Question: I would like to know why the pathologist feels highly suspicious for plasma cell neoplasm in a background of normal plasma cells? The marrow is mildly hypo cellular (30%) and contains all 3 hematopoietic lines. Immunoperoxidase staining for CD138(performed on the biopsy) demonstrates approximately 15% plasma cells while in situ hybridization for kappa and lama light chains (performed on the the biopsy) demonstrates a kappa:lama ratio of approximately 2.5:1. Immunoperoxidase for CD56 does not demonstrate reactivity with these cell populations. The myeloid:erythroid ratio is within normal limits(2.5:1) and the maturation of both cell lines proceeds normally with no increase of blast or maturational arrest. Adequate number of megakaryocytes are present and are morphologically unremarkable. Special stain for iron( performed on the biopsy, clot section and pirate smear) demonstrate 1-2+ iron; occasional siderblasts are seen but no increase of ringed sideroblast is identified.
Flow cytometry performed demonstrates a kappa light chain excess among polytypic plasma cells with a subset demonstrating immunophenotypic aberrancy. These findings are reported as highly suspicious for plasma cell neoplasm in a background of normal plasma cells. This population cannot be definitely identified by light microscope methods.

HISTORY OF PRESENT ILLNESS: The patient is a 47 YO with no past medical history. noted to
have low bone density five years ago and repeat one again showed low bone density. SPEP show 09 g/dL M spike. White count ls 4.3. hemoglobin 14 3. and platelets 265.000. Creatinine 1.1 and IgG of 1468.
lgA 93. IgM 114 UPEP. urine protein lmmunoflxation negative and serum immunoflxation shows 196
kappa and kappa chain is 13. lambda is 8.69. kappa to lambda 1.50. We will order a skeletal survey and also bone marrow aspiration and biopsy and regroup in 10 days. However. i do not see any end-organ damage at this point, He probably has MGUS. No significant other symptoms,
WBC 3.7, RBC 4.56, HGB 13.9, HCT 41.4, MCV 90.8, MCH 30.4, MCHC 33.5, RDW 13.3, PLT 217 ,MVP 217 ANC 0
PAST MEDICAL HISTORY: No diabeles or hypertension, No heart problems.
SURGERIES:
1. Vasectomy.
2. Wisdom teeth extraction.
MEDICATIONS: Vyvanse and vitamin D and calcium.
SOCIAL HISTORY: No smoking. Drlnks alcohol almost 5 days a week. Married. Has three children and Lives In XXXXXXX Self-employed.
FAMILY HISTORY: Mother had heart valve replacement. She is on Coumadin. Father has stroke.
hypertension. diabetes. and has almost 14 half siblings. one half brother died of leukemia. Paternal
grandfather has skin cancer. Grand father liver cancer.
ALLERGIES: No known drug allergies.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: No fever. chills. or night sweats. No loss ofweight or appetite.
CARDIOVASCULAR: No shortness of breath, chest pain. PND. orthopnea. palpitations.
RESPIRATORY: No lever. cough, or mucoid sputum
GASTROINTESTINAL: No abdominal pain. nausea. vomiting. homelemeels. or mslena.
NEUROLOGICAL: No headaches. dlplopia. seizures. loss ofconsciousness.
ENDOCRINE: No heat or cold intolerance.
PHYSICAL EXAMINATION:
HEENT: There is no pallor icterus.
LUNGS: Clear. No palpable adenopathy.
HEART: SI and S2 heard, No murmur or gallop.
ABDOMEN: Soft. non-tender. Bowel Bounds positive,
EXTREMITIES: No edema.
LABORATORY RESULTS: White count 5.9, hemoglobin 14.8, and platelets 277,000. Creatinine 1.1,
Sodium 138. potassium 4.3. chloride 101, calcium 9.4.
IMPRESSION AND RECOMMENDATIONS: A 47 YO M with no past medical history. has M-protein of 1gIdL CBC normal. Calcium and creatlnin is normal. SPEP shows a g/dL lgG kappa. UPEp and urine immunofixation is negative. Quantitative Immunoglohulins are normal. At this point. no end-organ damage noted. We will check a bone marrow aspiration and biopsy and skeletal survey and will see him back within 10 days. Most likely he has MGUS.

Ok there was a skeletal evaluation included in the attachment. I am not sure if you were able to review the attached reports which included the bone scan survey. There were no focal lytic lesions. There was some mild acromioclavicular joint hypertrophy. (Please review the report for additional Impression Summary). Do you feel that smoldering myeloma patients with normal MRIs have a lower rate of progression to active, symptomatic disease? Please share with your success with prevention of progression of to MM.

Ok I provided your diagnostic opinion during the review of the reports today and was told that it before we are able consider this Smoldering Myeloma we must first look at the FLC report because this patient does not meet CRAB and even though there is a slight M-Spike, it is not nominal. Also the because of the CD138 shows 15% of Plasma Cells from the biopsy is considered vague until I review the Clonal Cell Type percentage. I was told told that the age and symptoms are another factor to consider MGUS rather than SMM. They said MGUS cases requiring staining for lambda/kappa/CD138 and look at plasma cells clonality. In most cases one can see that there are both normal PC and monoclonal population present , which results in s.c. clonal excess i.e. pathological kappa/lambda ratio. The difference with myeloma would be that the normal plasma cells are not there any more. Then I was told to go back over the lab reports. I looked at todays blood report again and the {WBC =3.4 (low) rng 4.8 -10.8} {RBC= 4.8(normal) rng 4.7-6.1}{LY#= 1.0(low) rng 1.2 -3.4}. I have gone over the reports and blood/urine/scans since March and reviewed old records with first report of osteopenia reported 4 yrs ago by PCP. I requested a MRI or PET/CT and now I must provide a reason why I want the imaging and explain why. I guess the role of PET scan (or spine and pelvic MRI ) for monitoring or following high risk SMM patients has not been studied to my knowledge. Also, I should avoid performing additional imaging during surveillance of SMM, particularly if the pertinent blood work is stable and the patient is asymptomatic. Really this is very frustrating seems like everything I present it challenged. I almost want to tell them I am speaking with a seasoned Oncologist who agrees with my findings. Yet I am unable to share this information with further objections. Please tell me how you would address this matter. I will wait to get the FCL report as suggested and then provide my final opinion report. As for the imagining I will request the MRI first. Because according to Dr. Kappor "Doctors are still learning to integrate these modalities into their practice. For example, MRI findings in smoldering myeloma patients (who by definition have no detectable areas of bone destruction on X-rays) can be predictive of outcomes as they provide additional information about the rate of progression to active myeloma. Smoldering myeloma patients with normal MRIs have a lower rate of progression to active, symptomatic disease. If more than 1 focal lesion is noted on MRI of smoldering myeloma patient, the chances of progression to active myeloma are greater. If the pattern of marrow involvement on MRI is similar to that seen in monoclonal gammopathy of undetermined significance (MGUS) patients, the chances to progressing into symptomatic multiple myeloma are lower. Importantly, areas with bone marrow abnormalities detected on MRI may not necessarily suggest increased threat to bone destruction. However, closer monitoring may be required due to higher risk of progression to active disease. So please tell me how I should present this without offending others opinions. I need to defend my opinion and request for additional testing.

I know you are correct and I appreciate your time. Dont worry there is no need for me to argue with the her. I will present these FACTS that I trust valid. Thank you and Be Blessed!

Dr. Juvvadi {http://www.texasoncology.com/doctors/sridevi-juvvadi} is unclear of how Smoldering Myeloma could be the diagnosis. According to her she says that when you look at the number of poly vs. mono plasma cells in the FISH report (it is the last 2 pages of the attached report). There is not enough of a significant difference of mono cells. However she says that she will order a PET CT if that help us see that Smoldering Myeloma is a premature diagnosis. I said no to PET CT because I feel that an MRI who be less radiation an would show a good whole body scope also. It really is frustrating to me because I have reviewed the Immunophenotypic analysis and based on a few things I wonder if it is "ALL". Please review and tell what you think.