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Answer 4
  1. Myeloma. This patient has classic myeloma with lytic lesions, a monoclonal protein spike, and increased plasma cells in the bone marrow. Additionally, there is renal dysfunction. Of note, there is no serum monoclonal spike, only a urine monoclonal spike. Approximately 60% of patients with myeloma have a serum IgG lambda or kappa spike, 20% have an IgA lambda or kappa spike, and 20% have only a light chain spike. Myelomas associated with IgD or IgE or nonsecretory myelomas are very rare. Because free light chains have a low molecular weight, they generally are not seen in the serum, only the urine. For the case patient, the initial treatment would include a combination chemotherapy regimen (ie, vincristine, doxorubicin, dexamethasone) with the aim of producing at least a good partial response. The standard approach today is to follow chemotherapy with an autologous stem cell transplantation; however, this approach is not curative. Additionally, most patients with myeloma receive a bisphosphonate, such as pamidronate or zoledronic acid, to decrease the risk of fractures.

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