Correspondence

Case 38-2004: A Large Tumor of the Skull

N Engl J Med 2005; 352:1610April 14, 2005

Article

To the Editor:

In Case 38-2004 (Dec. 16 issue),1 Richardson et al. provide an excellent discussion of the treatment options available for patients with multiple myeloma. In my opinion, the diagnostic workup for the patient is missing two important tests that should be done routinely, especially in the setting of oligosecretory and extramedullary myeloma. The first is functional imaging with whole-body positron-emission tomography (PET) scanning.2 In this patient, a PET scan would have helped identify occult sites of plasmacytoma, thus providing an accurate assessment of his tumor burden. The second test is the measurement of monoclonal free light chains in the serum, which is an easily available measure of tumor activity, even in oligosecretory settings.3 It would have been helpful to know the level of measurable free light chains in this patient before and after radiation treatment and during relapse. Measurement of free light chains is quite sensitive and specific for monitoring the response and for detecting an early relapse. An accurate assessment of the tumor burden early in the course of disease could improve patient outcomes by prompting the implementation of definitive therapy, rather than palliation of symptoms.

Ashraf Z. Badros, M.B., Ch.B.
University of Maryland, Baltimore, MD 21201
abadros@umm.edu

3 References

1. 1

   Case Records of the Massachusetts General Hospital (Case 38-2004). N Engl J Med 2004;351:2637-2645
   Full Text | Web of Science | Medline

2. 2

   Durie BG, Waxman AD, D'Agnolo A, Williams CM. Whole-body (18)F-FDG PET identifies high-risk myeloma. J Nucl Med 2002;43:1457-1463
   Web of Science | Medline

3. 3

   Mead GP, Carr-Smith HD, Drayson MT, Morgan GJ, Child JA, Bradwell AR. Serum free light chains for monitoring multiple myeloma. Br J Haematol 2004;126:348-354
   CrossRef | Web of Science | Medline

Author/Editor Response

Dr. Badros suggests that whole-body PET scanning and measurement of free light chains in the serum should be done routinely. We agree that in the setting of nonsecretory myeloma, PET scanning and measurement of free light chains can be helpful in establishing the extent of disease, particularly if protocol participation or intensive therapy is planned. However, the routine use of these tests is not supported by the clinical practice guidelines of the National Comprehensive Cancer Centers Network.1

We agree that studies have suggested that measurement of free light chains is sensitive and specific in monitoring the response and detection of early relapse, and if used in conjunction with PET scanning, provides an additional tool for the assessment of tumor burden.2 This patient chose a more conservative approach to therapy, and therefore, because more intensive treatment was deferred, the use of these additional tests would have been of less value in this particular setting.

Paul G. Richardson, M.D.
Dana–Farber Cancer Institute, Boston, MA 02115

Ara Kassarjian, M.D.
Wen Jing, M.D.
Massachusetts General Hospital, Boston, MA 02114

2 References

1. 1

   Multiple myeloma: clinical practice guidelines in oncology. J Natl Comp Cancer Network 2004;2:350-369
   Medline

2. 2

   Mead GP, Carr-Smith HD, Drayson MT, Morgan GJ, Child JA, Bradwell AR. Serum free light chains for monitoring multiple myeloma. Br J Haematol 2004;126:348-354
   CrossRef | Web of Science | Medline