Lymphadenopathy: Multiple Myeloma (Introduction)

by Carlo Raj, MD

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    00:01 Multiple myeloma.

    00:02 Okay, well, M.

    00:04 There are a lot of M’s in multiple myeloma.

    00:06 But it is not IgM that you’re producing right off the bat.

    00:12 It is an intact monoclonal immunoglobulin.

    00:14 You call this an M protein.

    00:16 And be very, very careful.

    00:18 So it’s called an M protein, but it is not referring to IgM.

    00:22 That must be understood.

    00:24 Before I move on further, I want you to pay attention to a very special type of electrophoresis and this is called serum protein electrophoresis, SPE.

    00:36 You’ll notice please from the left to the right, you’re moving from the cathode, the positive towards the negative on the right.

    00:43 And as you do so, well, we all know that the most abundant protein in our circulation, albumin, albumin, albumin.

    00:50 There it is.

    00:52 Next, take a look at the electrophoresis.

    00:54 Because this is normal – the top big picture by the way, normal, perfectly normal.

    00:59 You’ll notice because of all that albumin that we have that’s being produced by our liver, you’ll find a very strong band, right? Albumin, being the greatest.

    01:09 Then you have the others, alpha 1, alpha 2, and beta.

    01:12 And I’ll walk you through that a little bit.

    01:14 It’s called an alpha 1 zone, alpha 2 zone, a beta zone, and it would be in your best interest to at least note a few pathologic significance for these zones.

    01:24 And then, I want you to pay attention at this point for us to diagnose our plasma cell neoplasms, the gamma.

    01:33 You see that gamma wave, the Greek sign for gamma.

    01:36 Be careful, most students think that gamma is IgG only.

    01:41 No, no, no.

    01:42 Gamma refers to all immunoglobulin, all of them.

    01:45 So be very careful with that.

    01:47 What are they? G-A-M-E-D, gamed.

    01:50 That gamma wave represents normal all immunoglobulin.

    01:54 And I want you to take a look at the band below.

    01:57 By band, I mean immediately below the normal gamma wave.

    02:01 You see that band, it’s rather broad.

    02:04 It has to be because you’re producing a lot of immunoglobulin, the one that comes out first will be IgM, well, depending as to, you know, what kind of pathology that is taking place with your patient.

    02:14 Well, you might then do isotype searching and perhaps you have IgG for chronic infection, and then perhaps IgA if you’re dealing with type 1 hypersensitivity.

    02:24 Have we put things in perspective for you yet? If not, make sure you are well-versed with serum protein electrophoresis versus – Now, take a look at the bottom.

    02:35 We have a monoclonal gammopathy, you’ll notice that I said monoclonal gammopathy.

    02:39 I did not say multiple myeloma specifically.

    02:41 I did not mention here Waldenstrom specifically and I did not mention MGUS specifically.

    02:46 I said monoclonal gammopathy.

    02:48 The three that I just mentioned, multiple myeloma, Waldenstrom, and MGUS, monoclonal gammopathy of undetermined significance, those are all monoclonal gammopathies.

    02:59 So what does that mean to you? If you have monoclonality that’s taking place with plasma cells, plasma cells that are found where? Good.

    03:09 Bone marrow.

    03:11 Because in the bone marrow, you’d expect to find quite a bit of plasma cells that are doing what? Producing tons of immunoglobulins, whatever that may be.

    03:18 I’ll get into the details as to what immunoglobulin is being produced in what disease.

    03:24 But give me a second here.

    03:26 You’ll notice, please, the normal’s on top and the pathology’s on the bottom.

    03:31 You say pathology on the bottom first beginning by looking at the albumin.

    03:36 The albumin is still going to be abundant, but it’s a little bit decreased when compared to normal, obviously.

    03:42 I’ll show you why.

    03:44 And then you go alpha 1, alpha 2, beta, okay? Oh, my goodness gracious.

    03:48 Then you have a gamma spike, okay? A gamma spike.

    03:52 What does that gamma wave normally represent? All immunoglobulins, so let it be MGUS, let it be Waldenstrom or let it be multiple myeloma, you’re going to be producing a lot of immunoglobulins in general.

    04:05 Therefore, wouldn’t you expect there to be a gamma spike? Of course, you do.

    04:09 Compare that – Well, take a look at that gamma spike and I want you to correlate that spike to the band below, you’d find a darkened, broadened band.

    04:21 Compare that dark band to the above normal band and obviously you see the difference.

    04:28 Increased concentration or increased secretion of immunoglobulins.

    04:33 So multiple myeloma, which one is it? Not IgM.

    04:38 Not IgM.

    04:41 Not IgM.

    04:43 What is it? It would be IgG most likely or perhaps IgA, but sure as heck, it’s not going to be IgM.

    04:52 So therefore, with all these immunoglobulin that you’re producing, either IgG or IgA, would you not expect your gamma wave to then become a spike? Yes, you do.

    05:02 That’s exactly what’s happened here.

    05:04 In addition, what else would you expect to find in terms of anatomy of the immunoglobulin with multiple myeloma? The light chains.

    05:13 Which ones are they? Kappa and lambda.

    05:16 Kappa by far being the most common.

    05:18 What happens with these light chains? Well, these would then pass through your glomerulus or may even deposit on your glomerulus.

    05:27 And so therefore, if I told you Congo red, then you would tell me? Remember we talked about this in nephrology.

    05:33 You would tell me amyloid accumulation on your glomerulus.

    05:36 When it passes through, the light chains passes through the glomerulus, it ends up being in your urine, what do you call this? Bence Jones protein, right?

    About the Lecture

    The lecture Lymphadenopathy: Multiple Myeloma (Introduction) by Carlo Raj, MD is from the course Lymphadenopathy – White Blood Cell Pathology (WBC).

    Included Quiz Questions

    1. Albumin
    2. Fibrin
    3. Immunoglobulin M
    4. Globulin
    5. Heptoglobin
    1. …albumin
    2. …gamma
    3. …alpha1
    4. …beta1
    5. …alpha2
    1. Bence Jones protein
    2. Coronin
    3. Amyloid
    4. Albumin
    5. Globulins

    Author of lecture Lymphadenopathy: Multiple Myeloma (Introduction)

     Carlo Raj, MD

    Carlo Raj, MD

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