3. Prof. Arry_MM MM Case Management Experience in Multiple Myeloma

Case Management Experience in Multiple Myeloma

Name : Prof. DR. Dr. Arry Harryanto Reksodiputro, SpPD-KHOM

Posisi : Divisi Hematologi-Onkologi Medik Bagian Ilmu Penyakit Dalam FKUI-RSUPNCM

Pendidikan

1963 : Fakultas Kedokteran Universitas Indonesia

1969 : Spesialis Ilmu Penyakit Dalam, Fakultas Kedokteran Universitas Indonesia

1970 : Pendidikan Hematologi di Rumah Sakit St. Louis, Universitas De Paris, Perancis

1978 : Pendidikan Teknik Membrane Marker pada Imperial Cancer Research Fund,

Department of Medical Oncology, St. Bartholomews Hospital, London

1979 : Pendidikan Sitologi Limfoma Malignum pada The Hospitalier Pitie-Salpetriere,

Paris

1984 : Doktor pada Fakultas Kedokteran Universitas Indonesia-Universitas Leiden

1991 : Guru Besar pada Fakultas Kedokteran Universitas Indonesia

Case Management Experience in Multiple Myeloma

A.HARRYANTO REKSODIPUTROSRI AGUSTIN

SUB BAG HEMATOLOGI ONK MEDIK

FKUI,RSCM,RSKD2

Patients Characteristic (N=14)N %

Age=65 8 57.14

GenderMale 6 42.86

Female 8 57.14

Heavy chain type

IgG 4 28.57

IgA 3 21.43

LCD 1 7.14

NA 6 42.86

Hb

10 2 14.29

PatientsCharacteristic

(N=14)

N %

>=2.0 3 21.43

NA 2 14.29

Serum albumin

=3.5 7 50

NA 1 7.14

Serum B2M

5.5 4 28.57

NA 6 42.86

Plasma cells of BM

70% 1 7.14

NA 4 28.57

ISS Staging

I 3 21.43

II 1 7.14

III 4 28.57

NA 6 42.86

Durie Salmon Staging

IIA 4 28.57

IIIA 5 35.71

IIIB 3 21.43

NA 2 14.294

5FRONTLINE THERAPY OPTIONSOPTIONS COMMENTS

Melphalan/prednisone

Alkylating agent combinations

Still an option, especially for elderly people

Really only an option if stem cell transplant

is not planned

Cytoxan alone or in combination Can be useful alone or in combination with

less stem cell injury than melphalan

Still a major frontline approach; can have

significant disadvantages

Dexamethasone or other steroid alone A valid option, especially with renal

insufficiency and/or blood count values

Thalidomide plus Dexamethasone A new oral option worthy of consideration

but without a long track record

VAD regimen

Bortezomib plus Dexamethasone, or in

combination with other agents

A novel agent, option if stem cell transplant

is planned, option if theres renal

insufficiency

Choice of Therapy

Bortezomib-based regimen

Non bortezomib-based regimen

First line therapy, (in newly diagnosedMultiple Myeloma)

3 patients 11 patients

Salvage therapy (in Relapsed/refractoryMultiple Myeloma)

4 patients

7

8RECOGNIZED PROGNOSTIC FACTORS2

Factor Significance

Specialized tests

Plasma cell labeling index High-poor

Plasma cell morphology Plasmablastic-poor

Bone marrow cytogenetics

Standard cytogenetics Hypodiploidy/deletion 13-poor

FISH analysis (chromosome 13) 13 deletion-poor

Microarray techniques Differential patterns

Whole-body FDG/PET scan Extramedullary-disease poor

0 10 20 30 40 50 60 70 80 90 100

1

2

3

4

5

6

7

8

9

10

11

12

13

14

Months

Pat

ien

t

Range time of Survival

Bortezomib-based first lineNon bortezomib-based first lineNon bortezomib-based as first line, Bortezomib-based as salvage

1st year 2nd year 6th year3rd year 5th year4th year 7th year

9

Survival (Bortezomib vs Non-Bortezomib)

0 10 20 30 40 50 60 70 80 90 100

II A

II A

NA

III A

III A

III B

III B

II A

NA

II A

III A

III A

III A

III B

Bortezomib Vs Non Bortezomib

Survival times (months)

10

Note for Range time of Survival

Patients didnt start the treatment at the same time

Bortezomib as salvage therapy seemed could prolong the range time of survival

Bortezomib as first line therapy looked like not having very long range time survival, but the patients actually are new and still on going and others are using Bortezomib in short period due to financial reason

11

Durie Salmon Staging

Stadium IIAStadium IIIAStadium IIIBNot applicable

0 10 20 30 40 50 60 70 80 90 100

B

NB than B

B

NB

NB

NB

NB

NB

NB

NB

NB than B

NB than B

NB than B

B

Months

Pat

ien

t

12

Role of Stage in Survival Bortezomib vsNon Bortezomib Pts

0 10 20 30 40 50 60 70 80 90 100

II A

II A

NA

III A

III A

III B

III B

II A

NA

II A

III A

III A

III A

III B

Bortezomib Vs Non Bortezomib


13

Note for Durie Salmon Staging


Two patients staging are not applicable because criteria is not complete

The staging seemed not really influence the range time of survival, as its not the only factor that determine patients survival

Bortezomib are used in all staging

14

Quality of Life

Good QoLPoor QoL

0 10 20 30 40 50 60 70 80 90 100

B

NB than B

B

NB

NB

NB

NB

NB

NB

NB

NB than B

NB than B

NB than B

B

Months

Pat

ien

t

15

Quality of Life

0 10 20 30 40 50 60 70 80 90 100

Non B

Non B

Non B

Non B

Non B

Non B

Non B

Bortezomib

Bortezomib

Bortezomib

Bortezomib

Bortezomib

Bortezomib

Bortezomib

Good QoL vs Poor QoL


Good QoLPoor QoL

16

Note for Quality of Life


Criteria for good or poor quality life is based on the patients condition and history of hospitalization

Most patients used Non-bortezomib based regimen only, had poor quality of life, disease progression, and died

More patients used Bortezomib-based regimen (as first line, or salvage) had good Quality of Life

17

PATIENTS HISTORY OF TREATMENT

18

Patient 1 Male CD, 65 yrs, IIIB, (anemia, hypercalcemia,

renal impairment, bone lesions)Oct 2014

Diagnosed as Multiple Myeloma,

Symptoms: low back pain, postural

dizziness, renal impairment

Nov-Dec 2014

Used VTD/VTregimen,

Outcome: hematological tests and renal functions

are improved

Jan, 2015

Using TP regimen

March 2015

Being hospitalized, because anemia,

hypercalcemia, acute renal injury

19

Patient 2

Male DS, 77 yrs, Stage NA

Jan, 2010

Diagnosed as Multiple

Myeloma,

Symptoms: anemia

Apr 2010-Sept 2014

Used TDregimen,

Sept, 2014

Stop Thalidomide maintenance, progression,

(anemia, bone lesions, SPEP+, IF+)

Sept-Dec 2014

Used VT regimen

Jan 2015,

Live, hematological

tests are improved,

globulin normal

20

Patient 3

Male TW, 60 yrs, IIA

June, 2011


Myeloma,

Symptoms: waist pain

Oct Dec 2011

Used VD/V regimen4#,

Outcome : Protein and SPEP become

normal

Sept, 2012

Relaps,

Then using TD/T/TD regimen,

(anemia, bone lesions, SPEP+, IF+)

Oct 2013

Stop all therapy

Jan 2015,

Live, Relaps,

21

Patient 4

Male RBS, 77 yrs, IIIA

Mar, 2008


Symptoms: nosebleed, gumbleed, melena,

waist pain

Jul 2008

Used MT/MP regimen

Apr, 2009

Disease progression,

Dead

22

Patient 5

Female JL, 31 yrs, Stad NA

Aug, 2005


Symptoms: weakness

Aug 2005 Jan 2007

Used TD/T regimen

Jul, 2009

Relaps,

Jul 2009 Jul 2011

Used TD/COP/MT regimen

After Jul 2011,

Loss to follow-up

23

Patient 6

Female MM, 60 yrs, IIIA, hypercoagulation

Oct, 2011


Symptoms: limb pain, weakness

Oct 2011 Dec 2012

Used MTD/MT/MP/COP/D but irreguler admission due to

nonadherence, patient also used Herbal

Mar, 2013

Dead,

Progressive Disease

24

Patient 7

Female WIH, 65 yrs, IIA

Oct, 2006


Myeloma,


Oct 2006 May 2007

Used COP/C regimen, Outcome : Stable

Disease

Aug 2007 - .. 2009

On vacation to abroad, T stop used

treatment

Apr Sept 2009, Used MTregimen

Jul, 2010

Disease Progression,

Dead

25

Patient 8

Male N, 57 yrs, IIIB, renal impairment

Mar, 2009


Symptoms: waist pain, renal impairment

Apr 2009 Jan 2010

Used TD/M/MT regimen

Feb, 2010

Febrile neutropenia, admissioned at ICU, very bad

condition, Dead

26

Patient 9

Female CH, 58 yrs, IIIB, Free light chain disease

Dec, 2009



Dec 2009 Mar 2010

Used MTD regimen

Mar, 2010

Disease progression, Dead

27

Patient 10

Female SL, 65 yrs, IIA

Nov, 2012


symptom: weakness

Dec 2012 Sept 2014

Used MP regimen until now

Feb 2015

Live, partial response

28

Patient 11

Male R, 70 yrs, IIIAJun, 2006Diagnosed

as Multiple

Myeloma,

Symptoms: low back

pain, postural

dizziness, renal

impairment

Jun 2006 ..

Used CTD/COP/CTD

/MTD regimen,

Outcome: Stable

disease

Oct 2008

Used Vregimen,

AE: herpes, pneumonia, neuropathy

. - .

Used MT/MPregimen

. 20..,

Relaps

May-Jul 2011,

Used V/MDregimen

Outcome: Partial

Response, no AE

.. 2013, Relaps,

Used TD regimen

Aug 2013, Disease

Progression, Dead

29

Patient 12

Female R, 69 yrs, IIA

Mar, 2013


Myeloma,


May 2013 Sept 2014

Used COP/MP regimen,

Outcome: Partial Response

Nov Dec 2014

Used Bortezomibregimen,

Stopped due to financial reason

Jan 2015

Used M regimen

Feb 2015,

Live, Stable

disease

30

Patient 13

Female MSH, 51 yrs, IIIA

Aug, 2007


Myeloma,

Symptoms: coccyx pain,

weakness

Aug 2007 Jul 2011

Used TD/MP/M

PT/V/Tregimen,

Outcome: Stable

Disease

Jan 2012,

Relaps

Jan May 2012

Used Bortezomib regimen

6#,

Outcome: Partial

Response

Sept Oct 2012

UsedMT/CD/MD regimen

Jun 2013,

Relaps

Sept Nov 2013,

Used VDregimen

Apr 2014, Relaps,

Used MDregimen

Jun 2014,

Disease Progressio

n, Dead

31

Patient 14

Female NM, 75 yrs, IIIA

Dec, 2012



Sept 2013

Used VT/V regimen,

Outcome: Protein normal, SPEP normal

Sept 2013 Dec 2014

Used CP/P regimen,

Mar 2015

Live

32

Conclusions

Most patients came with unspecific symptoms, like pain, weakness

With patients with anemia, renal impairment, and bone lesions, think about differential diagnosis of Multiple Myeloma

Give therapy that could give longer time of survival and preserve the good quality of life

Bortezomib give good result in patient with newly diagnoses or in relaps/refractory patient, even if the patient had stadium IIIB and renal impairment

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Documents

3. Prof. Arry_MM MM Case Management Experience in Multiple Myeloma