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{{WBRQuestion
{{WBRQuestion
|QuestionAuthor={{Rim}}
|QuestionAuthor={{Rim}}, {{AJL}} {{Alison}}
|ExamType=USMLE Step 1
|ExamType=USMLE Step 1
|MainCategory=Pathology
|MainCategory=Pathology
Line 20: Line 20:
|MainCategory=Pathology
|MainCategory=Pathology
|SubCategory=Hematology
|SubCategory=Hematology
|Prompt=A 78 year old patient presents to the physician’s office complaining of back pain that is not relieved by medications and fatigue of several weeks duration. Evaluation of the patient reveals anemia, elevated levels of serum calcium, and renal insufficiency. Peripheral smear of the patient’s blood shows characteristic “rouleaux formation”.  The diagnosis of multiple myeloma is made. Which of the following markers is most commonly used for staging of multiple myeloma?
|Prompt=A 78-year-old male presents to the physician’s office with complaints of back pain, which is not relieved by medications, and fatigue of several weeks duration. Evaluation reveals anemia, elevated levels of serum calcium, and renal insufficiency. A peripheral smear of the patient’s blood shows characteristic “rouleaux formation”, characteristic of multiple myeloma. Which of the following markers is most frequently used for the staging of multiple myeloma?
|Explanation=[[Multiple myeloma]] is a common hematologic cancer characterized by [[monoclonal gammopathy]]. It manifests as [[hypercalcemia]], [[renal insufficiency]], [[anemia]], and lytic bone lesions; but occurrence of all 4 is not necessarily always present (mnemonic: CRAB – Calcium, Renal, Anemia, Bone).  [[Rouleaux formation]] on peripheral smear is also a characteristic feature of multiple myeloma.  
|Explanation=[[Multiple myeloma]], a common hematologic cancer characterized by [[monoclonal gammopathy]], frequently manifests with [[hypercalcemia]], [[renal insufficiency]], [[anemia]], and lytic bone lesions (mnemonic: CRAB – Calcium, Renal, Anemia, Bone).  [[Rouleaux formation]] on peripheral smear is also characteristic of [[multiple myeloma]].  
 
Multiple myeloma staging does not utilize the [[TNM system]]. Instead, the [[International Staging System]] (ISS) for multiple myeloma depends on levels of serum [[β2 microglobulin]] and [[albumin]].  
Multiple myeloma staging does not utilize the [[TNM system]]. Instead, the [[International Staging System]] (ISS) for multiple myeloma depends on levels of serum [[β2 microglobulin]] and [[albumin]].  
Stage I: Serum β2 microglobulin < 3.5 mg/L and serum albumin ≥ 3.5 g/dL
Stage I: Serum β2 microglobulin < 3.5 mg/L and serum albumin ≥ 3.5 g/dL
Stage II: Between stage I and III
Stage II: Between stage I and III
Stage III: Serum β2 microglobulin ≥ 5.5 mg/L
Stage III: Serum β2 microglobulin ≥ 5.5 mg/L


Educational Objective:
|EducationalObjectives= [[Multiple myeloma]] staging does not utilize the TNM system.  Instead, the [[International Staging System]] (ISS) for multiple myeloma is dependent on levels of serum β2 microglobulin and albumin.  
Multiple myeloma staging does not utilize the TNM system.  Instead, the International Staging System (ISS) for multiple myeloma depends on levels of serum β2 microglobulin and albumin.  


Reference:
|References= Mihou D, Katodritou E, Zervas K. Multiple myeloma staging based on the combination of beta-2-microglobulin and albumin: the role of albumin in the model.  Hematology.  2007;12(6):527-31.
Mihou D, Katodritou E, Zervas K. Multiple myeloma staging based on the combination of beta-2-microglobulin and albumin: the role of albumin in the model.  Hematology.  2007;12(6):527-31.






|AnswerA=BUN / Creatinine ratio
|AnswerA=BUN/Creatinine ratio
|AnswerAExp=BUN / Creatinine ratio is not useful for staging f multiple myeloma.  It is helpful in determining the type of renal injury, as to whether it is pre-renal, instrinsic, or post-renal.
|AnswerAExp=A [[BUN/Creatinine ratio]], not useful for staging multiple myeloma, aids in distinguishing between types of renal injury (pre-renal, instrinsic, or post-renal).
|AnswerB=β2 microglobulin and albumin levels
|AnswerB=β2 microglobulin and albumin levels
|AnswerBExp=β2 microglobulin and albumin levels are used in the ISS for multiple myeloma staging system.
|AnswerBExp= Serum β2 microglobulin and albumin levels are used by the ISS for staging multiple myeloma.
|AnswerC=CA-125 level
|AnswerC=CA-125 level
|AnswerCExp=CA-125 levels are useful marker in follow-up of patients with ovarian cancer.  However, CA-125 is not considered a diagnostic test of ovarian cancer and should not be used for diagnostic purposes.
|AnswerCExp=CA-125 levels are frequently checked in the follow-up of patients with ovarian cancer, but should not be used for diagnostic purposes.
|AnswerD=p53 and Retinoblastoma gene (Rb) activities
|AnswerD=p53 and Retinoblastoma gene (Rb) activities
|AnswerDExp=p53 and Rb are tumor suppressor genes that are inactivated in many cancers.  They are not useful for staging in multiple myeloma.
|AnswerDExp=The tumor suppressor genes, p53 and Rb, are inactivated in many cancers, but are not useful for staging multiple myeloma.
|AnswerE=Hemoglobin S levels
|AnswerE=Hemoglobin S levels
|AnswerEExp=Hemoglobin S levels, detected by hemoglobin electrophoresis, is diagnostic of sickle cell disease.
|AnswerEExp=Hemoglobin S levels, detected by hemoglobin electrophoresis, is used in the diagnosis of sickle cell disease.
|RightAnswer=B
|RightAnswer=B
|WBRKeyword=beta, microglobulin, albumin, multiple, myeloma, rouleaux, formation, anemia, hypercalcemia, lytic, bone, renal, insufficiency, failure, gammopathy, monoclonal
|WBRKeyword= beta-2-microglobulin, albumin, multiplemyeloma, anemia, hypercalcemia, bone, renal, staging, ISS, rouleaux formation
|Approved=No
|Approved=Yes
}}
}}

Revision as of 18:55, 21 July 2014
Author [[PageAuthor::Rim Halaby, M.D. [1], Alison Leibowitz [2] (Reviewed by Alison Leibowitz)]]
Exam Type ExamType::USMLE Step 1
Main Category MainCategory::Pathology
Sub Category SubCategory::Hematology
Prompt [[Prompt::A 78-year-old male presents to the physician’s office with complaints of back pain, which is not relieved by medications, and fatigue of several weeks duration. Evaluation reveals anemia, elevated levels of serum calcium, and renal insufficiency. A peripheral smear of the patient’s blood shows characteristic “rouleaux formation”, characteristic of multiple myeloma. Which of the following markers is most frequently used for the staging of multiple myeloma?]]
Answer A AnswerA::BUN/Creatinine ratio
Answer A Explanation [[AnswerAExp::A BUN/Creatinine ratio, not useful for staging multiple myeloma, aids in distinguishing between types of renal injury (pre-renal, instrinsic, or post-renal).]]
Answer B AnswerB::β2 microglobulin and albumin levels
Answer B Explanation AnswerBExp::Serum β2 microglobulin and albumin levels are used by the ISS for staging multiple myeloma.
Answer C AnswerC::CA-125 level
Answer C Explanation AnswerCExp::CA-125 levels are frequently checked in the follow-up of patients with ovarian cancer, but should not be used for diagnostic purposes.
Answer D AnswerD::p53 and Retinoblastoma gene (Rb) activities
Answer D Explanation AnswerDExp::The tumor suppressor genes, p53 and Rb, are inactivated in many cancers, but are not useful for staging multiple myeloma.
Answer E AnswerE::Hemoglobin S levels
Answer E Explanation AnswerEExp::Hemoglobin S levels, detected by hemoglobin electrophoresis, is used in the diagnosis of sickle cell disease.
Right Answer RightAnswer::B
Explanation [[Explanation::Multiple myeloma, a common hematologic cancer characterized by monoclonal gammopathy, frequently manifests with hypercalcemia, renal insufficiency, anemia, and lytic bone lesions (mnemonic: CRAB – Calcium, Renal, Anemia, Bone). Rouleaux formation on peripheral smear is also characteristic of multiple myeloma.

Multiple myeloma staging does not utilize the TNM system. Instead, the International Staging System (ISS) for multiple myeloma depends on levels of serum β2 microglobulin and albumin. Stage I: Serum β2 microglobulin < 3.5 mg/L and serum albumin ≥ 3.5 g/dL Stage II: Between stage I and III Stage III: Serum β2 microglobulin ≥ 5.5 mg/L
Educational Objective: Multiple myeloma staging does not utilize the TNM system. Instead, the International Staging System (ISS) for multiple myeloma is dependent on levels of serum β2 microglobulin and albumin.
References: Mihou D, Katodritou E, Zervas K. Multiple myeloma staging based on the combination of beta-2-microglobulin and albumin: the role of albumin in the model. Hematology. 2007;12(6):527-31.]]

Approved Approved::Yes
Keyword WBRKeyword::beta-2-microglobulin, WBRKeyword::albumin, WBRKeyword::multiplemyeloma, WBRKeyword::anemia, WBRKeyword::hypercalcemia, WBRKeyword::bone, WBRKeyword::renal, WBRKeyword::staging, WBRKeyword::ISS, WBRKeyword::rouleaux formation
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