From the Guidelines
The workup for multiple myeloma should include a comprehensive set of laboratory tests, imaging studies, and bone marrow evaluation, as outlined in the most recent guidelines from 2023 1. The initial laboratory tests should include a complete blood count to assess for anemia, serum calcium to check for hypercalcemia, creatinine to evaluate kidney function, and serum protein electrophoresis with immunofixation to identify monoclonal proteins.
- Quantitative immunoglobulins and serum free light chain assay should be performed to measure the amount and type of abnormal proteins.
- Urine studies including 24-hour urine protein electrophoresis and immunofixation are essential to detect Bence Jones proteins. Imaging studies are crucial and should include a skeletal survey or low-dose whole-body CT scan to identify bone lesions; more advanced imaging like MRI or PET-CT may be needed for certain cases.
- Bone marrow aspiration and biopsy are necessary to confirm the diagnosis by demonstrating clonal plasma cells (typically ≥10%). Additional testing should include beta-2 microglobulin, albumin, and lactate dehydrogenase for prognostic assessment, and cytogenetic studies like FISH to identify high-risk genetic abnormalities such as t(4;14), t(14;16), or deletion 17p, as recommended by the NCCN guidelines 1. This comprehensive workup allows for accurate diagnosis, staging according to the Revised International Staging System (R-ISS), and appropriate treatment planning for multiple myeloma, and is supported by previous studies 1.
From the Research
Diagnostic Workup for Multiple Myeloma
The diagnostic workup for multiple myeloma includes:
- Measurement of hemoglobin, serum creatinine, serum calcium, and serum free light chain levels 2
- Serum protein electrophoresis with immunofixation 2
- 24-hour urine protein electrophoresis 2
- Full-body skeletal imaging with computed tomography, positron emission tomography, or magnetic resonance imaging 2
- Complete blood count with differential 3
- Serum chemistries 3
- Creatinine, lactate dehydrogenase, and beta2-microglobulin tests 3
- Immunoglobulin studies 3
- Skeletal survey 3
- Bone marrow evaluation 3, 4
Staging and Risk Stratification
The Revised International Staging System combines data from serum biomarkers β2 microglobulin, albumin, and lactate dehydrogenase in conjunction with malignant plasma cell genomic features to assess estimated progression-free survival and overall survival 2
- The staging system has been revised to combine both measures of tumor burden and disease biology 5
- Risk stratification is also important in determining the treatment approach 6
Treatment Approach
The treatment approach for multiple myeloma includes:
- Induction therapy with a combination of an injectable proteasome inhibitor, an oral immunomodulatory agent, and dexamethasone 2
- Autologous hematopoietic stem cell transplantation 2, 4
- Maintenance therapy with lenalidomide 2
- Supportive therapy, including bisphosphonates, radiation therapy, and orthopaedic surgery, may be required to manage complications of the disease and side effects of treatment 4