LWBK1006-34 LWW-Govindan-Review November 24, 2011 11:25
472 DeVita, Hellman, and Rosenberg’s CANCER: Principles and Practice of Oncology Review(Sonnoveld et al. Blood. 2010 Nov;116:40 and Attal et al. Blood. 2010
Nov;116:310).Answer 34.8. The answer is D.
The International Myeloma Working Group (IMWG) consensus guide-
lines on diagnostic workup in plasma cell neoplasms was recently pub-
lished (Dimopoulos et al. Blood. 2011;117:4701–4705). These recom-
mend MRI of spine and pelvis as mandatory workup of patients with
solitary plasmacytoma. An MRI should also be considered in patients
with smoldering myeloma because it can detect occult lesions and if pos-
itive can predict for more rapid progression to symptomatic myeloma.
An MRI of the spine is indicated in case of back pain to exclude any soft
tissue mass arising from a bone lesion or for the investigation of patients
with a suspicion of cord compression. An MRI of the spine may also be
valuable in defining the etiology of new, painful collapsed vertebra. An
MRI is also strongly indicated in patients with nonsecretory myeloma for
the initial assessment and follow-up of response to treatment. PET-CT has
been shown to provide prognostic information at diagnosis in myeloma
(Bartel et al. Blood. 2009;114(10):2068–2076). A PET-CT is helpful for
detection of extraosseous soft tissue masses and evaluation of rib and
appendicular bone lesions. PET-CT is especially useful in patients with ele-
vated LDH, Bence Jones protein escape, and otherwise rapidly recurrent
disease or with suspected extramedullary plasmacytoma. Unlike MRI,
PET-CT obviates the need for a skeletal survey (Durie BG, et al. J Nucl
Med. 2002;43(11):1457–1463). In a large study studying gene expres-
sion profiling, it was shown that 70 genes linked to shorter durations of
complete remission, even-free survival, and OS (Shaughnessy et al. Blood.
2007 Mar 15;109(6):2276–2284). This 70-gene chip is now approved for
clinical use by Medicare. The SFLC assay is unlikely to provide any addi-
tional useful information in a patient with a quantifiable M spike on SPEP
at this time.Answer 34.9. The answer is B.
In patients with light chain myeloma, the IMWG recommends monitoring
the difference between the involved and uninvolved light chains to moni-
tor response (Dimopoulos et al. Blood. 2011;117:4701–4705). A decrease
of greater than or equal to 50% in the difference between involved and
uninvolved FLC levels is considered a partial response. In amyloidosis, it
is recommended to follow the absolute level of light chains for assessment
of response. The kappa/lambda light chain ratio is of prognostic impor-
tance in patients with MGUS and multiple myeloma (Kyle RA, et al.
N Engl J Med. 2007 Jun 21;356(25):2582–2590 and Rajkumar SV, et al.
Blood. 2005 Aug 1;106(3):812–817).Answer 34.10. The answer is A.
This patient has a solitary bone plasmacytoma. A large retrospective study
using the SEER database reported on prognostic factors and survival
of patients with plasmacytoma (Ramsingh et al. Br J Haematol. 2009