Dyscrasia in medicine

1. Plasma Cell Dyscrasia : Grading

2. Introduction : Definition
•Plasma cell neoplasms (PCNs) are derived from the expansion of
mutated, terminally differentiated, postgerminal center B cells.
• These neoplasms include
•monoclonal gammopathy of undetermined significance (MGUS)
and monoclonal gammopathy of renal significance (MGRS)
•smoldering myeloma
•myeloma
•solitary plasmacytomas
•plasmacytomas with minimal marrow involvement
• light-chain amyloidosis

3. Criteria for diagnosis of Myeloma :
• All 3 criteria must be met except as noted:
• Clonal marrow plasma cells ≥10% and/or presence of a biopsy- proven
plasmocytoma
• Presence of serum and/or urinary monoclonal protein
• Evidence of end-organ damage specifically: ( CRAB )
• Hypercalcemia: serum calcium ≥11.5 mg/100 mL or
• Renal insufficiency: serum creatinine >2 mmol/L)
• Anemia: normochromic, normocytic with a hemoglobin value of >2 g/100 mL
below the lower limit of normal or a hemoglobin value <10 g/100 mL
• Bone lesions: lytic lesions, severe osteopenia, or pathologic fractures

4. Staging of Myeloma : Durie Salmon Grading
• Multiple attempts have been made to define clinical and laboratory
parameters that have prognostic significance in myeloma.
• The Durie-Salmon staging system was historically the most commonly
used
• It relates myeloma cell mass to the extent of bony disease, hemoglobin,
and calcium levels, as well as the monoclonal Ig levels in serum and
urine
• Disadvantage : measurement of bone disease by skeletal survey in
myeloma is observer dependent and potentially subjective

5. Durie Salmon staging
:

6. Current method : The ISS system
• Based on two widely available parameters—serum β2 Microglobulin and
albumin
• It recognizes 3 stages

7. Why ISS preferred ?
• β2 M correlates with tumor mass and impairment in renal function, whereas
low albumin reflects the effect of IL-6 produced by the microenvironment of
myeloma cells on the liver.
• This helped to predict the outcome of the patients in different stages of the
disease when offered the appropriate treatment
• Disadvantage : Lack of inclusion of cytogenetics and other markers of tumor
burden, such as LDH
• Current : Revised ISS — ———includes LDH values and Chromosomal
abnormalities

8. R-ISS score :

9. mSMART score : Cytogenetic risk based scoring

10. Future outlook :
• To include other novel methods for further high risk
assessment and stratification
• iFISH method to be replaced with Seq-FISH which
has validated the prognostic power of the R-ISS and
increased the sensitivity and reproducibility of
identifying chromosomal anomalies .

11. References :
•Wintrobe’s CLINICAL HAEMATOLOGY 14th edition
•Williams Hematology 10th edition
•Jain, A., Malhotra, P. Plasma Cell Dyscrasias in India-2017 Updates. Indian J
Hematol Blood Transfus 34, 1–4 (2018). https://doi.org/10.1007/s12288-017-
0910-0
•Hagen, P., Zhang, J. & Barton, K. High-risk disease in newly diagnosed multiple
myeloma: beyond the R-ISS and IMWG definitions. Blood Cancer J. 12, 83
(2022). https://doi.org/10.1038/s41408-022-00679-5