Community Oncology

47 year old female with pmh of Obesity, HTN, HLD, GERD, IBS who has been referred to Hematology/Oncology for monoclonal gammopathy evaluation. Lab testing: Free Lambda 105, Free Kappa 16.89, K/L 0.16, SPEP M-spike 1.82 g/dl, SIFE IgG Lambda, Serum IgG 2760, B2M 2.05, Coags including Factor X WNL's, 24 hour Urine IFE Faint IgG Lambda monoclonal Immunoglobulin detected, CBC WNL's including HB 12.8, Creatinine [0.6] and Calcium [9.3] WNL's. Skeletal survey reported "isolated small lucent lesion in temporal calvarium measuring 5 mm" ---> CT head reports "subtle areas of lucency within the calvarium with slight thinning of the adjacent cortex." BM Biopsy: lambda restricted plasma cells (20-30%). staining for amyloid negative. Cytogenetics normal. FISH shows hyperdiploidy [chromosome 5 and 9]. Workup showing smoldering myeloma. Except for those "calvarium spots." which I favor are benign. I'm considering MRI brain vs. PET/CT. Wanted to ask if you have had any suggestions/recommendations.

Myeloma Specialist

This happens quite frequently and can be difficult as our instincts tell us they are benign, they are almost certainly beign (ie venous lakes), but the radiologist read makes this more complex. i always favor an MRI of the brain, preferrably with diffusion weighted images. this will hopefully officially tell you that they are hypocellular and not sites of myeloma