1. AN UNUSUAL CASE OF MULTIPLE MYELOMA
DEPARTMENT OF MEDICAL ONCOLOGY

2. A 37 years old female pt house wife by occupation hailing from Madurai presented with
3/15
Pain in RT inguinal region
USG
Increased renal echogenicity
Normal sized kidneys
RFT
Urea- 78 mg/dl U.alb- ++
Creatinine- 4.2 mg/dl

3. RENAL FAILURE EVALUATION
ANA
neg
C3,C4
normal
SPEP
M band detected in gamma region
MRI SPINE
Multiple lytic lesions
BMA
Plasma cells -20%

4. RENAL BIOPSY
Lambda light chain deposition
Cast nephropathy

5. DIAGNOSIS
multiple myeloma

6. TREATMENT 3 cycles HD 4 cycles T.Lenalidomide 10 mg 2 od
T.ASA 75 mg od
T.Dexamethasone 40 mg once weekly
Inj.Zoledronate 4mg iv once monthly

7. BMA - plasma cells<3%
Refered to madurai- 9/15
BMA - plasma cells<3%
Inj Bortezomib 2 mg sc weekly* 20 doses
T. Thalidomide 100 mg hs
T.ASA 75 mg od
T.Dexamethasone 40 mg once weekly
* 1 yr

8. Presenting complaint LBA Breast lump * 15 days Swelling in the neck
PLAN: RE EVALUATION

9. EXAMINATION NECK: 5*5 cm firm swelling, fixed
skin over swelling normal
BREAST:
multiple firm swellings in both breasts
mobile
no skin changes
no axillary lymphadenopathy

10. INVESTIGATIONS HB- 9 g/dl TC- 4900 Cells/cu.mm
DC- P-72% L- 26% Mix- 2%
ESR-60 mm in 1st hr
PLC- 1.7 lakhs/cu mm
PCV- 27%
Sr proteins- T- 4.7 g/dl
A-2.4g/dl
G- 2.3g/dl

11. Enzymes- normal
RBS- 110 mg/dl
Urea- 34 mg/dl
Creatinine- 1.1 mg/dl
Sr uric acid- 2.2 mg/dl
Sr LDH- 111 mg /dl
Sr calcium mg/dl

12. Peripheral smear RBCs – normochromic normocytes
Rouleaux formation noted
WBC count and distribution normal
DC- P-63%
L-35%
M-2%
Platelet count adequate

13. BMA

14. REPORT Erythropoiesis and myelopoiesis mildly suppressed
Predominantly seen are plasma cells- 70%
With abundant bluish cytoplasm with eccentrically placed round nuclei
Few plasmablasts noted
DC:
plasma cells- 70%, all other cell lines normal

15. SKELETAL SURVEY

21. USG BREAST
RT breast: E/O 3.5*1.7 cm mixed echogenic lesion in upper inner and outer quadrant
LT breast: E/O3.6*2.8 cm similar lesions in all quadrants
No E/O axillary lymphadenopathy

22. MAMMOGRAM
E/O multiple well defined radiodense lesion noted in upper outer and retroareolar region of both breasts
Suggessted HPE correlation

23. CT- CHEST (P)

24. CT CHEST (C)

25. REPORT
E/O multiple enhancing soft tissue dense lesion noted in bilateral breast largest measuring 3.3*3 cm
E/O multiple lytic lesions noted in multiple vertebral levels

26. CT NECK(P)

27. CT NECK (C)

28. REPORT
E/O 3*2 Cm measuring enhancing soft tissue dense lesion noted over medial end of left clavicle
Underlying bone appears normal
?cutaneous myeloma deposits
Multiple lytic lesions noted from C2-T2 vertebra

29. CT abdomen and pelvis( p)

30. CT PELVIS (C)

31. REPORT
E/O 8.5*4.7 cm measuring enhancing lesion noted in L iliac region with infiltration of iliacus muscle
E/O multiple lytic lesion noted in both iliac bones, sacrum and superior pubic rami, vertebra

32. FNAC from breast lump

33. REPORT
Smear studied show dyscohesive, clusters and diffusely scattered mature and immature plasma cells in an eosinophilic background, few binucleate and multinucleate forms seen
IMP- plasmacytoma both breasts

34. FNAC from clavicular swelling

35. REPORT
Smears show scattered and clusters of plasma cells with occassional binucleate forms of plasma cells
IMP:
plasmacytoma

36. RELAPSED REFRACTORY MULTIPLE MYELOMA WITH EXTRAMEDULLARY DEPOSITS
DIAGNOSIS
RELAPSED REFRACTORY MULTIPLE MYELOMA WITH EXTRAMEDULLARY DEPOSITS

37. TREATMENT Inj vincristine 2mg iv Inj cyclophosphamide 800 mg iv
T.Dexamethasone 40 mg once weekly
Inj Zoledronate 4 mg iv once monthly

38. AIM OF PRESENTATION
To show the extramedullary involvement of multiple myeloma
To discuss the IMWG criteria 2015
This presentation is a rarity with the advent of immunomodulators and proteasome inhibitors
To read about the newer drugs in pipeline

39. THANK YOU