Case Management Experience in Multiple Myeloma
Name : Prof. DR. Dr. Arry Harryanto Reksodiputro, SpPD-KHOM
Posisi : Divisi Hematologi-Onkologi Medik Bagian Ilmu Penyakit Dalam FKUI-RSUPNCM
Pendidikan
1963 : Fakultas Kedokteran Universitas Indonesia
1969 : Spesialis Ilmu Penyakit Dalam, Fakultas Kedokteran Universitas Indonesia
1970 : Pendidikan Hematologi di Rumah Sakit St. Louis, Universitas De Paris, Perancis
1978 : Pendidikan Teknik Membrane Marker pada Imperial Cancer Research Fund,
Department of Medical Oncology, St. Bartholomews Hospital, London
1979 : Pendidikan Sitologi Limfoma Malignum pada The Hospitalier Pitie-Salpetriere,
Paris
1984 : Doktor pada Fakultas Kedokteran Universitas Indonesia-Universitas Leiden
1991 : Guru Besar pada Fakultas Kedokteran Universitas Indonesia
Case Management Experience in Multiple Myeloma
A.HARRYANTO REKSODIPUTROSRI AGUSTIN
SUB BAG HEMATOLOGI ONK MEDIK
FKUI,RSCM,RSKD2
Patients Characteristic (N=14)N %
Age=65 8 57.14
GenderMale 6 42.86
Female 8 57.14
Heavy chain type
IgG 4 28.57
IgA 3 21.43
LCD 1 7.14
NA 6 42.86
Hb
10 2 14.29
PatientsCharacteristic
(N=14)
N %
>=2.0 3 21.43
NA 2 14.29
Serum albumin
=3.5 7 50
NA 1 7.14
Serum B2M
5.5 4 28.57
NA 6 42.86
Plasma cells of BM
70% 1 7.14
NA 4 28.57
ISS Staging
I 3 21.43
II 1 7.14
III 4 28.57
NA 6 42.86
Durie Salmon Staging
IIA 4 28.57
IIIA 5 35.71
IIIB 3 21.43
NA 2 14.294
5FRONTLINE THERAPY OPTIONSOPTIONS COMMENTS
Melphalan/prednisone
Alkylating agent combinations
Still an option, especially for elderly people
Really only an option if stem cell transplant
is not planned
Cytoxan alone or in combination Can be useful alone or in combination with
less stem cell injury than melphalan
Still a major frontline approach; can have
significant disadvantages
Dexamethasone or other steroid alone A valid option, especially with renal
insufficiency and/or blood count values
Thalidomide plus Dexamethasone A new oral option worthy of consideration
but without a long track record
VAD regimen
Bortezomib plus Dexamethasone, or in
combination with other agents
A novel agent, option if stem cell transplant
is planned, option if theres renal
insufficiency
Choice of Therapy
Bortezomib-based regimen
Non bortezomib-based regimen
First line therapy, (in newly diagnosedMultiple Myeloma)
3 patients 11 patients
Salvage therapy (in Relapsed/refractoryMultiple Myeloma)
4 patients
7
8RECOGNIZED PROGNOSTIC FACTORS2
Factor Significance
Specialized tests
Plasma cell labeling index High-poor
Plasma cell morphology Plasmablastic-poor
Bone marrow cytogenetics
Standard cytogenetics Hypodiploidy/deletion 13-poor
FISH analysis (chromosome 13) 13 deletion-poor
Microarray techniques Differential patterns
Whole-body FDG/PET scan Extramedullary-disease poor
0 10 20 30 40 50 60 70 80 90 100
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Months
Pat
ien
t
Range time of Survival
Bortezomib-based first lineNon bortezomib-based first lineNon bortezomib-based as first line, Bortezomib-based as salvage
1st year 2nd year 6th year3rd year 5th year4th year 7th year
9
Survival (Bortezomib vs Non-Bortezomib)
0 10 20 30 40 50 60 70 80 90 100
II A
II A
NA
III A
III A
III B
III B
II A
NA
II A
III A
III A
III A
III B
Bortezomib Vs Non Bortezomib
Survival times (months)
10
Note for Range time of Survival
Patients didnt start the treatment at the same time
Bortezomib as salvage therapy seemed could prolong the range time of survival
Bortezomib as first line therapy looked like not having very long range time survival, but the patients actually are new and still on going and others are using Bortezomib in short period due to financial reason
11
Durie Salmon Staging
Stadium IIAStadium IIIAStadium IIIBNot applicable
0 10 20 30 40 50 60 70 80 90 100
B
NB than B
B
NB
NB
NB
NB
NB
NB
NB
NB than B
NB than B
NB than B
B
Months
Pat
ien
t
12
Role of Stage in Survival Bortezomib vsNon Bortezomib Pts
0 10 20 30 40 50 60 70 80 90 100
II A
II A
NA
III A
III A
III B
III B
II A
NA
II A
III A
III A
III A
III B
Bortezomib Vs Non Bortezomib
Survival times (months)
13
Note for Durie Salmon Staging
Patients didnt start the treatment at the same time
Two patients staging are not applicable because criteria is not complete
The staging seemed not really influence the range time of survival, as its not the only factor that determine patients survival
Bortezomib are used in all staging
14
Quality of Life
Good QoLPoor QoL
0 10 20 30 40 50 60 70 80 90 100
B
NB than B
B
NB
NB
NB
NB
NB
NB
NB
NB than B
NB than B
NB than B
B
Months
Pat
ien
t
15
Quality of Life
0 10 20 30 40 50 60 70 80 90 100
Non B
Non B
Non B
Non B
Non B
Non B
Non B
Bortezomib
Bortezomib
Bortezomib
Bortezomib
Bortezomib
Bortezomib
Bortezomib
Good QoL vs Poor QoL
Survival times (months)
Good QoLPoor QoL
16
Note for Quality of Life
Patients didnt start the treatment at the same time
Criteria for good or poor quality life is based on the patients condition and history of hospitalization
Most patients used Non-bortezomib based regimen only, had poor quality of life, disease progression, and died
More patients used Bortezomib-based regimen (as first line, or salvage) had good Quality of Life
17
PATIENTS HISTORY OF TREATMENT
18
Patient 1 Male CD, 65 yrs, IIIB, (anemia, hypercalcemia,
renal impairment, bone lesions)Oct 2014
Diagnosed as Multiple Myeloma,
Symptoms: low back pain, postural
dizziness, renal impairment
Nov-Dec 2014
Used VTD/VTregimen,
Outcome: hematological tests and renal functions
are improved
Jan, 2015
Using TP regimen
March 2015
Being hospitalized, because anemia,
hypercalcemia, acute renal injury
19
Patient 2
Male DS, 77 yrs, Stage NA
Jan, 2010
Diagnosed as Multiple
Myeloma,
Symptoms: anemia
Apr 2010-Sept 2014
Used TDregimen,
Sept, 2014
Stop Thalidomide maintenance, progression,
(anemia, bone lesions, SPEP+, IF+)
Sept-Dec 2014
Used VT regimen
Jan 2015,
Live, hematological
tests are improved,
globulin normal
20
Patient 3
Male TW, 60 yrs, IIA
June, 2011
Diagnosed as Multiple
Myeloma,
Symptoms: waist pain
Oct Dec 2011
Used VD/V regimen4#,
Outcome : Protein and SPEP become
normal
Sept, 2012
Relaps,
Then using TD/T/TD regimen,
(anemia, bone lesions, SPEP+, IF+)
Oct 2013
Stop all therapy
Jan 2015,
Live, Relaps,
21
Patient 4
Male RBS, 77 yrs, IIIA
Mar, 2008
Diagnosed as Multiple Myeloma,
Symptoms: nosebleed, gumbleed, melena,
waist pain
Jul 2008
Used MT/MP regimen
Apr, 2009
Disease progression,
Dead
22
Patient 5
Female JL, 31 yrs, Stad NA
Aug, 2005
Diagnosed as Multiple Myeloma,
Symptoms: weakness
Aug 2005 Jan 2007
Used TD/T regimen
Jul, 2009
Relaps,
Jul 2009 Jul 2011
Used TD/COP/MT regimen
After Jul 2011,
Loss to follow-up
23
Patient 6
Female MM, 60 yrs, IIIA, hypercoagulation
Oct, 2011
Diagnosed as Multiple Myeloma,
Symptoms: limb pain, weakness
Oct 2011 Dec 2012
Used MTD/MT/MP/COP/D but irreguler admission due to
nonadherence, patient also used Herbal
Mar, 2013
Dead,
Progressive Disease
24
Patient 7
Female WIH, 65 yrs, IIA
Oct, 2006
Diagnosed as Multiple
Myeloma,
Symptoms: limb pain, weakness
Oct 2006 May 2007
Used COP/C regimen, Outcome : Stable
Disease
Aug 2007 - .. 2009
On vacation to abroad, T stop used
treatment
Apr Sept 2009, Used MTregimen
Jul, 2010
Disease Progression,
Dead
25
Patient 8
Male N, 57 yrs, IIIB, renal impairment
Mar, 2009
Diagnosed as Multiple Myeloma,
Symptoms: waist pain, renal impairment
Apr 2009 Jan 2010
Used TD/M/MT regimen
Feb, 2010
Febrile neutropenia, admissioned at ICU, very bad
condition, Dead
26
Patient 9
Female CH, 58 yrs, IIIB, Free light chain disease
Dec, 2009
Diagnosed as Multiple Myeloma,
Symptoms: limb pain, weakness
Dec 2009 Mar 2010
Used MTD regimen
Mar, 2010
Disease progression, Dead
27
Patient 10
Female SL, 65 yrs, IIA
Nov, 2012
Diagnosed as Multiple Myeloma,
symptom: weakness
Dec 2012 Sept 2014
Used MP regimen until now
Feb 2015
Live, partial response
28
Patient 11
Male R, 70 yrs, IIIAJun, 2006Diagnosed
as Multiple
Myeloma,
Symptoms: low back
pain, postural
dizziness, renal
impairment
Jun 2006 ..
Used CTD/COP/CTD
/MTD regimen,
Outcome: Stable
disease
Oct 2008
Used Vregimen,
AE: herpes, pneumonia, neuropathy
. - .
Used MT/MPregimen
. 20..,
Relaps
May-Jul 2011,
Used V/MDregimen
Outcome: Partial
Response, no AE
.. 2013, Relaps,
Used TD regimen
Aug 2013, Disease
Progression, Dead
29
Patient 12
Female R, 69 yrs, IIA
Mar, 2013
Diagnosed as Multiple
Myeloma,
Symptoms: limb pain, weakness
May 2013 Sept 2014
Used COP/MP regimen,
Outcome: Partial Response
Nov Dec 2014
Used Bortezomibregimen,
Stopped due to financial reason
Jan 2015
Used M regimen
Feb 2015,
Live, Stable
disease
30
Patient 13
Female MSH, 51 yrs, IIIA
Aug, 2007
Diagnosed as Multiple
Myeloma,
Symptoms: coccyx pain,
weakness
Aug 2007 Jul 2011
Used TD/MP/M
PT/V/Tregimen,
Outcome: Stable
Disease
Jan 2012,
Relaps
Jan May 2012
Used Bortezomib regimen
6#,
Outcome: Partial
Response
Sept Oct 2012
UsedMT/CD/MD regimen
Jun 2013,
Relaps
Sept Nov 2013,
Used VDregimen
Apr 2014, Relaps,
Used MDregimen
Jun 2014,
Disease Progressio
n, Dead
31
Patient 14
Female NM, 75 yrs, IIIA
Dec, 2012
Diagnosed as Multiple Myeloma,
Symptoms: limb pain, weakness
Sept 2013
Used VT/V regimen,
Outcome: Protein normal, SPEP normal
Sept 2013 Dec 2014
Used CP/P regimen,
Mar 2015
Live
32
Conclusions
Most patients came with unspecific symptoms, like pain, weakness
With patients with anemia, renal impairment, and bone lesions, think about differential diagnosis of Multiple Myeloma
Give therapy that could give longer time of survival and preserve the good quality of life
Bortezomib give good result in patient with newly diagnoses or in relaps/refractory patient, even if the patient had stadium IIIB and renal impairment
33