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Answer 1
  1. Bone marrow biopsy with cytogenetic analysis. Although this patient with a serum monoclonal protein level, immunoparesis (depressed normal immunoglobulins), anemia, and lytic bone lesions almost certainly has myeloma,1 confirmation of the diagnosis with a bone marrow biopsy is essential. Patients with MM typically have more than 10% plasma cells in sheets and clusters. Although the patient has no physical symptoms, she does not meet the criteria for asymptomatic (ie, smoldering) myeloma, as she has multiple lytic bone lesions and mild anemia.2 A biopsy of the large femoral lesion would likely confirm the diagnosis of MM, but a posterior iliac crest biopsy is simpler to perform. Cytogenetic analysis, including fluorescence in situ hybridization for common abnormalities such as deletion of chromosome 13, provides important prognostic information. This patient meets criteria for systemic antimyeloma therapy, but this should not be initiated until the diagnostic work-up is completed.

    1. Bataille R, Harousseau JL. Multiple myeloma. N Engl J Med 1997;336:1657-64.

    2. Durie BG, Kyle RA, Belch A, et al. Myeloma management guidelines: a consensus report from the Scientific Advisors of the International Myeloma Foundation [published erratum appears in Hematol J 2004;5:285]. Hematol J 2003;4:379-98.

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