investigations

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Recommended tests for the diagnosis of myeloma and related organ dysfunction are as follows (1):

history and physical examinations

investigations recommended by British Committee for Standards in Haematology (BCSH)/UK Myeloma Forum (UKMF)

The UKMF/BCSH guidelines on the diagnosis and management of multiple myeloma recommends that investigation of a suspected myeloma patient should include screening tests followed by further tests to confirm the diagnosis (1).

Screening test

full blood count (FBC), ESR or plasma viscosity
urea, creatinine, calcium, albumin
electrophoresis of serum and concentrated urine
quantification of non-isotypic immunoglobulins

NICE state (2):

use serum protein electrophoresis and serum-free light-chain assay to confirm the presence of a paraprotein indicating possible myeloma or monoclonal gammopathy of undetermined significance (MGUS)
if serum protein electrophoresis is abnormal, use serum immunofixation to confirm the presence of a paraprotein indicating possible myeloma or MGUS
do not use serum protein electrophoresis, serum immunofixation, serum-free light-chain assay or urine electrophoresis (urine Bence-Jones protein assessment) alone to exclude a diagnosis of myeloma

Tests to establish diagnosis

bone marrow aspirate + trephine biopsy with plasma cell phenotyping
immunofixation of serum and urine
skeletal survey

Tests to estimate tumour burden and prognosis

Fluorescence in situ hybridisation (FISH) analysis
quantification of monoclonal protein in serum and urine
albumin 2 - microglobulin
skeletal survey

NICE state with respect to prognostic information (2):

when performing a bone marrow aspirate and trephine biopsy to provide prognostic information:
- perform fluorescence in-situ hybridisation (FISH) on CD138-selected bone marrow plasma cells to identify the adverse risk abnormalities t(4;14), t(14;16), 1q gain, del(1p) and del(17p)(TP53 deletion). Use these abnormalities alongside International Staging System (ISS) scores to identify people with high-risk myeloma
- consider performing FISH on CD138-selected bone marrow plasma cells to identify the adverse risk abnormality t(14;20), and the standard risk abnormalities t(11;14) and hyperdiploidy
- consider performing immunophenotyping of bone marrow to identify plasma cell phenotype, and to inform subsequent monitoring
- consider performing immunohistochemistry (including Ki-67 staining and p53 expression) on the trephine biopsy to identify plasma cell phenotype and give an indication of cell proliferation, to provide further prognostic information
perform serum-free light-chain assay and use serum-free light-chain ratio to assess prognosis

Tests to assess myeloma related organ impairment (ROTI)

FBC
serum urea and creatinine
creatinine clearance (measured or calculated)
calcium albumin plasma viscosity
tissue biopsy (or fat pad aspirate) for amyloid (if suspected)
quantification of non-isotypic immunoglobulins
skeletal survey

Special tests indicated in some patients

SFLC assay in oligo secretory, light chain only and non secretory disease
MRI, CT scan (1)

NICE state (2):

imaging for people with suspected myeloma
- offer imaging to all people with a plasma cell disorder suspected to be myeloma
- consider whole-body MRI as first-line imaging
- consider whole-body low-dose CT as first-line imaging if whole-body MRI is unsuitable or the person declines it
- only consider skeletal survey as first-line imaging if whole-body MRI and whole-body low-dose CT are unsuitable or the person declines them
- do not use isotope bone scans to identify myeloma-related bone disease in people with a plasma cell disorder suspected to be myeloma

Reference:

Last reviewed 12/2019

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