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A Model for Managing Patients with Monoclonal Gammopathy of Undetermined Significance
When should bone marrow sampling be performed in patients with monoclonal gammopathy of undetermined significance (MGUS)? Currently, algorithmic approaches based on a Mayo Clinic model are used widely (Blood 2005; 106:812), but researchers in Iceland now propose an alternative model based on their iStopMM study.
About 1000 people (median age, 68) with presumed MGUS underwent bone marrow sampling; those with the IgM isotype were excluded. The researchers developed a multivariable model to predict ≥10% plasma cells — indicating a diagnosis of smoldering multiple myeloma — on bone marrow examination. The model incorporated MGUS isotype (i.e., IgG, IgA, light chain, or biclonal), monoclonal protein concentration, free light chain ratio, and total concentrations of IgG, IgA, and IgM.
The model's performance for predicting ≥10% plasma cells in bone marrow was as follows:
- Sensitivity was 86% (14% of cases were missed).
- Specificity was 67% (33% of patients with <10% plasma cells were incorrectly predicted to have ≥10%).
- Specificity was substantially better than that of the Mayo Clinic model, applied to this cohort (67% vs. 41%); sensitivities were similar in the two models.
- Assuming a goal of identifying patients with ≥10% plasma cells, this model would have allowed deferral of bone marrow sampling in 59% of patients in this cohort (compared with 37% using the Mayo Clinic model).
Comment
For primary care clinicians who diagnose MGUS (which requires absence of symptoms or signs of myeloma or related conditions), this model could inform decisions on whether to refer patients for possible bone marrow sampling — an online calculator is available. For hematologists and oncologists, the model could inform decisions to perform or defer bone marrow sampling. Because of the relatively homogeneous white population in Iceland, the model ideally would be validated elsewhere; however, a validation study of this size seems unlikely.
Citation(s)
Author:
Eythorsson E et al.
Title:
Development of a multivariable model to predict the need for bone marrow sampling in persons with monoclonal gammopathy of undetermined significance: A cohort study nested in a clinical trial.
Source:
Ann Intern Med
2024
Apr
; [e-pub].
(Abstract/FREE Full Text)
Empfohlen von
Allan S. Brett, MD