TUMOR BOARD 15/09/14 DR. C. MWANIKI

BIO DATA NAME: M.M AGE: 52 YEARS SEX: MALE

PRESENTING COMPLAINT EASY FATIGABILITY FOR ONE MONTH LOWER BACK PAIN (LONG STANDING)

HISTORY OF PRESENTING COMPLAINT M.M. is a patient with multiple myeloma on follow up in the haemato-oncology clinic. Was well until a month ago when he started experiencing easy fatigability which was gradual in onset He reports a positive history of awareness of heart beats, dizziness, exertional dyspnea, paroxysmal nocturnal dyspnea and on and off bilateral swelling of the lower limbs. Does not report orthopnea. No history of loss of consciousness. No cough/chest pain No hotness of body

Cont… Patient also complains of a longstanding lower back pain. Not radiating to other parts of the body. Persistent. Get relieved when he takes analgesics No history of trauma/ strain to the back.

TREATMENT HISTORY Patient was started on melphalan (12mg od for 4/7) and prednisone (35mg for 4/7) on 4/6/12 which he has been using up to 27/5/14. He was then changed to thalidomide (100mg od) and dexamethasone (40mg weekly) due to failure to respond to therapy. He used thalidomide and dexamethasone up to 4/8/14. Regimen stopped after patient developed neutropenia and deep venous thrombosis. Patient is now on analgesics and on follow up in the anticoagulation clinic- on warfarin.

PAST MEDICAL HISTORY Patient has been hospitalized twice for blood transfusion. First was in 2012 where he received 5 units of blood then early 2014 where he got transfused 2 units. No history of surgery He does not suffer from other chronic illnesses

FAMILY/ SOCIAL HISTORY Patient is married with 2 children He is a teacher. He does not drink/ smoke There is no one with similar illness in the family/ other chronic illness.

SUMMARY M.M. is a 52 year old patient with multiple myeloma presenting with easy fatigability for one month and longstanding lower back pain

GENERAL PHYSICAL EXAM Sick looking man. No signs of wasting Moderate palor No jaundice/cyanosis/lymphadenopathy Pedal edema on both lower limbs- pitting and non tender Not dehydrated Blood pressure 118/80 Pulse rate 80 beats/minute Respiratory rate 18 breathes/minute Temp 35.5 ◦c

Respiratory system: -respiratory rate of 18 bpm -Normal breath sounds Cardiovascular system -blood pressure 118/80 -pulse rate 80 bpm -normal heart sounds Abdomen -no organomegally -not tender

INVESTIGATIONS DATE 21/5/12 2/7/12 5/11/12 20/5/13 26/5/14 4/8/14 8/9/14 WBC 2.75 2.66 3.82 3.44 4.91 5.6 8.7 ANC 2.22 0.93 2.23 2.09 1 2.06 2.4 Hb 5.08 10.78 9.35 8.45 8.65 10.17 7.9 MCV 95.90 87.63 90.34 87.78 94.38 89.65 95 HCT 14.3 32.40 26.63 23.54 25.54 29.88 23.5 PLT 125 40 116 81 76 166 Cr - 97.1 294 272.34 272 PO 1.21 K 4.63 Na 138 Urea 12.21

Bone marrow Apirate Done on 6/5/12 ( Nairobi hopital) Upper normal cellularity marrow. M:E ratio of 3:1 Plasmacytosis is present making 35-40% of nucleated cells with dysplastic forms Lymphoid cells not increased Features of myelomatosis.

Repeat BMA Done on 26/5/14 (Moi teaching and referral hospital) Increased cellularity M:E ratio- not given Erythropoiesis- few normoblasts Myelopoiesis- Reduced Megakaryopoiesis- Few noted Lymphocytes- Normal Plasma cells- Increase in neoplastic plasma cells. More than 90% nucleated cells Features of relapse of plasma cell myeloma

Serum Protein electrophoresis Done on 25/5/12(Lancet) S alpha 1 globulin- 5g/L S alpha 2 globulin 10g/L S beta 1 globulin 3g/L S beta 2 globulin 4g/L S gamma globulin 9g/L S ‘M’ component globulin 10g/L*elevated

Repeat SPEP Done on 18/8/14(Lancet) S alpha 1 globulin- 8g/L *elevated S beta 1 globulin 5g/L S beta 2 globulin 3g/L S gamma globulin 6g/L S ‘M’ component globulin 9g/L *elevated

Current management Analgesics for pain Warfarin for DVT Palliative team on board

discussion Multiple myeloma is a type of cancer that starts in the plasma cells in the bone marrow In M.M. Serum Protein electrophoresis which usually shows elevated ‘M’ component Its more common in men and Africans are affected twice as much compared to other races M.M. affects many organs. Commonly causes: -Elevated Calcium level (osteoclastic activity from over expression of receptor activator for RANKL), -Renal failure( excessive production of immunoglobulins and light chains, nephrocalcinosis and amyloidosis) -Anemia (infiltration into the bone marrow) -Bone lessions

Punched out lessions are normally seen on skull xray and extensive lytic lessions in bone scan Related conditions include solitary plasmacytoma,plasma cell dyscrasia, and POEMS syndrome. Staging (I-III) -International staging system ( b2 microglobulin & albumin) -Durie salmon staging system (Hb, Calcium, Skeletal survey,Serum paraproteins levels-IgG,IgA and Urinary light chain excretion)

Issues How long should it take before we change from one regimen to another? Is it possible to re- treat with the agents we started with i.e melphalan/thalidomide.how effective will that be? at this stage, is there a role for third line agents like Linolinamide/ Bortezumab. Availability of drugs/feasibility? Generally, we have had poor outcomes in multiple myeloma patients in the hospital, what is it that we could be doing wrong?