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Hematology Multiple Myeloma Diagrrosis: The CRAB mnemonic encompasses most myeloma-related signs and symptoms: . C (hyperCalcemia) . R (Renal failure) . A (Anemia) . B (Bone disease: lytic lesions, fractures, or osteoporosis) Testing: Diagnostic tests for multiple myeloma include CBC; serum chemistries; SPEP; 24 hour UPEP; serum and urine immu- nofixation assays; serum free light chain testing; and serum IgG, IgA, and IgM measurements. Think of multiple myeloma in patients with a low anion gap. Whole body, low dose CT or PET CT is recommended to detect lytic bone lesions. STUDY TAELEt Diagnosis of Multiple Myeloma and MGUS Multiple Myeloma/MGUS Findings MGUS Serum monoclonal protein <3 g/dL or urinary M protein <500 mg/24 6 Bone marrow clonal plasma cells <10% No CRAB Monoclonal gammopathy of renal significance See Nephrology; Kidney Manifestations of Deposition Diseases Smoldering multiple myeloma Serum monoclonal protein >3 g/dL or urinary free light chain M protein >500 mg/24 h Bone marrow clonal plasma cells 10%-59% No CRAB Multiple myeloma requiring therapy Serum monoclonal protein present Bone marrow clonal plasma cells >10% CRAB positive Most smoldering multiple myeloma progresses to multiple myeloma requiring therapy or to AL amyloidosis DOil'T BE TRICKED . In patients with myeloma and back pain, MRI should also be performed to assess for spinal cord impingement, even in the absence ofmotor or sensory deficits. . Do not use bone scans in patients with suspected myeloma because they are not as sensitive as a CT or PET CT. Treatment: Treat multiple myeloma requiring therapy with induction chemotherapy. Following induction chemotherapy, autologous HSCT may be considered.

DOil'T BE TRICKED . In patients with myeloma and back pain, MRI should also be performed to assess for spinal cord impingement, even in the absence ofmotor or sensory deficits. . Do not use bone scans in patients with suspected myeloma because they are not as sensitive as a CT or PET CT. Treatment: Treat multiple myeloma requiring therapy with induction chemotherapy. Following induction chemotherapy, autologous HSCT may be considered. DOil'T BE TRICKED . Do not treat MGUS. o Bortezomib and thalidomide used in induction chemotherapy are associated with a high risk of peripheral neuropathy. . Thalidomide, lenalidomide, or pomalidomide used in induction chemotherapy is associated with an increased risk ofVTE. ALAmyloidosis Diagnosis: AL amyloidosis is found in 10'7, of patients with multiple myeloma but may be diagnosed in patients who Iack other myeloma findings. 199