 mEq/L Chloride (Cl-) 95-105 mEq/L Potassium (K+) 3.5-5.0 mEq/L Bicarbonate (HCO3-) 22-28 mEq/L Magnesium (Mg2+) 1.5-2.0 mEq/L Estriol, total, serum (in pregnancy) 24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL 28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL Ferritin, serum Male: 15-200 ng/mLFemale: 12-150 ng/mL Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250 pH 7.35-7.45 PCO2 33-45 mmHg PO2 75-105 mmHg Glucose, serum Fasting: 70-110 mg/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative stimuli: > 7ng/mL Immunoglobulins, serum IgA 76-390 mg/dL IgE 0-380 IU/mL IgG 650-1500 mg/dL IgM 40-345 mg/dL Iron 50-170 μg/dL Lactate dehydrogenase, serum 45-90 U/L Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL Osmolality, serum 275-295 mOsmol/kd H2O Parathyroid hormone, serume, N-terminal 230-630 pg/mL Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L Phosphorus (inorganic), serum 3.0-4.5 mg/dL Prolactin, serum (hPRL) < 20 ng/mL Proteins, serum Total (recumbent) 6.0-7.8 g/dL Albumin 3.5-5.5 g/dL Globulin 2.3-3.5 g/dL Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h Thyroxine (T4), serum 5-12 μg/dL Triglycerides, serum 35-160 mg/dL Triiodothyronine (T3), serum (RIA) 115-190 ng/dL Triiodothyronine (T3) resin uptake 25%-35% Urea nitrogen, serum 7-18 mg/dL Uric acid, serum 3.0-8.2 mg/dL Hematologic Reference Range Bleeding time 2-7 minutes Erythrocyte count Male: 4.3-5.9 million/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 12.0-16.0 g/dL Hemoglobin, plasma 1-4 mg/dL Leukocyte count and differential Leukocyte count 4,500-11,000/mm3 Segmented neutrophils 54%-62% Bands 3%-5% Eosinophils 1%-3% Basophils 0%-0.75% Lymphocytes 25%-33% Monocytes 3%-7% Mean corpuscular hemoglobin 25.4-34.6 pg/cell Mean corpuscular hemoglobin concentration 31%-36% Hb/cell Mean corpuscular volume 80-100 μm3 Partial thromboplastin time (activated) 25-40 seconds Platelet count 150,000-400,000/mm3 Prothrombin time 11-15 seconds Reticulocyte count 0.5%-1.5% of red cells Thrombin time < 2 seconds deviation from control Volume Plasma Male: 25-43 mL/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 19-31 mL/kg Cerebrospinal Fluid Reference Range Cell count 0-5/mm3 Chloride 118-132 mEq/L Gamma globulin 3%-12% total proteins Glucose 40-70 mg/dL Pressure 70-180 mm H2O Proteins, total < 40 mg/dL Sweat Reference Range Chloride 0-35 mmol/L Urine Calcium 100-300 mg/24 h Chloride Varies with intake Creatinine clearance Male: 97-137 mL/minFemale: 88-128 mL/min Estriol, total (in pregnancy) 30 wks 6-18 mg/24 h 35 wks 9-28 mg/24 h 40 wks 13-42 mg/24 h 17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 6-15 mg/24 h Osmolality 50-1400 mOsmol/kg H2O Oxalate 8-40 μg/mL Potassium Varies with diet Proteins, total < 150 mg/24 h Sodium Varies with diet Uric acid Varies with diet Body Mass Index (BMI) Adult: 19-25 kg/m2 Calculator ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M1.ON.4754) A 68-year-old female presents to her primary care physician with a 7-month history of fatigue and low back pain. Her pain is not improved by over the counter analgesics. Laboratory analysis is notable for a calcium level of 11.5 mg/dL, creatinine level of 2.0 mg/dL, and blood urea nitrogen level of 30 mg/dL. Large eosinophilic casts are seen on renal biopsy. Which of the following findings is most likely to be seen on peripheral blood smear? Review Topic QID: 108696 1 Abundant reticulocytes 6% (3/47) 2 Linear aggregations of red blood cells 55% (26/47) 3 Schistocytes 9% (4/47) 4 Leukocytosis with abundant mature myeloid cells 23% (11/47) 5 Smudge cells 2% (1/47) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (M1.ON.4671) A 74-year-old man presents complaining of back pain. He has also been feeling fatigued for the last several months and says he has lost about 20 pounds. On laboratory exam, his creatinine has increased from baseline, and his serum calcium is 11.5 mg/dL. He is referred to a nephrologist, and the results of a renal biopsy are shown in Figure A. Microscopic examination of the urine is shown in Figure B and notably also shows the presence of eosinophilic casts. What is the most likely explanation for his renal findings? Review Topic QID: 107158 FIGURES: A B 1 Monoclonal protein overproduction 61% (46/75) 2 Ischemic tubular injury 15% (11/75) 3 Acute pyelonephritis 8% (6/75) 4 Diabetic nephropathy 4% (3/75) 5 Nephritic syndrome 9% (7/75) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (M1.ON.75) A 68-year-old male presents to his primary care physician with a complaint of increased fatigue and back pain that has not resolved over the past few months despite adequate rest and treatment with over the counter analgesics. The physician orders basic blood work including a CBC and BMP that demonstrates anemia, renal failure, and hypercalcemia. The physician orders a renal biopsy to evaluate the etiology for the renal failure. Which of the following figures is most likely to be observed on renal biopsy? Review Topic QID: 106765 FIGURES: A B C D E 1 Figure A 38% (38/99) 2 Figure B 13% (13/99) 3 Figure C 18% (18/99) 4 Figure D 14% (14/99) 5 Figure E 14% (14/99) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (M1.ON.27) A 74-year-old female presents to her primary care physician complaining of an 8-month history of malaise and lower back pain. Laboratory findings reveal a serum M spike and urinalysis is positive for light chain proteinuria. MRI imaging is obtained (Figure A). Which cellular component is likely to be found in abundance in the dominant cells on bone marrow biopsy in this patient? Review Topic QID: 105637 FIGURES: A 1 Mitochondria 9% (3/33) 2 Golgi bodies 6% (2/33) 3 Rough endoplasmic reticulum 55% (18/33) 4 Smooth endoplasmic reticulum 9% (3/33) 5 Lysosomes 12% (4/33) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 3
Results from AMBER, a randomized phase 2 study of bevacizumab and bortezomib versus bortezomib in relapsed or refractory multiple myeloma. Oncology - Humanitarian White D, Kassim A, Bhaskar B, Yi J, Wamstad K, Paton VE Cancer. 2013 Jan;119(2):339-47. PMID: 22811009 (Link to Abstract)
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