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

2. 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.

3. 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 (+) ’ TAH
Family history None
Personal history Alcohol (-) Smoking (-)

4. 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 (-)

5. Physical examination
Vital sign /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 (-)

6. 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

7. 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

8. 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

9. Chest X-ray

10. 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

11. 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

12. Bone lesion

13. Bone marrow examination

14. Approach & Treatment

15. Peripheral blood stem cell collection
Induction
VAD (vincristine 0.4mg, adriamycin 14mg, dexamethasone 40mg)
#1 ’06.2.8~ #2 ’06.3.9~ #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 x10*8
sum of CD34/kg x10*6
목표 : mononuclear cell 4x10*8/kg
CD34+ cell 2x10*6/kg

16. 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

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

18. Supportive care and discharge
day 3 : diarrhea – smecta, loperamide
day 4 : hemoglobin 8.2 – pRBC 2pint transfusion
day 5 : platelet – 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.