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MGUS/Myeloma

MGUS and myeloma encompass a wide spectrum of problems from an incidental finding that will be of no consequence to the patient and is very common (eg a small MGUS paraprotein in an elderly patient) to a life threatening emergency that requires treatment as soon as possible (eg myeloma with cord compression or acute renal failure).

There is no single diagnostic test. Diagnosis is made based on a variety of results. Plain xrays do not detect all myelomatous bone lesions. CT/MRI are required if there is a high index of suspicion. When associated with neoplasia, IgM paraproteins are usually associated with a low grade lymphoma whereas IgG/IgA paraproteins and BJP tend to be associated with myeloma but there is cross over.

When to refer 2 week wait haem OPD  - if you are concerned that the patient has myeloma for example –

1)      Presence of unexplained anaemia/renal failure/hypercalcaemia/excess infection/bone pain, or lytic lesions/vertebral collapse that is not typical of osteoporosis (eg younger man)

AND

2)      A paraprotein (if you are very concerned you do not need to wait for the full result please discuss with the on call haematologist on basis of the initial results) or immuneparesis (some patients do not have a paraprotein but may have low IgG/IgA/IgM) or positive BJP result.

(Note this is a more detailed explanation of the 2ww criteria on the 2ww form which essentially says ‘results of PE/BJP/radiology suggest myeloma’)

When to refer routine haem OPD:

·         IgG paraprotein >15g/l or IgA paraprotein >10g/l or BJP >0.2g/l or IgM paraprotein >15g/l any age group where further investigation considered appropriate

OR

·         Younger (<60 years) or more anxious patient with a paraprotein that would like further investigation and follow up via the MGUS distance clinic rather than in the community

OR

·         A paraprotein plus any concerning features (eg anaemia, renal failure, bone pain, infection) that require further investigation, but are stable and not urgent

OR

·         If the paraprotein level increases by more than 25% in 6 months during monitoring (a minimum absolute increase of 5g/l)

If a patient has an IgG paraprotein <15g/l or an IgA paraprotein <10g/l or a BJP <0.2g/l or an IgM paraprotein <15g/l and there is no evidence of end organ damage (no unexplained anaemia, renal impairment, hypercalcaemia, unexplained bony lesions, organomegaly or lymphadenopathy) then it is reasonable for their MGUS to be monitored in the community. See MGUS community follow up for RMS sheet for further advice.

MGUS patient information: http://www.macmillan.org.uk/information-and-support/diagnosing/causes-and-risk-factors/pre-cancerous-conditions/mgus.html

MGUS community follow up for RMS

If a patient has either:

·         an IgG paraprotein <15g/l or

·         an IgA paraprotein <10g/l or

·         a BJP <0.2g/l or

·         an IgM paraprotein <15g/l

and there is no evidence of end organ damage -               no unexplained anaemia

no renal impairment

no hypercalcaemia

no unexplained bony lesions

no organomegaly or lymphadenopathy

then it is reasonable for their MGUS to be monitored in the community. Tests (FBC U&E Ca PE and a BJP if the BJP was positive) should initially be repeated in 3-4 months and if stable monitor 6-12 monthly thereafter.

Paraproteins usually increase in size with time. There is no set number at which they become a specific concern if the patient is otherwise well and there are no other concerns. If an IgG or IgM paraprotein has risen to >20g/l or an IgA to >15g/l or BJP >0.2g/l or if the paraprotein level increases by more than 25% in 6 months  (with minimum absolute increase of 5g/l) then you might wish to refer to the haematology OPD or take advice.

 As patients become frailer, or have a limited prognosis due to their other conditions, you may wish to take a pragmatic decision not to continue to monitor their paraprotein especially if it is small or has been stable for a long period of time.

If you are not happy to monitor an MGUS patient in the community or have any concerns please contact the haematology team either :

1.       via C&B for advice or routine clinic review or

2.       if there is suspicion of myeloma, via the 2ww or

3.       if concerns about acute renal failure, cord compression or hyperviscosity speak to the on call haematology consultant via switchboard.

MGUS patient information: http://www.macmillan.org.uk/information-and-support/diagnosing/causes-and-risk-factors/pre-cancerous-conditions/mgus.html