multiple myeloma prognosis case
A 48-year-old woman presents with back pain, osteoporosis, and fatigue. A complete evaluation finally reveals that she has multiple myeloma. She asks about the prognosis. She is a mother of two small children and is quite frightened. You order a battery of tests. Which of the following laboratory results indicates a more favorable (survival of 1 year or more) prognosis?
A. Albumin of 2.4 g/dL
B. Creatinine of 2.3 mg/dL
C. Hemoglobin of 7.5 g/dL
D. Low β2-microglobulin level
E. Platelet count of 18,000/mm
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ADVERSE PROGNOSTIC FACTORS IN MULTIPLE MYELOMA:
-Serum albumin <3 g/dL
-Serum creatinine ≥ 2 mg/dL
-Platelet count <150,000/microL
-Age ≥ 70 years
-Beta-2-microglobulin >4 mg/L
-Plasma cell labeling index ≥ 1 percent
-Serum calcium ≥ 11 mg/dL
-Hemoglobin <10 g/dL
-Bone marrow plasma cell percentage ≥ 50 percent
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ption D (Low β2-microglobulin level) is correct. Low β2-microglobulin levels indicate a more favorable prognosis.
Option A (Albumin of 2.4 g/dL) is incorrect. Low albumin is not a prognosticator of disease severity.
Option B (Creatinine of 2.3 mg/dL) is incorrect. Renal impairment is an adverse prognostic factor.
Option C (Hemoglobin of 7.5 g/dL) is incorrect. A low hemoglobin is an adverse prognostic factor.
Option E (Platelet count of 18,000/mm3) is incorrect. Platelet counts are not a prognosticator of disease severity.
High-yield Hit 1
Promptly diagnose and treat infections. Common bacterial agents are Streptococcus pneumoniae and Haemophilus influenzae. Prophylactic therapy against Pneumocystic carinii with trimethoprim sulfamethoxazole must be considered in patients receiving chemotherapy and high-dose corticosteroid regimens.
Control hypercalcemia and hyperuricemia.
Control pain with analgesics; radiation therapy and surgical stabilization may also be indicated.
Treat anemia with epoetin alfa.
Monthly infusions of the biphosphonate pamidronate provide significant protection against skeletal complications and improve the quality of life of patients with advanced multiple myeloma. Zoledronic acid (Zometa) can be infused over 15 min and is more effective than pamidronate for treatment of hypercalcemia of malignancy. Biphosphonates (pamidronate, zoledranate, and ibandronate) also appear to have an antitumor effect.
Prognosis is better in asymptomatic patients with indolent or smoldering myeloma: median survival time is approximately 10 yr in persons with no lytic bone lesions and a serum myeloma protein concentration <3 g/dl.
As compared with a single autologus stem-cell transplantation, double transplantation (two successive autologus stem-cell transplantations) improves survival among patients with myeloma, especially those who do not have a very good partial response after undergoing one transplantation.
Taken from Ferri's Clinical Advisor 2006 by Ferri
High-yield Hit 2
Multiple myeloma is a malignancy of plasma cells characterized by overproduction of intact monoclonal immunoglobulin or free monoclonal kappa or lambda chains.
203.0 Multiple myeloma
EPIDEMIOLOGY & DEMOGRAPHICS
ANNUAL INCIDENCE: 4 cases/100,000 persons (blacks affected twice as frequently as whites); multiple myeloma accounts for 10% of all hematologic cancers
PREDOMINANT AGE: Peak incidence in the seventh decade at a median age of 69 yr
PHYSICAL FINDINGS & CLINICAL PRESENTATION
The patient usually comes to medical attention because of one or more of the following:
Bone pain (back, thorax) or pathologic fractures caused by osteolytic lesions
Fatigue or weakness because of anemia secondary to bone marrow infiltration with plasma cells
Recurrent infections as a result of impaired neutrophil function and deficiency of normal immunoglobulins
Nausea and vomiting caused by constipation and uremia
Delirium secondary to hypercalcemia
Neurologic complications, such as spinal cord or nerve root compression, blurred vision from hyperviscosity
Pallor and generalized weakness from anemia
Purpura, epistaxis from thrombocytopenia
Evidence of infections from impaired immune system
Bone pain, weight loss
Swelling on ribs, vertebrae, and other bones
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