New Myeloma Diagnostic Criteria: To Treat or Not to Treat? Monocentric Experience of 220 Newly Multiple Myeloma Diagnosed Patients Retrospectively Analyzed

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 5629-5629 ◽  
Author(s):  
Lorenza Torti ◽  
Stefano Pulini ◽  
Anna Maria Morelli ◽  
Francesco Bacci ◽  
Paolo Di Bartolomeo
Keyword(s):  
Multiple Myeloma ◽  
Bone Marrow ◽  
Diagnostic Criteria ◽  
Time Course ◽  
Plasma Cells ◽  
Young Patients ◽  
Organ Damage ◽  
Diagnostic Markers ◽  
Monoclonal Protein ◽  
End Organ Damage

Abstract Newly significant advances have been made in diagnosis and treatment of multiple-myeloma (MM).Until recently,MM was defined by presence of end-organ-damage,specifically hypercalcemia, renal-failure, anemia and bone-lesions(CRAB-features). International-Myeloma-Working-Group(IMWG)revised diagnostic-criteria adding three specific-markers:clonal-bone-marrow-plasma-cells greater than 60%, serum-free-light-chain-ratio (FLC)more than 100 and at least two focal-lesions on magnetic-resonance-imaging(MRI). After this update,it's now time to change therapeutic-paradigm: new-IMWG-guidelines allow earlier intervention without waiting end-organ-damage to treat . Nevertheless there is much to learn and share about these new standards that change treatment. When is the right-time to start therapy?We have tried to answer to this dilemma in our work comparing traditional-CRAB-features with recent-myeloma-diagnostic-criteria in a group of 220 newly-diagnosed-MM followed in our Department from 1999 to 2015. The aim of our retrospective-study was to analyze development of new-IMWG-biomarkers during disease-course before CRAB-events and beginning-treatment,discussing their strengths and weaknesses as well as lights and shadows. We evaluated 110 young-patients elegible for high-dose-chemotherapy and autologous-stem-cell-transplant(ASCT)and 110 old(more than 65-year-old)treated with different-kind of therapies. We highlighted presence of IMWG-new-criteria as myeloma-defining-events(MDEs) before CRAB-markers in 44 MM-patients (20% of all): 33 of them are old (median-age of 72 years,range 53-91)and 11 are young (median-age 57,range 41-65) and treated with transplant-procedure. In details most of them presented FLC ratio >100 (30 patients as 68% of this subgroup), following by MRI-lesions(10 patients as 23%) and lastly plasma-cells-bone-marrow-involvement greater of 60%(4 patients as 9%). The majority of these patients (39 as 89%) developed CRAB-characteristics after six months (median value, range 3-15) and have evolved in myeloma-requesting-treatment in less than a year. 27 of them have IgG, 12 IgA and 5 micromolecular-MM. The largest-part (40 patients)has an antecedent MGUS and smouldering-MM.Moreover five young-patients of the whole-population analysed with MDEs and good-clinical-status weren't treated based-on our clinical-judgement and continued close-observation,saving them from both early-therapeutic-toxicity and clonal-selection. Only two patients of 220 started treatment based-on new-IMWG-biomarkers,presenting with clinical-deterioration and increase in monoclonal-component. In conclusion our paper proved that movement from symptoms to biomarkers is a huge-step-forward expecially for elderly-patients,considering both clinical-signs and biological-features. However we need more pratical-implementation of new markers that are changing philosophy of treatment: these patients should be offered appropriate clinical-trial. More caution is needed in high-risk-group expecially young to avoid an overtreating-policy,considering also counter-arguments. Physicians should continue monitoring patients using tools- now-available,while waiting for results from future-prospective-studies. Increase of monoclonal-componenent was analysed not as CRAB-classic-criterion but like disease-marker. The time-difference between new -IMWG-criteria and CRAB-events is less than one year (mean-value 6 months). Figure 1 New-IMWG-criteria-versus-traditional-CRAB. We have studied in our 44-patients with new-diagnostic-markers,time-course of hemoglobin, monoclonal-protein and creatinine-values. Figure 1. New-IMWG-criteria-versus-traditional-CRAB. We have studied in our 44-patients with new-diagnostic-markers,time-course of hemoglobin, monoclonal-protein and creatinine-values. Disclosures No relevant conflicts of interest to declare.

Serum Free Light Chain Ratio in Distinguishing Smoldering Multiple Myeloma From Active Multiple Myeloma,

Blood ◽  
2011 ◽  
Vol 118 (21) ◽  
pp. 3948-3948
Author(s):  
Jeremy T Larsen ◽  
Shaji Kumar ◽  
S. Vincent Rajkumar
Keyword(s):  
Multiple Myeloma ◽  
Bone Marrow ◽  
Predictive Value ◽  
Plasma Cells ◽  
Organ Damage ◽  
End Organ Damage ◽  
Cut Point ◽  
Smoldering Multiple Myeloma ◽  
Bone Marrow Plasma

Abstract Abstract 3948 Background: Smoldering multiple myeloma (SMM) is an asymptomatic precursor disease of multiple myeloma, and is defined by excess bone marrow plasma cells and monoclonal protein without evidence of end-organ damage (hypercalcemia, renal insufficiency, anemia, or bone lesions [CRAB]). The identification of SMM patients with more aggressive underlying disease remains a challenge. We hypothesize that SMM is a clinical entity comprised of both premalignant, high-risk MGUS and early multiple myeloma in transition to malignant disease, which may be differentiated with the use of the serum FLC (FLC) ratio. Methods: This was a retrospective analysis of 586 patients with newly diagnosed SMM from 1970–2010 with available stored serum samples around the time of diagnosis to be utilized for quantification of FLC ratios. SMM was defined by the International Myeloma Working Group 2003 definition; serum M-protein ≥ 3 g/dL and/or ≥ 10% bone marrow plasma cells with no evidence of CRAB features. The immunoglobulin FLC assay (Binding Site, U.K.) was used for testing. The FLC ratio was calculated as κ/λ (reference range 0.26–1.65). The involved/uninvolved FLC ratio was recorded to simplify the reporting of data. Receiver Operating Characteristics (ROC) curves were created to assess the ability of the FLC ratio to discriminate patients who progressed to symptomatic multiple myeloma (MM) in the first 2 years or at any point during follow-up versus patients without evidence of progression. Patients with less than 24 months follow-up without progression were censored. The optimal diagnostic cut-point for FLC involved/uninvolved ratio to identify patients with progressive disease from the ROC curve was >88.6 (equivalent to <0.011 or >88.6). For ease of clinical application, the optimal value for involved/uninvolved FLC ratio was rounded to >100. Time to progression (TTP) from date of the initial FLC to active MM was calculated using Kaplan-Meier analysis and compared to patients with a high (>100) and low (<100) involved/uninvolved FLC ratio at time of SMM diagnosis. TTP within 24 months of the initial FLC was also calculated. Results: During the study period, 54% of patients progressed to active MM. On ROC analysis, a cut-point of >100 corresponded to a sensitivity of 25% (95% CI, 20.5–30.4) and specificity of 99.3% (97.3–99.9), with positive likelihood (+LR) ratio of 33.9 (38.1–41.0), negative likelihood ratio (−LR) of 0.75 (0.2–3.0), positive predictive value (PPV) of 97.6 (91.5–99.7) and negative predictive value of 53.0 (48.5–57.4). Using the ROC to assess progression to MM within 24 months (Figure 1), sensitivity was 29.6% (23.5–36.4), specificity 94.5% (91.7–96.5), +LR 5.36 (4.3–6.6), -LR 0.75 (0.5–1.1), PPV 85.8 (77.7–91.8), and NPV 54.3 (49.8–58.9). Median TTP to active MM in the FLC >100 group was 15 months (9–17) versus 52 months (44–60) in the FLC <100 group (p <.0001) [Figure 2]. In the FLC ratio >100 group, progression at 1 year was 47%, 76% at 2 years, and 90% at 3 years. Only 25% of the FLC <100 patients had progressed at 2 years. The most common progression event was bone disease (42%), followed by anemia (26%), renal impairment (23%), and hypercalcemia (5%). Conclusion: Elevation of the FLC ratio >100 (or <0.01) is highly specific for the future development of active MM, with 76% of these patients developing end-organ damage requiring therapy within 2 years. Risk of transformation to MM in the FLC <100 group was similar to previously reported rates of 10% per year for the first 5 years. Development of an FLC ratio >100 is associated with increasing disease burden and in this study behaved in a malignant fashion rather than a precursor state. The FLC is a simple and useful predictor of progression to MM in SMM, and patients with FLC ratios of <0.01 or >100 within the first 2 years of SMM diagnosis should be monitored especially closely. Future studies are needed to determine optimum cutoffs for FLC ratio to where a change in definition of MM could be considered. Disclosures: No relevant conflicts of interest to declare.

Updated Diagnostic Criteria and Staging System for Multiple Myeloma

2016 ◽  
pp. e418-e423 ◽  
Author(s):  
S. Vincent Rajkumar
Keyword(s):  
Multiple Myeloma ◽  
Diagnostic Criteria ◽  
Plasma Cells ◽  
Staging System ◽  
Organ Damage ◽  
Focal Lesion ◽  
Bone Lesions ◽  
End Organ Damage ◽  
Serum Free Light Chain ◽  
Disease Definition

There has been remarkable progress made in the diagnosis and treatment of multiple myeloma (MM). The median survival of the disease has doubled as a result of several new active drugs. These advances have necessitated a revision of the disease definition and staging of MM. Until recently, MM was defined by the presence of end-organ damage, specifically hypercalcemia, renal failure, anemia, and bone lesions (CRAB features) that can be attributed to the clonal process. In 2014, the International Myeloma Working Group (IMWG) updated the diagnostic criteria for MM to add three specific biomarkers that can be used to diagnose the disease in patients who did not have CRAB features: clonal bone marrow plasma cells greater than or equal to 60%, serum free light chain (FLC) ratio greater than or equal to 100 provided involved FLC level is 100 mg/L or higher, or more than one focal lesion on MRI. In addition, the definition was revised to allow CT and PET-CT to diagnose MM bone disease. These changes enable early diagnosis and allow the initiation of effective therapy to prevent the development of end-organ damage for patients who are at the highest risk. A new staging system has been developed that incorporates high-risk cytogenetic abnormalities in addition to standard laboratory markers of prognosis.

Multiple myeloma and related conditions

2018 ◽  
Author(s):  
Graham Collins ◽  
Chris Bunch
Keyword(s):  
Multiple Myeloma ◽  
Bone Marrow ◽  
Monoclonal Gammopathy ◽  
Plasma Cells ◽  
Cell Clone ◽  
Bone Marrow Failure ◽  
Organ Damage ◽  
End Organ Damage ◽  
Clonal Proliferation ◽  
Uncertain Significance

Multiple myeloma is a cancerous disorder of the bone marrow and arises from a clonal proliferation of plasma cells, resulting in end-organ damage (e.g. renal failure, hypercalcaemia, bone disease, and bone marrow failure). When a plasma cell clone is only detected in one site (either bony or soft tissue), it is termed a plasmacytoma. Monoclonal gammopathy of uncertain significance is also a clonal proliferation of plasma cells but, by definition, does not result in end-organ damage. This chapter addresses the diagnosis and management of multiple myeloma.

scholarly journals Evolving diagnostic criteria for multiple myeloma

Hematology ◽  
2015 ◽  
Vol 2015 (1) ◽  
pp. 272-278 ◽  
Author(s):  
S. Vincent Rajkumar
Keyword(s):  
Multiple Myeloma ◽  
High Risk ◽  
Diagnostic Criteria ◽  
Organ Damage ◽  
Bone Lesions ◽  
End Organ Damage ◽  
Positron Emission ◽  
Disease Definition ◽  
Risk Of Progression ◽  
Asymptomatic Phase

Abstract Multiple myeloma (MM) is a plasma cell malignancy historically defined by the presence of end-organ damage, specifically, hypercalcemia, renal failure, anemia, and bone lesions (CRAB features) that can be attributed to the neoplastic process. In 2014, the International Myeloma Working Group (IMWG) updated the diagnostic criteria for MM to add specific biomarkers that can be used to make the diagnosis of the disease in patients who did not have CRAB features. In addition, the update allows modern imaging methods including computed tomography (CT) and positron emission tomography-CT to diagnose MM bone disease. These changes enable early diagnosis, and allow the initiation of effective therapy to prevent the development of end-organ damage in patients who are at the highest risk. This article reviews these and several other clarifications and revisions that were made to the diagnostic criteria for MM and related disorders. The updated disease definition for MM also automatically resulted in a revision to the diagnostic criteria for the asymptomatic phase of the disease termed smoldering MM (SMM). Thus the current diagnosis and risk-stratification of SMM is also reviewed in this article. Using specific prognostic factors, it is possible to identify a subset of patients with SMM who have a risk of progression to MM of 25% per year (high-risk SMM). An approach to the management of patients with low- and high-risk SMM is discussed.

Multiple Myeloma Course with Renal Insufficiency in Young Patient: Case Report

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 26-26
Author(s):  
Hugo Henrique de Freitas Ferreira ◽  
Alessandra Suelen Jardim Silva ◽  
Lenilton Silva DA Silva Júnior ◽  
Gustavo Henrique de Medeiros Oliveira ◽  
Maria das Graças Pereira Araujo ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Bone Marrow ◽  
Young Patient ◽  
Mononuclear Cells ◽  
Plasma Cells ◽  
Serum Proteins ◽  
Conflicts Of Interest ◽  
Young Patients ◽  
Treatment Strategies ◽  
Malignant Neoplasm

Introduction: Multiple myeloma (MM) is a malignant neoplasm characterized by the clonal proliferation of abnormal plasma cells in the bone marrow (OM). The average age of patients diagnosed with MM is approximately 70 years, being relatively uncommon in younger individuals. Objective: To report a case of a young patient with multiple myeloma. Case Description: A 42-year-old male patient presented with continuous and progressive low back pain for 3 months, associated with adynamia, weight loss (10 kg), episodes of constipation and bleeding in the oral cavity in this period. Examinations at the first appointment revealed moderate anemia (Hb 7.4 g / dL), leukocytosis, thrombocytopenia, hypercalcemia, and altered renal function (Cr 5.9 and Ur 178), chest tomography indicating vertebral fracture in T6, T11, L2 and L4. Referred for specialized follow-up, he performed electrophoresis of serum proteins with the presence of a monoclonal peak in the gamma globulin fraction. The immunofixation test confirmed monoclonality for IgA isotype and Kappa light chain (IgA / Kappa). The myelogram showed plasmacytosis of more than 50% of mononuclear cells in the bone marrow. He developed renal failure (with dosage of creatinine of 10.1 mg/ dL. and urea of 208 mg/dL) and hypercalcemia requiring dialysis therapy on the third day of hospitalization, having undergone chemotherapy with Bortezomib, cyclophosphamide and dexamethasone. During this period, infection by the multisensitive S. aureus in catheter occurred and, despite being treated with specific antibiotic therapy, it evolved with clinical worsening and hemodynamic instability and was referred to the Intensive Care Unit, going to death after 2 days. Conclusion: Young patients with MM may study with more aggressive characteristics. Despite the use of new therapeutic agents, more effective treatment strategies need to be studied more for patients in this age group. Disclosures No relevant conflicts of interest to declare.

An Intact Immunoglobulin IgAλ Multiple Myeloma Patient Exhibiting Light Chain Escape

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 5008-5008
Author(s):  
Maria Kraj ◽  
Barbara Kruk ◽  
Krzysztof Warzocha ◽  
Andrzej Szczepinski ◽  
Kelly Endean ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Bone Marrow ◽  
Bone Marrow Biopsy ◽  
Light Chain ◽  
Plasma Cells ◽  
Induction Treatment ◽  
Mild Renal Impairment ◽  
Multiple Myeloma Patient ◽  
Monoclonal Protein ◽  
Serum And Urine

Abstract Abstract 5008 A 48 year old man was referred to the Institute of Hematology and Transfusion Medicine, Warsaw, Poland in April 2008 with anemia (Hemoglobin; 10. 4 g/dl) and mild renal impairment (eGFR; 75. 4 mL/min/1. 73m2). An initial diagnostic monoclonal protein screen (serum protein electrophoresis (SPE), serum immunofixation electrophoresis (IFE) and serum free light chain (FLC) analysis) revealed an IgAλ monoclonal protein (0. 8g/dL) with monoclonal serum FLC and an abnormal serum FLC κ/λ ratio (0. 0001; RI, 0. 26–1. 65). A bone marrow biopsy at that time confirmed 60% involvement of monoclonal λ - restricted plasma cells; a bone survey did not detect any osteolysis. The patient was diagnosed with multiple myeloma (MM) (ISS stage I, Durie and Salmon stage IA) and was initially treated with 6 cycles of vincristin, doxorubicin and dexamethasone (VAD). The patient responded well to the induction treatment and subsequently underwent a successful autologous stem cell transplantation (ASCT). The patient was monitored for 3 years subsequent to the ASCT with both serum and urine electrophoresis, serum FLC analysis (Freelite) and heavy chain/light chain (HLC) immunoassays (Hevylite). Sixteen months following the ASCT the dFLC (involved λ FLC– uninvolved κ FLC) concentration began to increase, the FLC κ/λ ratio became abnormal with a trace of λ Bence Jones protein (BJP) detected by urine IFE. However, both SPE and IFE were normal and the HLC ratio (IgAλ/IgAκ) was within the normal range. During the next 9 months the dFLC continued to increase and a λ BJP could now be clearly detected on the urine IFE. 27 months following the ASCT the patient sustained a pathological fracture of the tibiae and was referred to our centre 4 months later. At this point, the dFLC concentration was highly elevated (3168 mg/L) with a λ BJP detectable by both serum and urine IFE. However, there was no detectable monoclonal intact immunoglobulin by serum IFE or HLC analysis, indicating disease relapse by a separate FLC clone; referred to as light chain escape (LCE). A bone marrow biopsy revealed 15% involvement of λ restricted plasma cells; this time a bone survey identified osteolysis. The patient was diagnosed with progression of multiple myeloma and received 6 cycles of bortezomib, cyclophosphamide and dexamethasone (VCD regimen). He responded well to treatment and 3 years following the ASCT achieved a CR as indicated by a normalized κ/λ FLC ratio, negative immunofixation with 1–3% bone marrow plasma cells. The patient is now well and able to continue with normal life. In this case study the increase in the dFLC levels was the first indication of disease progression and highlights the importance of monitoring intact immunoglobulin MM patients with serum FLC immunoassays for early detection of LCE. Disclosures: Endean: The Binding Site Group Ltd: Employment. Harding:Binding Site: Employment.

Plasma Cell Dyscrasias

2019 ◽  
pp. 33-38
Author(s):  
Kevin B. Hoover
Keyword(s):  
Multiple Myeloma ◽  
Bone Marrow ◽  
Clinical Trials ◽  
African Americans ◽  
Plasma Cell ◽  
Plasma Cells ◽  
Organ Damage ◽  
Disease Staging ◽  
Plasma Cell Dyscrasias ◽  
Urine Testing

Chapter 76 discusses plasma cell dyscrasias, which are currently incurable diseases resulting from the proliferation of plasma cells and the secretion of immunoglobulins with associated anemia and end-organ damage. These diseases are more common in men than women and more common in African Americans than whites. Multiple myeloma is the most common of the plasma cell dyscrasias. Blood and urine testing, bone marrow biopsy, and radiography are the primary tests used for diagnosis. Radiographs are the standard tools in disease staging and monitoring with advanced imaging used primarily for evaluating symptomatic patients with negative radiographs and patients in clinical trials.

Myeloma and paraproteinaemias

2010 ◽  
pp. 4342-4355
Author(s):  
Robert A. Kyle ◽  
S. Vincent Rajkumar
Keyword(s):  
Bone Marrow ◽  
Renal Insufficiency ◽  
Plasma Cell ◽  
Plasma Cells ◽  
Organ Damage ◽  
Bone Lesions ◽  
Neoplastic Diseases ◽  
End Organ Damage ◽  
Single Clone

The paraproteinaemias are a group of neoplastic (or potentially neoplastic) diseases associated with the proliferation of a single clone of immunoglobulin-secreting plasma cells. This asymptomatic condition of unknown cause is characterized by a serum paraprotein concentration under 30 g/l, less than 10% monoclonal plasma cells in the bone marrow, and no evidence of end-organ damage (CRAB) hypercalcaemia, renal insufficiency, anemia, and bone lesions related to the plasma cell proliferative process....

scholarly journals Treatment Approaches of Multiple Myeloma

2021 ◽  
Author(s):  
Minyahil Alebachew Woldu ◽  
Atalay Mulu Fentie ◽  
Tamrat Assefa Tadesse
Keyword(s):  
Multiple Myeloma ◽  
Bone Marrow ◽  
Plasma Cells ◽  
Clinical Investigation ◽  
Malignant Neoplasm ◽  
Bone Destruction ◽  
Organ Damage ◽  
Autologous Stem Cell Transplant ◽  
Bone Lesions ◽  
Newly Diagnosed

Multiple Myeloma (MM) is the most common malignant neoplasm of plasma cells that accumulate in bone marrow, leading to bone destruction and marrow failure. Clinical investigation of MM requires the evaluation of bone marrow for plasma cell infiltration, and detection and quantification of monoclonal protein in the serum or urine, and evidence for end-organ damage (i.e., hypercalcemia, renal insufficiency, anemia, or bone lesions). The overall goal of treatment of MM is to improve survival. The treatment landscape and clinical outcome of MM have changed in the last two decades, with an improved median survival of 8–10 years. Management of MM involves induction, consolidation, and maintenance therapy. Currently, Autologous stem cell transplant (ASCT) is considered as the standard care of treatment for newly diagnosed fit MM patients. Multiple combinations of proteasome inhibitors (PIs) and immunomodulatory drugs (IMIDs) such as Thalidomide, lenalidomide, and pomalidomide have been under evaluation in ASCT-eligible and ineligible settings, and studies are still ongoing. For patients with ASCT-eligible newly diagnosed MM, induction therapy with triple drugs should contain an IMiD, a PI, and a corticosteroid, usually lenalidomide-bortezomib-dexamethasone. For ASCT-ineligible patients on lenalidomide with dexamethasone (Rd), with addition of bortezomib or daratumumab can be considered.

Multiple Myeloma Variant with Ascites and Cytoplasmic Crystalline Granules in Plasma Cells

Blood ◽  
2011 ◽  
Vol 118 (21) ◽  
pp. 5088-5088
Author(s):  
Cesar Rodriguez ◽  
Anthony Janckila ◽  
Sylvia Potenziani ◽  
Vivek R. Sharma
Keyword(s):  
Multiple Myeloma ◽  
Bone Marrow ◽  
Monoclonal Gammopathy ◽  
Plasma Cells ◽  
Conflicts Of Interest ◽  
Clinical Work ◽  
Cytoplasmic Inclusions ◽  
Monoclonal Protein ◽  
Crystalline Inclusions ◽  
Work Up

Abstract Abstract 5088 CASE REPORT: CLINICAL HISTORY: A 62-year-old male patient who presented with anemia and findings of monoclonal gammopathy of IgA type was referred to the Hematology clinic for work-up and management of possible multiple myeloma. At the same time, the patient was being managed by the Gastroenterology service with diuretics and recurrent paracentesis for an ongoing significant ascites of unclear etiology. These interventions had been performed for a year on a biweekly basis. CLINICAL WORK-UP: The patient had IgA gammopathy with a monoclonal protein level of 1.2 Gm/dL and findings on skeletal survey consistent with lytic lesions in the pelvic bones. PROCEDURE: A bone marrow biopsy obtained from the patient revealed a plasmacytosis of 15% with atypical crystalline cytoplasmic inclusions seen in the majority of plasma cells and some histiocytes as well. The transudative ascitic fluid was analyzed for crystalline deposits, but these could not be conclusively detected even though there were inclusions seen in some macrophages that may represent remnants of the crystals. TREATMENT: The patient was diagnosed with IgA myeloma given the above findings and was treated with a combination of Revlemid, Velcade and Dexamethazone with good response in terms of his IgA monoclonal protein as well as in significant improvement in his ascites, which essentially resolved. He no longer required therapeutic paracentesis upon initiation of chemotherapy and was able to get weaned off of diuretics as part of his treatment. CONCLUSION: This case represents what we believe to be a rare variant of multiple myeloma that presented with monoclonal gammopathy in the blood as well as concomitant ascites. The bone marrow showed plasma cells containing crystalline inclusions. The precise nature of these inclusions is presently unknown, however it is felt most likely to be precipitated immunoglobulins. We plan to investigate this further. For reasons that are not entirely clear, this particular biology appears to induce a reactive process in the peritoneum causing a development of ascites. The resolution of such ascites with treatment directed toward the myeloma seems to indicate that the two are related. A case similar to this was reported by Doctors Martin, et al in 1987 with a patient presenting with similar type of crystalline inclusions in plasma cells with clinically associated ascites.1 There was no information available on treatment effect and so it was not possible to tie the clinical presentation of the myeloma and ascites together. Disclosures: No relevant conflicts of interest to declare.

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