RESUMEN
A 43-year-old female with a medical history of renal stones, hypertension, diabetes mellitus Type 2, and depression presented to her urologist with bilateral flank pain. She complained of worsening exertional dyspnea over the last several months with recent weight gain. She also endorsed night sweats and intermittent, scant hemoptysis over the past year. She denied fever, chills, nausea, vomiting, diarrhea, constipation, hematuria, or excessive joint or muscle pain. Physical examination was unremarkable. Computed tomography scan of abdomen and pelvis demonstrated bilateral nonobstructing renal stones and a 1.8 cm × 1.7 cm nodular opacity in the right lower lobe of the lung, not present on previous scan 1 year prior. Surgical wedge resection was performed and subsequent pathologic examination demonstrated a 1.2 cm × 0.6 cm × 0.5 cm soft, gelatinous well-demarcated mass in the right lower lobe wedge specimen without gross evidence of necrosis or hemorrhage confirming colloid adenocarcinoma of the lung.
RESUMEN
OBJECTIVES: Serum protein electrophoresis is a commonly used test in the diagnosis and follow-up of patients with monoclonal gammopathies. The practice of documenting the location of the peak may serve as delta check flags in SPEP samples. METHODS: We report on the inconsistent finding on two tests performed about three months apart. The inconsistency was discovered due to recognition of the change in the location of the monoclonal immunoglobulin on protein electrophoresis. RESULTS: Repeat testing with a third specimen revealed that the first test was run on a wrong specimen. CONCLUSION: Recording the location of the monoclonal spike is recommended to serve as an additional "delta" check.
RESUMEN
BACKGROUND: Serum and urine protein electrophoreses and immunofixation electrophoreses are the gold standards in diagnosing monoclonal gammopathy. Identification of oligoclonal bands in post-treatment patients has emerged as an important issue and recording the location of the malignant monoclonal peak may facilitate prospective identification of a new "monoclonal" spike as being distinct from the malignant peak. METHODS: We recorded the locations of monoclonal spikes in descriptive terms, such as being in the cathodal region, mid-gamma region, anodal region, and beta region. The location of monoclonal or restricted heterogeneity bands in subsequent protein electrophoreses was compared to the location of the original malignant spike. RESULTS: In a patient with plasma cell myeloma, the original monoclonal IgG kappa band was located at the anodal end of gamma region. Post-treatment, an IgG kappa band was noted in mid-gamma region and the primary malignant clone was not detectable by serum protein immunofixation electrophoresis (SIFE) in post-treatment sample. Even though the κ/λ ratio remained abnormal, we were able to recognize stringent complete response by noting the different location of the new IgG kappa band as a benign regenerative process. CONCLUSIONS: Recording the location of the malignant monoclonal spike facilitates the identification of post-treatment oligoclonal bands, prospectively. Recognizing the regenerative, benign, bands in post-transplant patients facilitates the determination of stringent complete response despite an abnormal κ/λ ratio.
RESUMEN
OBJECTIVES: Overuse of laboratory tests is a persistent issue. We examined the use and overuse of serum immunofixation electrophoresis and serum free light chain assays to develop an algorithm for optimizing utilization. METHODS: A retrospective review of all tests, for investigation of monoclonal gammopathies, for all patients who had any of these tests done from April 24, 2014, through July 25, 2014, was carried out. The test orders were categorized as warranted or not warranted according to criteria presented in the article. RESULTS: A total of 237 patients were tested, and their historical records included 1,503 episodes of testing for one or more of serum protein electrophoresis, serum immunofixation electrophoresis, and serum free light chain assays. Only 46% of the serum immunofixation and 42% serum free light chain assays were warranted. Proper utilization, at our institution alone, would have obviated $64,182.95/year in health care costs, reduced laboratory cost of reagent alone by $26,436.04/year, and put $21,904.92/year of part B reimbursement at risk. CONCLUSIONS: Fewer than half of the serum immunofixation and serum free light chain assays added value. The proposed algorithm for testing should improve utilization. Risk to part B billing may be a disincentive to reducing test utilization.