Oncology Case Challenge: A Daily Beer Drinker With Bruises, Back Pain, and Bleeding

Arun Gupta, MD, DNB


July 28, 2022

Numerous studies have demonstrated that autologous stem cell transplantation is superior to combination chemotherapy for patients with myeloma who are younger than 65 years. Patients usually receive 4-6 courses of initial chemotherapy, and their stem cells are mobilized with a growth-promoting factor specific for early marrow cells. Some patients (approximately 10%) relapse even after autologous stem cell transplantation, with the average time to relapse being 4 years. At relapse, select patients may benefit from a repeat stem cell transplant, particularly if an adequate number of previously harvested stem cells are still available. The major problems are transplant-related mortality and a late relapse, with patients relapsing as long as 10 years after allogeneic stem cell transplantation.[17] Bisphosphonates are used for the prevention of bony complications, and their use results in an improvement of pain and an overall better quality of life. Radiation therapy is employed to treat areas where there is localized bone damage or pain, or to prevent or treat a fracture. It may be used in combination with chemotherapy.[18]

Patients with nonsecretory myeloma are treated in the same fashion as classic multiple myeloma. The diagnosis and monitoring of patients with nonsecretory myeloma depends on an excess of monoclonal plasma cells in the bone marrow and lytic lesions of the bone. Most published reports suggest that there is no significant difference in survival between NSMM and multiple myeloma. Patients with NSMM usually have more advanced disease than those with classic myeloma, and the overall survival ranges from 6 months to 12 years. In this case, examination of the bone marrow aspiration smears showed 65% plasmacytoid cells that were positive for CD38 and CD138 on flow cytometric analysis. Conventional cytogenetic evaluation did not reveal any chromosomal abnormalities.

The patient in this case belongs to the producer subtype of NSMM and is currently on induction therapy with cyclophosphamide, dexamethasone, and thalidomide. She is clinically stable, and her biochemical parameters have started improving. During her most recent visit, her hemoglobin level was 10.5 g/dL, platelet count was 95 × 109/L, alkaline phosphatase was 150 U/L, LDH was 610 IU/L, and beta-2 microglobulin was 2.1 µg/mL. Radiographs of the skull showed significant resolution of the lytic lesions. She is scheduled for bone marrow transplantation.


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