Diagnostic Workup for Anemia Caused by Multiple Myeloma or Other Bone Marrow Processes

Initial Laboratory Testing

The National Comprehensive Cancer Network recommends a comprehensive laboratory workup, including complete blood count with differential, to assess for anemia characteristics, rouleaux formation, and circulating plasma cells 1, 2
A comprehensive chemistry panel, including renal function tests, serum calcium, serum albumin, lactate dehydrogenase, and β2-microglobulin, is recommended for initial laboratory testing 2, 3

Serum protein electrophoresis and serum immunofixation electrophoresis are recommended to detect and characterize monoclonal proteins 1, 4
Quantitative immunoglobulin levels, including IgG, IgA, and IgM, should be measured by nephelometry 1, 4
Serum free light chain assay with kappa/lambda ratio is crucial for detecting light chain myeloma, according to the International Myeloma Society 5, 6
A 24-hour urine collection is recommended for total protein quantification, urine protein electrophoresis, and urine immunofixation electrophoresis 1, 4

Bone marrow aspiration and biopsy are recommended to quantify plasma cell infiltration, with ≥10% clonal plasma cells required for myeloma diagnosis, according to the World Health Organization 1, 6
CD138 staining is recommended to accurately determine plasma cell percentage 5, 6
Cytogenetic analysis and fluorescent in situ hybridization are recommended to detect chromosomal abnormalities 2, 7

A skeletal survey, including X-rays of the spine, pelvis, skull, humeri, and femurs, is recommended to detect lytic bone lesions 1, 6
MRI of the spine and pelvis should be considered if conventional imaging is negative but bone disease is suspected, according to the American College of Radiology 5, 6

Anemia in multiple myeloma is typically normochromic, normocytic, with a hemoglobin value of ≥2 g/dL below the lower limit of normal, or a hemoglobin value <10 g/dL, according to the National Institutes of Health 1, 4

A 24-hour urine specimen is necessary for proper evaluation, as a random urine sample is insufficient, according to the American Urological Association 1, 4
Bone marrow examination is essential, even if monoclonal protein is detected in serum or urine, as it confirms the diagnosis and rules out other bone marrow disorders, according to the International Myeloma Society 1, 6