Diagnosis and Management of Multiple Myeloma

The guidelines compiled by the UK Myeloma Forum, British Committee for Standards in Haematology (2001) will certainly be a great boon to diagnosis and treatment in the future. However, I wish to point out what I believe to be a significant omission regarding the recommended facets of investigation in a patient suspected of having multiple myeloma. The guidelines recommend a bone marrow aspirate and state that, ‘Trephine biopsy…[is] helpful in selected patients.’ In comparison with an aspirate, using a trephine/core biopsy to assess plasma cells has the added efficacy of containing a greater percentage of plasma cells in nearly half the cases and has been shown to be more representative of the patient's disease (Terpstra et al, 1992; Bartl & Frisch, 1999). Thus, bone marrow textbooks (e.g. Foucar, 2001), as well as the World Health Organization classification (Jaffe et al, 2001), recommend that both an aspirate and a trephine biopsy be performed in all patients. In a recent study, we found that the core biopsy contained a greater percentage of plasma cells than the aspirate in 44% of plasma-cell dyscrasia patients and that the average difference exceeded 20% (Ely & Knowles, 2002). In fact in some patients, the aspirate was essentially normal, while the core biopsy was diagnostic of multiple myeloma. In addition, the core biopsy gives useful prognostic information that cannot be provided by an aspirate (Bartl & Frisch, 1999; Foucar, 2001; Jaffe et al, 2001). Thus, although these guideline are sure to be of great help and are quite thorough in most respects, I believe that a trephine biopsy should be recommended in all patients suspected of having multiple myeloma. Perhaps a trephine biopsy may be included in the 2004 revision.