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Possible multiple myeloma presenting with persistent groin-region bone pain — MSRA MCQ

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HardHip and GroinPossible multiple myeloma presenting with persistent groin-region bone painMSRA

A 71-year-old man presents with 10 weeks of progressively worsening deep left groin pain. It is present at rest, wakes him most nights and is now limiting him to walking indoors with a stick. There has been no trauma. He has lost 4 kg unintentionally but attributes this to reduced appetite since the pain began. He has no fever, urinary symptoms, back pain, neurological symptoms or previous malignancy. Examination shows an antalgic gait. Passive hip flexion, internal rotation and external rotation are mildly uncomfortable but near-full. There is no trochanteric tenderness, erythema or swelling. An anteroposterior pelvis radiograph performed 2 weeks ago shows mild bilateral osteoarthritic change without fracture or focal lesion. Full blood count, creatinine and CRP performed at that time were normal. What is the most appropriate next step in primary care?

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Correct answer: B — Arrange serum calcium, erythrocyte sedimentation rate or plasma viscosity, serum protein electrophoresis and serum free light-chain testing

This is persistent, unexplained bone-region pain in a person aged over 60 years, with rest/night pain, functional decline and unintentional weight loss. Mild radiographic osteoarthritis is common at this age and does not adequately explain the disproportionate, progressive pain or systemic feature. Near-preserved hip movement also makes advanced symptomatic hip osteoarthritis less convincing. A normal full blood count, creatinine and CRP does not complete the NICE-recommended initial investigation for possible myeloma. NICE NG12 advises a myeloma screen for persistent bone pain in people aged 60 years and over: full blood count plus calcium, ESR or plasma viscosity, serum protein electrophoresis and serum free light chains. The full blood count has already been checked, but the remaining tests are required. If these suggest myeloma, the combination with persistent bone pain warrants suspected cancer pathway referral. MRI may become appropriate after initial assessment if another focal hip pathology remains likely, but it is not the best next primary-care step here. Routine orthopaedic referral and delayed repeat radiography risk anchoring on incidental osteoarthritis. PSA may be relevant where metastatic prostate cancer is clinically suspected, but it is not the recommended targeted investigation for this presentation and should not replace the myeloma investigation set.

Reference: Suspected cancer: recognition and referral (NG12) — Recommended actions organised by symptom and findings of primary care investigations (Last updated April 2026) — https://www.nice.org.uk/guidance/ng12/chapter/Recommended-actions-organised-by-symptom-and-findings-of-primary-care-investigations Suspected cancer: recognition and referral (NG12) — Primary care investigations (Last updated April 2026) — https://www.nice.org.uk/guidance/ng12/chapter/Recommended-actions-organised-by-symptom-and-findings-of-primary-care-investigations NHS — Symptoms of myeloma (2025) — https://www.nhs.uk/conditions/myeloma/symptoms/