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What's the Take Home?

A 72-Year-Old Woman With an Abnormality on Incidental Blood Testing

  • AUTHOR:
    Ronald N. Rubin, MD1,2Series Editor

    AFFILIATIONS:
    1Lewis Katz School of Medicine at Temple University, Philadelphia, PA
    2Department of Medicine, Temple University Hospital, Philadelphia, PA

    CITATION:
    Rubin RN. A 72-year-old woman with an abnormality on incidental blood testing. Consultant. 2022;62(4):e39-e41. doi:10.25270/con.2022.04.00004

    DISCLOSURES:
    The author reports no relevant financial relationships.

    CORRESPONDENCE:
    Ronald N. Rubin, MD, Temple University Hospital, 3401 N Broad Street, Philadelphia, PA 19140 (blooddocrnr@yahoo.com)


    A 72-year-old woman presented for her annual routine Medicare examination. She reported that she does not routinely visit a primary care physician but undergoes sporadic blood pressure checks for mild essential hypertension, which is managed by an angiotensin-converting enzyme (ACE) inhibitor. There were no other significant findings in the patient’s history, systems review, and physical examination.

    A routine complete blood cell count, basic chemistry panel, and biochemical screen were obtained. Results of these tests—specifically her hemoglobin level, creatinine level, and chemistries— were within normal limits, except for an elevated total protein level of 8.5 g/dL (normal range, 6.0-8.0 g/dL). The reference laboratory performed a “reflex” serum protein electrophoresis (SPEP) test suspicious for the presence of an IgG kappa monoclonal (M) protein level of 0.7 g/dL.

    After a telephone consultation with a hematologist, the attending general internist ordered an immunofixation blood test, which confirmed an M protein level of IgG kappa of 0.8 g/dL with normal levels and ratios of free gamma and lambda light chains.

    Which of the following is the best strategic option for further managing this patient’s condition?

    A. She should be managed by clinical observation and repeat blood studies at 6 to 12 months.

    B. She should be monitored at 3-month intervals with initiation of therapy if there is any increase in the M protein levels.

    C. She should be started on a standard multiple myeloma regimen to prolong her overall survival.

    D. She should be referred for autologous bone marrow transplantation while her tumor burden is minimal and a cure is possible.

References

1. Kyle RA, Finkelstein S, Elveback LR, Kurland LT. Incidence of monoclonal proteins in a Minnesota community with a cluster of multiple myeloma. Blood. 1972;40(5):719-724.

2. Kyle RA. Monoclonal gammopathy of undetermined significance. Natural history in 241 cases. Am J Med. 1978;64(5):814-826. doi:10.1016/0002-9343(78)90522-3

3. Mouhieddine TH, Weeks LD, Brobrial IM. Monoclonal gammopathy of undetermined significance. Blood. 2019;133(23):2484-2495. doi:10.1182/blood.2019846782

4. Go RS, RajKumar SV. How I manage monoclonal gammopathy of undeterminedsignificance. Blood. 2018;131(2):113-173. doi:10.1182/blood-2017-09-807560

5. Kyle RA, Larson DR, Therneau TM, et al. Long-term follow-up at monoclonal gammopathy of undetermined significance. N Eng J Med. 2018;378(3):241-248. doi:10.1056/ NEJMoa1709974

6. Sigurdardottir EE, Turesson L, Lund SH, et al. The role of diagnosis and clinical follow up of monoclonal gammopathy of undetermined significance on survival in multiple myeloma. JAMA Oncol. 2015;1(2):168-174. doi:10.1001/ jamaoncol.2015.23

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