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    by: vidyasagar

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    1 : Case study Patient of 52 yrs admitted with complaints of, on and off cough with expectoration and breathlessness since 2 yrs. Past history is insignificant and he is not smoker or alcoholic. General examination is normal, respiratory examination revealed bilateral ronchi. Rest of the systems did not reveal any abnormality.
    2 : Routine investigations were within normal limits except for urine routine showing 1+ protien Chest x-ray revealed multiple punched out lytic lesions of ribs,scapulae and clavicles due to which Multiple myeloma was suspected. Skull and and vertebral x-ray revealed same abnormality
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    5 : Lytic lesions on ribs and clavicles
    6 : Punched out lesions
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    8 : Bone marrow examination- Plasma cells constituiting around 28% of total cells, and few plasmoblasts,gaint metamyelocytes are seen.RBC and platelet cell lines were normal. Serum electrophoresis-report is suggestive of Non Secreatory MM
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    10 : Normal Monoclonal Protein in Myeloma Serum Protein Electrophoresis
    12 : MYELOMA It is a malignant disease of plasma cells of bone marrow, accounting for 1% of all malignant diseases. Myeloma is a disease of elderly, the median age at presentation being over 60years. It is rare under 40 yrs of age, the annual incidence is 4 per 100000
    13 : CLINICOPATHOLOGICAL FEATURES Bone destruction: often causing fractures of long bones, vertebral collapse and hypercalcemia. Bone marrow infiltration:with plasma cells,resulting in anaemia, neutropenia, thrombocytopenia. Renal impairment: deposition of light chain proteins,hypercalcemia,hyperuricemia,deposition of amyloid. Reduction of normal immunoglobulin levels, recurrent infections of respiratory tract.
    14 : SYMPTOMS Bone pains,most commonly back ache, owing to vertebral involvement(60%). Symptoms of anaemia. Recurrent infections. Symptoms of renal failure(20 to 30%). Symptoms of hypercalcaemia. Symptoms of hyperviscosity, bleeding due to thrombocytopenia.
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    17 : Rationale for investigations in multiple myeloma Presence of lytic lesions,bone fractures Spinal cord compression?. Presence of urine or plasma paraprotein?. Type of paraprotein? Amount of paraprotein X-rays,skeletal survey,alkaline phosphatase MRI spine Blood &urine protein elcetrophoresis. Blood &urine protein electrophoresis Quantification of paraprotein
    18 : Cont’d Degree of immunoparesis? Presence of plasma cells in bone marrow? Degree of bone marrow failure? Renal function? Plasma immunoglobulins. Bone marrow aspiration &trephine. Full blood counts Urea,creatinine, urate, electrolytes.
    19 : Cont’d Presence of hypercalcemia?. Degree of haemostasis? Poor prognostic factors at diagnosis Blood calcium and albumin. Coagulation screen. Beta microglobulin >5.5mg/l,albumin<35gms/l
    20 : International Staging System (ISS) for Symptomatic Myeloma *ß2m < 3.5 mg/L and albumin < 3.5 g/dL or ß2m 3.5 - < 5.5 mg/L, any albumin
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    22 : Clearly not a transplant candidate Can include melphalan- based combinations Potential transplant candidate Non-alkylator based induction Stem cell harvest Approach to Treatment
    23 : Therapy Options: NonTransplant Candidate Melphalan + Prednisone (MP) Melphalan + Prednisone + Thalidomide (MPT) Dexamethasone (Dex) Thalidomide + Dexamethasone (Thal/Dex) Lenolidomide + Dexamethasone (Rev/Dex) Bortezomib +/- Dexamethasone (Vel/Dex) NCCN Practice Guideline-v.2.2008
    24 : Managing complications of MM Osteoporosis/bone pain/fractures All patients should be on bisphosphonate IV  pamidronate and zoledronic acid used most commonly, Orthopedic referral ==> Radiotherapy, vertebroplasty/kyphoplasty. Hypercalcemia Aggressive hydration, corticosteroids, bisphosphonates
    25 : Managing complications of MM Renal Insufficiency Hemodialysis.  Plasmaphereis for hyperviscosity induced thrombosis Anemia Erythopoetin, Transfusion Infection Treat aggressively with broad spectrum antibiotics  Vaccinations INFLUENZA, HIB, PNEUMOCOCCAL.
    26 : Take home message Usually MM is suspected based on clinical features,skull x-ray,blood examination etc. chest x-ray PA view may also be useful in suspecting multiple myeloma because of the lytic lesions of ribs,scapulae and clavicles.
    27 : THANK YOU

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