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NYU Medical Grand Rounds
Clinical Vignette
Ankit Parikh MD, PGY-2
January 6, 2009
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
A 69-year-old man with relapsed multiple myeloma
was referred for consultation regarding allogeneic
hematopoietic stem cell transplantation from his
HLA-identical brother.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• 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%).
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• 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 18.86 (normal 0.26-1.65).
• Urine immunofixation showed IgG kappa bands.
• The decision was made to start the patient on chemotherapy.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• 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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• 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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
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
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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
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
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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
• 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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
• Immunofixation: IgG kappa monoclonal gammopathy
• Protein electrophoresis: M-spike of 0.2 g/dl
• Bone marrow examination: Plasma cells 10% with
otherwise trilineage hematopoiesis
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Diagnosis
Relapsed IgG kappa Multiple Myeloma
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Therapeutic Plan
T-cell depleted, reduced-intensity allogeneic stem
cell transplantation from an HLA-identical sibling
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS