Multiple Myeloma Initial Assessment

Clinical Presentation

Multiple myeloma patients usually present with bone pain and fatigue due to anemia. On clinical evaluation, patients may present with bone pain and nonspecific symptoms such as nausea, vomiting, malaise, weight loss, generalized body weakness, and fatigue. 

Physical Examination

Patients usually have no obvious abnormalities upon examination, although pallor (due to anemia) may be present. 

Diagnosis or Diagnostic Criteria

Diagnostic Criteria for Smoldering Myeloma

The presence of both of the following clinches the diagnosis of smoldering myeloma: 

• Serum monoclonal protein ≥3 g/dL or Bence-Jones protein ≥500 mg/24 hours and/or 10-59% clonal bone marrow plasma cells (BMPCs)
• Absence of myeloma-defining events (CRAB criteria) or amyloidosis 

Patients with ≥2 of the following risk factors are considered to have a high risk of progression to multiple myeloma: 

• BMPCs >20%
• M-protein >2 g/dL
• Free light-chain (FLC) ratio of >20

Diagnostic Criteria for Active Multiple Myeloma  

≥10% clonal BMPCs or biopsy-proven bony or extramedullary plasmacytoma plus evidence of ≥1 myeloma-defining event: 

• CRAB criteria: 
  • Elevated Calcium levels (>0.25 mmol/L [>1 mg/dL] higher than the upper limit of normal [ULN] or >2.75 mmol/L [>11 mg/dL])
  • Renal insufficiency (serum creatinine >2 mg/dL [>177 μmol/L] or creatinine clearance <40 mL/min)
  • Anemia (hemoglobin [Hgb] <10 g/dL or Hgb >2 g/dL below the lower limit of normal)
  • ≥1 osteolytic Bone lesion/s on skeletal radiography, CT scan, or fluorodeoxyglucose (FDG) positron emission tomography with computed tomography (PET/CT)
• Biomarkers:
  • ≥60% clonal BMPCs 
  • Involved/uninvolved serum FLC ratio ≥100 or involved FLC concentration ≥10 mg/L 
  • More than 1 focal lesion based on skeletal MRI ≥5 mm in size