AN UNUSUAL CASE OF MULTIPLE MYELOMA DEPARTMENT OF MEDICAL ONCOLOGY

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

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

RENAL BIOPSY Lambda light chain deposition Cast nephropathy

DIAGNOSIS multiple myeloma

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

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

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

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

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

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- 10.5 mg/dl

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

BMA

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

SKELETAL SURVEY

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

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

CT- CHEST (P)

CT CHEST (C)

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

CT NECK(P)

CT NECK (C)

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

CT abdomen and pelvis( p)

CT PELVIS (C)

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

FNAC from breast lump

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

FNAC from clavicular swelling

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

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

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

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

THANK YOU