Multiple myeloma with renal involvement, bone lesions and Neuropathy
71-year-old-male had been diagnosed as having multiple myeloma (MM), apparently of the IgA-Lambda type, with renal involvement. The disease course is characterized by "ups and downs responding to anti-MM therapy. During the disease course, several problems and complications developed: Renal failure, Bone lesions and Neuropathy.
71 years old, male
- Renal failure: It is difficult to determine from the documents I have reviewed, what is the role of cyclosporine, previously administered to the patient for his psoriasis (see below), and what is due to MM involvement. Biopsy was more consistent with cyclosporine nephrotoxicity. However, the response to anti-MM therapy with decreasing creatinine, support the conclusion, that we are facing a myeloma kidney, at least partially. Another possibility, that apparently is not the case, is amyloidosis with kidney involvement, but the absence of significant proteinuria, as well as the findings in the renal biopsy, almost exclude it.
- Bone lesions which appear to be symptomatic (bone pain). This appears to be an integral part of MM.
- Neuropathy: The neurological symptoms are considered to be adverse effects of both Velcade and thalidomide. They are currently well treated by neurologists, as well as an attempt to avoid the potential offending drugs.
- Psoriasis: Recovered with anti-MM therapy (a known phenomenon) but recently recurred.
- Psoriatic arthritis: Treated over the years with NSAIDs, gold,steroids, methotrexate, cyclosporine.
- Renal failure: Related partially to cyclosporine toxicity (see above). I believe that at least part of the problem is related to MM.
- The protein profile of the patient, at diagnosis, and during the course. This includes the findings of the immunofixation and beta-2 microglobulin (although with renal failure it is not accurate), as well as the recent tests for free light chains.
- Prognostic parameters, such as cytogenetics.
- I still do not understand well the level of response to treatment.
- Most important, I need to know what the patient suffers from now. If the symptoms are mostly related to the psoriasis – then one should not be too aggressive with this particular patient.
In the absence of the information, I would like to specify several comments and suggestions:
- I tend to be quite conservative with a 71 year old gentleman. Thus, I agree with the general approach that has been taken. I tend not to submit such patients to autologous stem cell transplantation, but rather treat them with a relative conservative anti-MM therapy.
- If the patient has responded fairly, and this appears to be the case (unless I still miss information), and he is currently, relatively asymptomatic, then very mild approach can be taken at the present time. This means either no anti-MM treatment till we have to (see below), or a mid maintenance. Such maintenance can include dexamethasone, with or without melphalan or only melphalan.
- Only if the protein profile increases significantly (the monoclonal peak) or clinical symptoms or complications appear, that will be related to the hematological disease, this will force us to renew the more active aggressive anti-MM therapy. If this is the case, we might take several possible therapeutic approaches:
- Renew thalidomide-dexamethasone combination, with continued treatment for the neuropathy.
- Velcade also has not received its full chance, but I would avoid it because of the neuropathy.
- Since the patient is not a candidate for stem cell transplantation, melphalan, as a single agent, or probably better as a combination with steroids – can also be administered.
- Lenalidomide (Revlimid), as a single agent, or better in a combination, usually with dexamethasone, is a very attractive possibility for the future. I do not know the patient' health insurance status, since it is very expensive (about E 6500 per month) agent, but indeed very effective, with minimal adverse effects.
- Other therapeutic regimens that can be considered are a combination of doxorubicin (adriamycin) or Doxil with other agents (the old VAD), and cyclophosphamide based combinations.
- Supportive treatment is very important in MM:
- If the patient is anemic – erythropoietin is very effective
- If bone pain is significant – local radiation therapy might help
- The renal failure should be treated in parallel, and also as a separate problem. I suppose that together with the nephrologists one will have to take into consideration a dialysis strategy.
- There are several excellent medical centers in Italy and Italian very professional leading doctors experts in MM. Most of them I know personally:
- Prof. Antonio Palumbo – Turino
- Prof. Mario Boccadoro (Has seen the patient in the past)
- Prof. Michel Cavo