Review Question - QID 104660

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Multiple Myeloma Studies Invasive studies QID: 104660 (M2.ON.14.20)

QID 104660 (Type "104660" in App Search)

A 57-year-old woman with a history of hypertension presents to her physician with severe mid-back pain. She reports that the pain is sharp and began when she was reaching to retrieve a plate from a cabinet in her kitchen. She denies any major trauma to the back or any history of lifting heavy objects. On exam, she has spinal tenderness over the site, which is not warm or erythematous. On laboratory evaluation, she is found to have a creatinine of 5.6 mg/dL and a calcium of 16 mg/dL. Which of the following bone marrow biopsy findings is most likely to be found in this patient?

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Figure A

84%

16/19

Figure B

0/19

Figure C

1/19

Figure D

1/19

Figure E

0/19

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This patient's clinical presentation is consistent with multiple myeloma (MM). Bone marrow biopsy in this condition shows plasma cell overgrowth (Figure A).

MM is a plasma cell neoplasm characterized by overproduction of plasma cells that results in increased levels of IgG or IgA. It typically presents with bone pain, hypercalcemia, and renal failure, and is often found after a non-traumatic fracture in middle-aged patients. Definitive diagnosis requires a bone marrow biopsy, however serum protein electrophoresis showing a monoclonal immunoglobulin "M-spike" is highly suggestive of MM.

Nau and Lewis discuss the diagnosis and treatment of MM. They note that bone pain, fatigue, and pathologic fractures are common presentations of MM. Fevers are only present in 0.7% of patients. The differential diagnosis for monocolonal gammopathies should include asymptomatic MM, non-Hodgkin lymphoma, monoclonal gammopathy of uncertain significance (monoclonal antibody overproduction without end organ damage), and Waldenstrom macroglobulinemia.

Avigan and Rosenblatt discuss new developments in treatment for multiple myeloma. Although autologous stem cell transplant is currently the standard of therapy for MM, new data suggests that several immune modulating agents may also be effective in treatment of MM. They conclude that, among patients < 65 years old with MM, standard treatment should be autologous stem cell transplant with high-dose chemotherapy, followed by maintenance therapy with immune modulating agents.

Figure A shows a bone marrow biopsy with plasma cell overgrowth that is typical of MM, with notable "fried-egg" appearance. Figure B shows Call-Exner bodies, which are found in granulosa cell tumors and are characterized by eosinophilic, fluid-filled areas in granulosa cells. Figure C shows Reed-Sternberg cells, which are found in Hodgkin's lymphoma and are characterized by large B-cells with large, eosinophilic inclusions. Figure D shows Howell-Jolly bodies, which are found in asplenic patients and are characterized by uncleared, basophillic DNA remnants in erythrocytes. Figure E shows smudge cells, which are found in chronic lymphocytic leukemia and are characterized by fragile, burst lymphocytes that lack a functional cell membrane.

Incorrect Answers:
Answer 2: Call-Exner bodies are found in granulosa cell tumors.
Answer 3: Reed-Sternberg cells are found in Hodgkin's lymphoma.
Answer 4: Howell-Jolly bodies are found in asplenic patients.
Answer 5: Smudge cells are found in chronic lymphocytic leukemia.