Talk:Monoclonal gammopathy of undetermined significance

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[edit] Diagnosis, Haematology referral and skeletal surveying

Thanks to Gak for recent additions, but there is now seems a conflict in the article as to making the diagnosis and when a patient is referred to a haematologist.

Previously the article would have inferred (although not explicitly so stated) that diagnosis is purely by serum electrophoresis identifying a monoclonal band and of this being a small quantity (a high level indicating a multiple myeloma). Only with annual protein electrophoresis monitoring, showing an increasing level, would referral then be made to a haematologist and only then would they arrange an X-ray skeletal survey.

The current version of the article though implies that a skeletal survey is required as part of the original diagnosis, and thus that immediate initial referral to a haematologist is required in order to have this requested & arranged. Of the few cases that I have identified in the last few years, I seem to recall that on speaking to various local haematologists that not all cases were deemed needing referral, and of those that I did refer, not all had initial skeletal surveys performed.

Hence 2 questions:

• Firstly what is common practice at time of just a blood test suggesting a MGUS ? (are patients referred to haematologists, and what if any further tests vs. just explanation do haematologists arrange) - NB "common practice" is not necessarily the same as "textbook" list of complete and unabridged "all possible" investigation workup.
• Secondly, if initial haematologist arranged skeletal survey is performed as part of diagnosis, then mention of referral/arranging of X-rays at the end of the article under 'Annual review' is presumably misplaced in the article. David Ruben ^Talk 02:10, 31 December 2006 (UTC)

Off the cuff, my experience (in the U.S.) has been that if there's a positive SPEP and any reason at all to suspect frank myeloma (e.g. anemia, back pain, renal insufficiency, etc) then a skeletal survey and a marrow are warranted. And of course, in most cases you wouldn't be ordering an SPEP unless at least one of the above was present, so most patients end up getting the above workup. However, if it's a small M-spike found incidentally and the patient is asymptomatic, you could defer the survey/marrow, because even in the unlikely event that the criteria for myeloma were met, you might not actually treat the patient until they progress or develop an indication. Patients are often referred to a hematologist, because I think a lot of primary care docs are uncomfortable writing off an M-spike without specialist input. If it's a clear case of MGUS, then they often get sent back to the primary care doc with a recommendation to follow the SPEP alone every 6 months or yearly and re-refer if the M-spike is consistently rising or other signs (anemia, bone pain, etc) develop. I'll try to dig up a reference actually codifying that approach, for the article. MastCell 21:12, 31 December 2006 (UTC)

Thanks David Ruben ^Talk 03:06, 1 January 2007 (UTC)

My own experience (NHS UK) is that the skeletal survey is only performed by the haematologist after referral. I think practice is likely to vary from country to country, and probably region to region within the UK. I doubt that there are formal guidelines (except specifically for the US) that say whether a skeletal survey is done before or after referral of by whom. I have to say that I have not noticed that the skeletal survey ever contributes very much to the management of the patient anyway, unless the patient has bone pain or a pathological fracture. --Gak 19:26, 7 January 2007 (UTC)

I agree, it rarely contributes to management unless there's a clear-cut impending fracture of a weight-bearing bone, in which case XRT could be used. The survey is really important diagnostically though (i.e. if you have lytic lesions, it's myeloma and not MGUS). MastCell 20:56, 7 January 2007 (UTC)

I'm a practicing hematologist. I commonly will order a bone survey and repeat blood and urine electrophoresis at the first visit and do a bone marrow biopsy at the second visit. I have had cases of occult lytic disease, and it's nice to know about this from the "get-go," as they say. If the referring internist wants to get the bone survey, more power to them, but many times they are tempted to get a bone scan, which is not the same thing (if they even think about lytic disease in monoclonal disease, which ain't often).--Dr.michael.benjamin 07:56, 19 February 2007 (UTC)

[edit] Differential diagnosis

Hi, please don't delete my table before discussing it here on the talk page...I think it's important for people to consider the differential diagnosis of MGUS, because it ain't all myeloma. I had a rash of scared patients in my office last month for monoclonal gammopathy, convinced after "research on the internet" that they had myeloma, and one turned out to have Guillain-Barre (!) and the other a Splenic Marginal Zone Lymphoma (!). So we should consider the alternatives before doctors or patients assume the worst.--Dr.michael.benjamin 07:59, 19 February 2007 (UTC)