Hemato-Oncology-27-Myeloma Presentation

HEMATO-ONCOLOGY PART-27

Question: Dr. Chiragbhai, thank you for explaining last time about when to suspect Multiple Myeloma? Conditions seem nonspecific, but easy to diagnose, ifone considers diagnosis.

Answer: Yes, you are right. Back pain, anemia etc seem nonspecific but this is the most important message I would like the readers to remember i.e. when to consider diagnosis and how to reach diagnosis. Majority patients can be diagnosed early and one can prevent renal failure, spine fracture, paraplegia, sepsis.

Recently, I received a call from someone I know for IV iron injection. She is a 62 year old lady with anemia for several months, and was on oral iron and vitamins under medical supervision. Since she was not responding, family called me and we discussed possibility of IV iron. We still asked her to just come in once, and my colleague Dr Munjal Pandya, decided not to “label” her as iron deficiency anemia, without basic tests. He asked for cbc, esr, ferritin, protein, creatinine, liver function. Within few hours, we knew esr and protein were high with raised globulin. He added SPEP (serum protein electrophoresis) which was clearly abnormal. Bone marrow biopsy and other ancillary tests were done for completion, and myeloma was diagnosed EARLY.

It was easier to give her IV iron, and “forget” it for one month. It is possible that in one month, she would have developed any of the severe complications mentioned above.

So, the important message is that please do not assume a common diagnosis, without doing a common test e.g. iron deficiency anemia, without test for ferritin (especially if one month of iron has not increased Hb). Same holds true for Back pain. Do not assume that a back pain which has not resolved in few weeks requires change of analgesics, more rest and physiotherapy. I recently had a very interesting learning in this regard from my orthopedic friend. He asked his radiology friend at an MRI center about frequency of cancer diagnosed on MRI spine. To my shock, about 20% of all MRI spine done at that center, for evaluation of Back Pain, showed signs of a cancer, either metastatic disease from some cancer or myeloma. These are high risk patients for paraplegia, and dear colleagues, also high risk medicolegally. Patient with a missed cancer diagnosis, who develops paralysis, may not easily forgive his doctor.

A simple rule to reduce risk of missing a cancer diagnosis (and many other serious diseases) and at the same time not over investigating, is to use the following rule: Diagnosis must be made in following Time Frame (use judgment if you feel your particular pt does not fit this criteria or you use different cut off numbers) –

1. Mild symptom – one month e.g. Hb 10, or mild back pain
2. Moderate severity – 2 weeks e.g. Hb 8, Creatinine 2, or daily need for pain killer
3. Severe symptom/Asymptomatic lab value – hours to days e.g. do not sit on an Hb 4-5 (assuming it must be iron or B12 deficiency – it could be myeloma, leukemia, hemolysis, bleeding…), Creatinine 3 or more, or severe back pain (not relieved in one or two days inspite of rest, analgesics – investigate or refer to orthopedic – could be myeloma, metastatic cancer…)

Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA), 079 26754001. Diplomate American Board of Oncology and Hematology. Ahmedabad. drchiragashah@gmail.com

Shyam Hem-Onc Clinic. 402 Galaxy, Near Shivranjani, Opp Jhansi ki Rani BRTS, Ahmedabad. www.shyamhemoncclinic.com