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Oncological Terrain: “Conditio sine qua non” of Measuring monoclonal Bands in Patients with Osteoporosis.
- Sergio Stagnaro (8 April 2005)
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Risk for unnecessary intervention
- Piero Baglioni (10 April 2005)
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Re: Risk for unnecessary intervention
- Bo Abrahamsen (11 April 2005)
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Routine laboratory tests might be more cost - effective
- Venkata Sreekanth Sampath (12 April 2005)
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Re: Routine laboratory tests might be more cost - effective
- Bo Abrahamsen (13 April 2005)
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Re: Re: Routine laboratory tests might be more effective
- Venkata Sreekanth Sampath (13 April 2005)
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Re: Routine laboratory tests might be more effective
- Bo Abrahamsen (14 April 2005)
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Sergio Stagnaro, Specialist in Blood, Gastrointestinal, and Metabolic Diseases. Researcher in Biophysical Semeiotics. Via Erasmo Piaggio 23/8 16037 Riva Trigoso (Genova) Italy.
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Sirs, I cannot agree at all with paper’s authors, who state that measuring monoclonal bands (M component) in serum should be part of the investigation of patients referred to osteoporosis clinics, as multiple myeloma is 75 times more common in patients with osteoporosis (1). As a matter of fact that indicates the complete ignorance of the real existence of biophysical semeiotic constitutions, including osteoporotic and oncological constituions, the later termed Oncological Terrain (2-6) (See www.semeioticabiofisica.it). I foresee that “all” individuals around the world (1 in 20 among authors’ patients) with newly diagnosed osteoporosis who had multiple myeloma or monoclonal gammopathy of undetermined significance, all are and/or were positive for Oncological Terrain! Certainly, as a diagnostic test for multiple myeloma in patients with osteoporosis, M component in serum had a specificity of 95% and a positive predictive value of 17.6%, but exclusively in subjects with Oncological Terrain. 1) Abrahamsen B. et al.Test for M component in patients suspected of having osteoporosis. BMJ 2005;330 (9 April), doi:10.1136/bmj.330.7495.0-a 2) Stagnaro Sergio, Stagnaro-Neri Marina. Introduzione alla Semeiotica Biofisica. Il Terreno oncologico”. Travel Factory SRL., Roma, 2004. http://www.travelfactory.it/semeiotica_biofisica.htm 3) Stagnaro S., Stagnaro-Neri M., Le Costituzioni Semeiotico- Biofisiche.Strumento clinico fondamentale per la prevenzione primaria e la definizione della Single Patient Based Medicine. Ediz. Travel Factory, Roma, 2004. http://www.travelfactory.it/semeiotica_biofisica.htm 4) Stagnaro S., Stagnaro-Neri M., Single Patient Based Medicine.La Medicina Basata sul Singolo Paziente: Nuove Indicazioni della Melatonina. Travel Factory SRL., Roma, 2005. http://www.travelfactory.it/semeiotica_biofisica.htm 5) Stagnaro-Neri M, Stagnaro S. Co Q10 in the prevention and treatment of primary osteoporosis. Preliminary data. Clin Ter. 1995 Mar;146(3):215-9 [ MEDLINE] 6) Stagnaro-Neri M., Stagnaro S., Diagnosi Clinica Precoce dell’Osteoporosi con la Percussione Ascoltata. Clin.Ter. 137, 21-27, 1991 [MEDLINE] Competing interests: None declared |
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Piero Baglioni, Consultant Physician Prince Charles Hospital - Merthyr Tydfil CF47 - Wales (UK)
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I read with interest the paper by Abrahamsen et al (BMJ 2005 vol. 330 : 818-820) but I disagree with some of the conclusions expressed by the authors. Out of a studied population of 799 patients they identified three cases of multiple myeloma. On the base of these results they introduced routine measurement of serum M component in patients presenting to their clinic for osteoporosis. I question the routine introduction of a test whose false negative rate is unknown and with a positive predictive value of 17.6%. Cost aside, the predictable need for a confirmatory test would result in an increase in unnecessary (and invasive) bone marrow studies. Perhaps restricting the search for a serum monoclonal band to patients with proven osteoporosis and a history of fragility fractures (present in all three patients with myeloma detected in the study) would be more effective. I also question the statement that " regardless of age, patients with multiple myeloma benefit from early diagnosis ". While there is no evidence that treatment of asymptomatic (smouldering) myeloma is beneficial (1), elderly people - as aknowledged by the authors- may be unable to tolerate treatment due to comorbidity. (1) RA Kyle, SV Rajkumar - Multiple Myeloma - NEJM 2004 vol. 351 : 1860-1873 Competing interests: None declared |
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Bo Abrahamsen, Consultant endocrinologist Roskilde County, Denmark
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Thank you for the opportunity to correct a misunderstanding. The patient flow may not be fully clear in the abridged version of the paper. We tested the utility of monoclonal band measurements in all patients referred to the osteoporosis clinic, but the analyses were stratified for presence or absence of osteoporosis. Our results indicate that patients diagnosed with osteoporosis frequently suffer from MGUS or myeloma. The flow chart in the unabridged online version of the paper is perhaps the best illustration of this. We did not observe any cases of myeloma in persons with normal BMD. Therefore we do not endorse the notion that monoclonal bands should be measured in all referred patients but only in those who have osteodensitometric evidence of osteoporosis. However, the unstratified percentages will clearly be relevant for clincs where laboratory tests are performed before the patient undergoes densitometry. Competing interests: Author of the paper |
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Venkata Sreekanth Sampath, Critical Care Fellow Christie Hospital NHS Trust, Manchester M20 4 BX
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Patients with multiple myeloma have increased serum globulin levels. A full blood count with ESR,serum globulin level,serum creatinine and skeletal radiographs would pick up most cases of multiple myeloma in patients presenting with osteoporosis.The authors have not provided data regarding all the above tests in their patients and whether myeloma was diagnosed despite all these tests being normal. Measurement of M protein would be better used to prove or disprove myeloma in patients where atleast one of these tests is abnormal. Competing interests: None declared |
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Bo Abrahamsen, Consultant endocrinologist Roskilde County, Denmark
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Thank you for commenting on the study. Standard haematology including ESR and haemoglobin was often normal in patients with myeloma. By contrast, the diagnosis was readily made through establishing the presence of monoclonal bands in serum combined with significant marrow pathology and/or skeletal lesions. Screening for myeloma using skeletal x-rays is unlikely to be sufficiently sensitive or even available at lower cost than serum electrophoresis. Competing interests: Author of the paper |
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Venkata Sreekanth Sampath, Critical Care Fellow Christie Hospital NHS Trust, Manchester M20 4 BX
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Thank you for your response. The article mentions that ESR and haemoglobin was often normal; however there is no data regarding the serum globulin and serum creatinine levels in the patients studied. Most patients with osteoporosis would have had a skeletal radiograph of the spine and routine laboratory tests as well.So I presume that when assesing a patient with osteoporosis one would have the results of these tests and if any of these is abnormal, testing presence of a monoclonal band would be useful. Competing interests: None declared |
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Bo Abrahamsen, Consultant endocrinologist Roskilde County, Denmark
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X-rays of the spine are of very limited use in diagnosing multiple myeloma. By contrast, x-rays of the skull and long bones are useful, but they are not part of the usual array of investigations done in patients with osteoporosis. Competing interests: Author of the paper |
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