Multiple Myeloma Diagnosis

For additional information, please visit the National Cancer Institute.

The work-up for Multiple Myeloma involves 4-5 days of testing as follows:

Complete Blood Profile
This is used to identify counts of white cells, red cells, platelets, and other indicators of blood composition. These tests are done to determine the quality of bone marrow, kidney function and liver function.

Protein Electrophoresis
This measures the amount of M-protein in serum and urine. An abnormal amount of M-protein is an indicator of the extent of disease. Blood and urine samples of the patient will be collected to do this test. However, it is important to remember that myeloma cells may produce less or even no M-protein as the disease becomes more aggressive.

Bone Marrow Aspiration / Biopsy
These are used to estimate the number of myeloma cells, their activity in the bone marrow, and the degree of damage to normal bone marrow structure caused by myeloma cells. The sample will also be used for Cytogenetics testing. The test is preferably done on the back of the hipbone, although it may be done on the front of the hipbone or on the breastbone. A local anesthetic is normally used to numb the area. The procedure takes about 30 minutes. Bone marrow aspiration is done by inserting a needle through the bone into the marrow cavity and withdrawing a small amount of marrow. As the needle enters the bone marrow cavity, the patient may feel some pressure and discomfort. Once the needle is positioned, the technologist/physician attaches a syringe to collect the marrow material. The needle is then removed and the insertion site is bandaged. Bone marrow biopsy is done by inserting a larger, hollow needle through the bone into the marrow cavity to remove a sample of solid tissue. This procedure does not leave a permanent hole in the bone, as the cells immediately begin to fill in the area to create new bone. A small incision is made through the skin and the needle is inserted through the incision into the bone marrow cavity. Since the needle is hollow, a small piece of bone is retained and the needle is removed. The site is covered with a sterile dressing for a couple of days. It is important to remember that myeloma often is a focal disease, meaning that there can be areas in the bone with large numbers of myeloma cells and areas with small numbers of or no myeloma cells. The aspirate or biopsy may hit a pocket of myeloma cells and overestimate the overall amount of myeloma cells. It may also hit a spot with no myeloma cells, while there is still myeloma present in other areas of the bone marrow.

Complete Skeletal Bone Survey
The Survey is used to identify the extent of bone disease caused by the myeloma and to evaluate any significant bone damage that may need immediate attention. X-rays of the hands, arms, legs, feet, ribs, back, pelvis, and skull will be obtained with low doses of radiation.

Magnetic Resonance Imaging (MRI)
MRI is a computerized scan of bone and bone marrow, conducted via computerized measurements of radio waves, that enables a close-up view of the bone marrow. It is more effective than other x-rays in highlighting the presence of myeloma. MRI can identify the exact location and approximate volume of myeloma cells, and it can indicate whether the myeloma has spread. MRI is a safe procedure that does not involve x-rays, radiation, or surgery. In order to obtain clear images on the computer, dye may be injected into the patient’s vein. The patient is asked to lie still on a scan table that slides into the MRI machine while the computerized images are being obtained. The machine does not touch the patient. However, the machine makes loud sounds while the images are being produced. Some patients may feel uneasy about the MRI, in which case the doctor might give the patient medication for relaxation prior to the procedure. A complete MRI for new patients takes about 3 hours and a limited MRI for returning patients takes about an hour and a half. If lesions are seen during the MRI, the physician may order a fine needle aspiration of the lesion for additional testing.

Computerized Tomography (CT) Guided Needle Biopsy
When MRI indicates presence of myeloma, a biopsy may be necessary. To locate the exact position for the biopsy, a CT scan is performed. The biopsy needle is inserted into the area of bone destruction that is seen on the CT scan. This is more precise than a regular biopsy since the radiologist can pin point the site within a millimeter. During a CT Guided Needle Biopsy, the patient is asked to lie on the stomach or back. A local anesthetic shot is administered to the area to numb it. The patient is moved in and out of the CT scanner in order to find the exact location for placement of the biopsy needle. The biopsy sample is then analyzed. A CT Guided Needle Biopsy takes about an hour to perform.

Positron Emission Tomography (PET Scanning)
PET is utilized to show the presence of active cancer and other abnormalities that are too small to be shown by conventional methods. PET Scanning enables detection of myeloma outside the bone marrow and evaluation of the presence of remaining myeloma after transplantation. Since cancer involves metabolic processes, PET, which utilizes a metabolic imaging technique, works well. PET is the only imaging technique that shows whether a tumor is benign or malignant. Reports in the scientific literature indicate that PET correctly identifies detected lesions 97% of the time. It is an excellent test for monitoring recurrence of disease. Patients cannot eat prior to having a PET scan, although they can have water and can take prescribed medications, excluding insulin. Patients may experience slight discomfort from injection of radioactive dye. The scanning takes about 45 minutes.

Cytogenetics Testing
The testing identifies chromosomal abnormalities in the myeloma cells. Bone marrow samples obtained during aspiration and/or biopsy are used. The chromosomal abnormalities for myeloma are specific to the myeloma cells and are not present in other body cells. These chromosomal abnormalities have major significance for physicians’ treatment decisions.

Bone Densitometry
Bone Densitometry allows us to determine the status of bone strength and the amount of bone loss even when no symptoms exist. Bone densitometry testing provides baseline information that is helpful for future treatment decisions. It is a safe, painless, non-invasive test that does not require any special preparation. While having a bone densitometry done, the patient lies down on the back with feet propped up. No medication is needed unless the patient has new fractures that may hurt while lying down on their back. The test involves delivery of a very low radiation exposure (about 1/5 that of a chest x-ray). Usually scans are performed of the forearm, hip and spine. Bone densitometry testing takes about 30-40 minutes.

Echocardiogram (ECHO)
An ECHO produces, via sound waves, a moving image of the beating heart on a video screen. The physician can analyze the heart’s thickness, size, and function, as well as the motion pattern and structure of the four heart valves. ECHO is helpful in detecting damage and disease. When performing an echocardiogram, the technician first prepares the chest area by applying a conductive gel and then places a small device called a transducer on the patient's chest. An image of the area is viewable on a video monitor. An ECHO takes about 30 minutes.

Multi Gated Acquisition Scan (MUGA)
A MUGA provides, via radionuclide imaging, information about blood flow, how well the heart is pumping and the functions of lower heart chambers (ventricles). A very small amount of a radioactive isotope (tracer) is administered intravenously and then a gamma camera is used to produce very clear images of the heart tissues. The tracer is usually eliminated harmlessly from the body within 48 hours. There can be slight discomfort at the needle site. The procedure takes about 40 minutes.

Electrocardiogram (EKG)
An EKG graphically records the heart’s electrical activity on paper or video monitor. EKGs provide important information about the heart’s rate and rhythm, and the presence of past or current heart attacks. EKGs are routine tests. They are non-invasive, quick, safe, painless, relatively inexpensive, and do not utilize radiation. To perform an electrocardiogram, a technician applies gel to ten cleaned areas on the chest. Small metal devices (electrodes) are then applied and connected by wires to the electrocardiograph machine. The patient must lie perfectly still for about one minute as resting-heart activity is measured and recorded. Each electrode produces a "tracing" or "lead" of a particular area of the heart and its activity. As a stand-alone test, the entire EKG takes about 5 to 10 minutes.

Pulmonary Function Testing
Such testing provides important information about lung capacity and effectiveness and the quality of lung function.

Spirometry measures breathing capacity and flow rates. The patient inhales maximally and exhales forcefully and completely, and then immediately inhales maximally into a device called a spirometer.

Lung Volumes measure the total amount of air in the lungs and capacity volumes of the lung compartments. Lung volumes may be done using the following techniques:

Body Plethysmography: The patient sits in a clear chamber and breathes on a mouthpiece. During the test, the patient is asked to inspire against a closed shutter for 2 seconds, 2-3 times. At the end of the measurements, the patient performs a slow maximal inhalation followed by a maximal exhalation.

Helium Dilution: The patient breathes a helium gas mixture for 3-7 minutes and then performs a slow maximal inhalation followed by a maximal exhalation.

Single Breath Diffusing Capacity (DLCO)
This measures the ability of the lungs to transfer oxygen into the bloodstream and carbon dioxide out of the bloodstream. The patient is asked to exhale maximally, followed by maximal inhalation of a test gas. The patient is asked to hold his breath for 10 seconds followed by an exhalation. This is repeated 2-3 times.

Arterial Blood Gas measures the amount of oxygen, carbon dioxide and pH of an arterial blood sample. Most often a small sample of blood is drawn from the radial artery in the right or left wrist. These tests require some effort on the part of the patient, who must work cooperatively with the technician. The procedure takes 30 minutes to an hour.

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