Autologous PBSCT of Multiple myeloma Case of the week Hemato-oncology R2 한재준

C.C. : autologous PBSCT위해 입원함. 박O자 F/64 Admission :’06-8-6 C.C. : autologous PBSCT위해 입원함. P.I. : Back pain으로 본원 정형외과 방문하여 L-S spine MRI 촬영 후 multiple myeloma소견으로 혈액종양 내과로 전과. multiple myeloma IgG κ type stage IIIB 진단하였음. tandem autologous PBCST계획하여 ’06 2월 부터 VAD regimen으로 chemotherapy시작. VAD #4 항암치료 후 6월29일 입원하여 3차례에 걸쳐 stem cell mobilization과 luekapheresis시행 후 퇴원함.

Personal history Alcohol (-) Smoking (-) Past medical history DM (-) HTN (+) Tb (-) Hepatitis (-) cavedilol 6.25mg bid clinidipine(calcium channel antagonist) 10mg bid losartan (ARB) 50mg qd Op Hx (+) ’05-10-21 TAH Family history None Personal history Alcohol (-) Smoking (-)

Review of Systems General : fatigue (-) fever (-) chills (-) night sweat (-) Skin : rash (-) itching (-) pigmentation (-) Head / Neck : headache (-) sore throat (-) Respiratory : cough (-) sputum (-) dyspnea (-) cyanosis (-) Cardiac : orthopnea (-) chest pain (-) palpitation (-) GI : A/N/V/D/C (-/-/-/-/-) melena (-) abdominal pain (-)

Physical examination Vital sign 110/70 mmHg – 75/min – 22/min – 36.3 °C General appearance Alert mentality Chronically ill looking appearance Skin No rash or pigmentation Head & Neck No cervical lymph node enlargement Neck vein engorgement (-)

Physical examination Eyes and ENT Isocoric pupils with pupil light reflex (++/++) Whitish sclera Pinkish conjunctivae Chest Clear breath sounds without crackle or wheezing Regular heart beats without murmur

Physical examination Abdomen Soft and flat abdomen Normoactive bowel soud No tenderness or rebound tenderness No palpable abdominal mass Back and Extremities CVA tenderness ( - / - ) Pretibial pitting edema ( - / - ) Neurology Unremarkable

Initial Lab Results CBC/DC 5300/mm3 – 10.4g/dL– 31.8 % - 173K/mm3 MCV 97.6fL MCH 31.9pg (Seg 77.5%, Lymph 8.7%, Mono 4.9%) Chemisrty TB/DB 0.56/0.06 mg/dL ALP 90 U/L GGT 16 U/L Prot/Alb 6.6/3.5 g/dl AST/ALT 18/14 U/L LD 367 U/L Ca/P 8.8/4.3 mg/dl Bun/Cr 9/0.9 mg/dl Na/K/Cl 137/4.1/106 mmol/L Urinalysis RBC 0~1/ HPF WBC 0~1/ HPF

Chest X-ray

Initial Assessment / Plan Assessment #1. Multiple myeloma s/p VAD#4 s/p stem cell mobilization #2. HTN #3. mutiple uterine myoma s/p transabdominal hysterectomy Plan #1. conditioning(high dose melphalan therapy) 140mg C.I. for 30minutes x 2 days (8.7~8) after 48hrs : PBSC reinfusion supportive care : mucositis, diarrhea, parenteral nutrition blood component transfusion

Stage IIIB 아래 사항 중 하나 - III 혈청 크레아티닌에 의한 아분류 - B Hemoglobin 6.3g/dL (<8.5g/dL) Serum calcium 10.3mg/dL (>12mg/dL) Bone lesion M-protein : IgG 3080mg/dL (>7g/dL) IgA 160mg/dL (>5g/dL) 혈청 크레아티닌에 의한 아분류 - B Serum creatinune 6.3mg/dL (>2mg/dL) Serum β2-microglobulin 32100μg/dL (4μg/dL) - II

Bone lesion

Bone marrow examination

Approach & Treatment

Peripheral blood stem cell collection Induction VAD (vincristine 0.4mg, adriamycin 14mg, dexamethasone 40mg) #1 ’06.2.8~12 #2 ’06.3.9~12 #3 ’06.4.7~10 #4 ’06.6.1~ 4 Peripheral blood stem cell collection 7월 2일 cyclophosphamide 5500mg C.I. for 1hour 7월 9일~16일 G-CSF 투여하여 hematopoietic stem cell mobilization. 7월 14일~16일 Leukapheresis 3회 시행 sum of MNC/kg 18.65x10*8 sum of CD34/kg 79.76x10*6 목표 : mononuclear cell 4x10*8/kg CD34+ cell 2x10*6/kg

M-protein 변화 VAD#1 VAD#2 VAD#3 Total protein : 9.1g/dL M-peak : 5.2g/dL Total protein : 8.0g/dL M-peak : 2.7g/dL Total protein : 5.7g/dL M-peak : 0.9g/dL VAD#4 Total protein : 5.4g/dL M-peak : 0.6g/dL Total protein : 6.2g/dL M-peak : 0.7g/dL

Peripheral blood stem cell transplantation High dose melphalan 140mg C.I. for 30minutes x 2days Thawing and reinfusion

Supportive care and discharge day 3 : diarrhea – smecta, loperamide day 4 : hemoglobin 8.2 – pRBC 2pint transfusion day 5 : platelet 28000 – single donor pheresis transfusion day 6 : neutropenic fever( 38.4°C) – cefepime day 8 : nausea Gr 2, vomiting Gr 2 - parenteral nutrition day 20 : discharge → OPD follow up Second planned autologous PBSCT after recovered from the first.