NYU Medical Grand Rounds Clinical Vignette Ankit Parikh MD, PGY-2 January 6, 2009 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

A 69-year-old man with relapsed multiple myeloma was referred for consultation regarding allogeneic hematopoietic stem cell transplantation from his HLA-identical brother. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Four years ago, the patient was incidentally found to have an increased protein level on laboratory assessment; he was asymptomatic. Work-up led to the diagnosis of smoldering myeloma. The patient remained in his usual state of health until one year later, when the patient had a rapid increase of his IgG level to 5,630 mg/dl. Further testing, including a bone marrow biopsy, demonstrated an increase in plasma cells to 60% (normal <10%).

History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS A skeletal survey demonstrated no lytic or blastic lesions A total spine MRI was consistent with diffuse myeloma involvement with a heterogeneous pattern and a focal lesion at the level of T12. Free kappa to lambda ratio was (normal ). Urine immunofixation showed IgG kappa bands. The decision was made to start the patient on chemotherapy.

History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS His initial treatment consisted of the BiRD regimen: clarithromycin (Biaxin), lenalidomide (Revlimid), and dexamethasone for four cycles. The patient had a good response with a decline of his protein level. Treatment was complicated by the development of bilateral deep venous thromboses. The decision was made to proceed with autologous stem cell transplantation.

History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Autologous stem cell transportation was undertaken two years prior to the current presentation. The patient achieved complete remission by bone marrow biopsy and protein electrophoresis. The patient remained in remission for one year. Subsequently, he was diagnosed with relapsed disease and started on lenalidomide (Revlimid), bortezomib (Velcade), and dexamethasone.

History of Present Illness At the time of referral for allogeneic stem cell transplantation, the patient had completed four cycles of lenalidomide, bortezomib, and dexamethasone. He has been continued on lenalidomide maintenance of 15mg daily. Recent workup showed that the patient has achieved a good partial response. The patient otherwise has no complaints and is accompanied by his HLA-identical brother.

Additional History U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Past Medical History Multiple Myeloma Papillary Urothelial Neoplasm of Low Malignant Potential Hypertension Hyperlipidemia Celiac Disease Depression/Anxiety Past Surgical History Fulguration of bladder neoplasm Hiatal hernia repair Bilateral cataract surgery Family History Non-contributory Social History Retired executive Lives with wife Ex-smoker Social alcohol use Denies illicit drug use Gluten-free diet

Outpatient Medications U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Lenalidomide 15 mg daily Acyclovir 200 mg twice daily TMP/SMX 800/160 mg three times/week Fluconazole 100 mg daily Atenolol 25 mg daily Simvastatin 40 mg daily Escitalopram 5 mg daily Alprazolam 0.25 mg daily Temazepam 15 mg at bedtime prn Oxycodone/Acetaminophen prn Allergies: No known drug allergies

Physical Examination U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS General: Well-appearing man in no acute distress Vital Signs: T 36.7 C, BP 112/76, HR 63, RR 18 His physical examination was unremarkable.

Laboratory Findings U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS CBC: Hemoglobin 10.4 g/dl The remainder of the CBC was within normal limits Basic metabolic panel: Creatinine 1.4 mg/dl The remainder of the BMP was within normal limits Hepatic panel: Within normal limits

Laboratory Findings U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Immunofixation: IgG kappa monoclonal gammopathy Protein electrophoresis: M-spike of 0.2 g/dl Bone marrow examination: Plasma cells 10% with otherwise trilineage hematopoiesis

U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Diagnosis Relapsed IgG kappa Multiple Myeloma

Therapeutic Plan U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS T-cell depleted, reduced-intensity allogeneic stem cell transplantation from an HLA-identical sibling