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Case #815
Multiple Myeloma

A 58-year-old Hispanic male with previously diagnosed multiple myeloma reporting an increase in fatigue and edema.

Release Date: May 29, 2009
Expiration Date: May 28, 2010

To Start Case:

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Chief Complaint

Increased/progressive weakness and fatigue with new onset of peripheral edema

History of Present Illness

Miguel is a 58-year-old Hispanic male who presents with complaints of increased weakness and fatigue (onset about 6 months ago), new onset leg edema (onset about 4 weeks ago), episodic lightheadedness and changes in his bowel movements (over the past 3 months). Bilateral swelling of his ankles has now progressed, with swelling now extending to just below his knees. Recently he developed a feeling of numbness in all of his toes. He has been experiencing intermittent episodes of constipation, alternating with loose bowel movements with some urgency and incontinence of stool. He has no actual abdominal pain and denies blood in his bowel movements. He has not lost any weight and denies nausea, vomiting, fever or jaundice. He also complains of transient lightheadedness of a few seconds duration when he gets out of bed in the morning or when he stands up from a sitting position. He has not passed out.


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Disclosures and Important Information

Supported by an educational grant from Millennium Pharmaceuticals, Inc.

Release Date: May 29, 2009

Expiration Date: May 28, 2010

Estimated time to complete this activity: 2.0 hours

Accreditation Statement

MedCases, LLC is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education.

Credit Designation Statement

MedCases designates this educational activity for a maximum of 2.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Statement of Responsibility

MedCases takes responsibility for the content, quality, and scientific integrity of this CME activity.

Course Director and Principal Faculty

Kraft Family Professor of Medicine
Harvard Medical School
Chief, Division of Hematologic Neoplasia
Director, Jerome Lipper Multiple Myeloma Center
Dana-Farber Cancer Institute
Boston, MA

Director, Multiple Myeloma Program
Center for Excellence for Lymphoma & Myeloma
New York Presbyterian Hospital
Cornell University
New York, NY

Assistant Professor of Oncology and Medicine
Myeloma Program, Director
Sidney Kimmel Comprehensive Cancer Center
Johns Hopkins University
Baltimore, MD

Independent Reviewer

Instructor, Adult Oncology
Harvard Medical School
Myeloma Program Medical Staff
Dana-Farber Cancer Institute
Boston, MA

Target Audience

This activity is intended for hematologists and community oncologists.

Prerequisites

There are no prerequisites.

Statement of Need

Significant progress has been made in diagnosis, assessment, and treatment of patients with multiple myeloma. The utilization of new classes of therapy, as well as improved strategies for managing toxicities of these medications, have resulted in new and more effective options that can prolong disease control and survival. Clinicians are now able to change the traditional goals to a more ambitious objective of achieving a complete response, in the hopes of longer progression-free survival and improved quality of life for their patients. Further, the need for stem cell transplants and the potential for associated medical complications may continue to diminish based on the potential for achieving complete remissions with combination therapy in newer protocols.

However, healthcare practitioners are faced with overcoming several clinical barriers quickly to achieve optimal outcomes in their patients. The rapidity of change in this continually evolving arena may cause delays incorporating newer evidence into clinical practice. Lack of familiarity with the newer protocols and the mechanisms of action of newer agents, the potential for adverse effects, and concerns about management of toxicities are all important obstacles in updating the clinical paradigms. Overcoming these obstacles will enable physicians to apply updated guidelines and current evidence to improve the quality of care for multiple myeloma patients.

Objectives

After completing this activity, you should be able to:

Execute diagnostic and monitoring protocols appropriate for light-chain amyloidosis
Implement therapy for amyloidosis within current standards of care
Manage various comorbidities of systemic light-chain amyloidosis

Method of Participation

This Internet-based activity takes approximately 2 hours to complete. You should review the objectives and cases, answer the multiple-choice posttest, and complete an evaluation form online. Once completed, you will be able to save your certificate to your own computer and print it on your own printer.

Disclosure Statement

As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is MedCases policy to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a provider has with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. The following was reported:

Faculty
Kenneth C. Anderson, MD	Consultant and Grant/Research Support: Celgene Corporation, Millenium Pharmaceuticals, Novartis Pharmaceuticals
Ruben Niesvizky, MD	Speakers Bureau: Celgene Corporation, Millenium Pharmaceuticals, Novartis Pharmaceuticals, Ortho Biotech Grant/Research Support: Celgene Corporation, Millenium Pharmaceuticals Consultant: Millenium Pharmaceuticals
Carol Ann Huff, MD	Advisory Board: Amgen Inc., Celgene Corporation Royalties: Syndax

Independent Reviewer
Irene Ghobrial, MD	Speakers Bureau: Celgene Corporation, Millenium Pharmaceuticals

Planning Committee

Harvey Mossman, MD; Carolyn Darrow, MPH and Lillie Chen have indicated that they have not received financial support for consultation, research, evaluation, or have a financial interest relevant to this activity.

Notice of Off-Label Use Presentations

In accordance with US Food and Drug Administration (FDA) requirements regarding the disclosure of off-label, investigational, or unapproved recommendations for the use of drugs or devices, you are advised that content in this activity does not contain reference(s) to uses of drugs or devices that are off-label, investigational, or unapproved in the United States. The following information is provided for educational purposes and not to endorse off-label use.

Bortezomib is indicated for the treatment of multiple myeloma. It is not currently indicated for the treatment of amyloidosis.

Lenalidomide in combination with dexamethasone is indicated for the treatment of multiple myeloma in patients who have received at least one prior therapy. It is not currently indicated for the treatment of amyloidosis.

Melphalan is indicated for the palliative treatment of patients with multiple myeloma for whom oral therapy is not appropriate. It is not currently indicated for the treatment of amyloidosis.

Thalidomide in combination with dexamethasone is indicated for the treatment of patients with newly diagnosed multiple myeloma. It is currently not indicated for treatment of refractory myeloma or amyloidosis.

Vincristine is indicated for the treatment treatment of leukemias, Hodgkin's disease, non-Hodgkin's lymphomas, Wilms' tumor, neuroblastoma, rhabdomyosarcoma. It is currently not indicated for the treatment of multiple myeloma or amyloidosis.

Adriamycin is indicated to produce regression in acute lymphoblastic leukemia, acute myeloblastic leukemia, Wilms’ tumor, neuroblastoma, soft tissue and bone sarcomas, breast carcinoma, ovarian carcinoma, transitional cell bladder carcinoma, thyroid carcinoma, gastric carcinoma, Hodgkin's disease, malignant lymphoma and bronchogenic carcinoma in which the small cell histologic type is the most responsive compared to other cell types. It is currently not indicated for the treatment of multiple myeloma or amyloidosis.

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Hardware/Software Requirements and Technical Assistance

This Web-based CME activity is best experienced using a current generation browser, such as Internet Explorer 5.5 or higher. This Web site requires that JavaScript and session cookies be enabled. In addition, you will require the Adobe Flash Player plugin to view the case simulation.

Detailed Requirements:

128 MB RAM
Windows 98 or newer
Adobe Flash Player 8 minimum needed
Audio playback with speakers for programs that have video content
Internet Explorer 5.5 or higher or Mozilla Firefox 1.0 or higher or Apple Safari
1024 x 768 resolution
Broadband connection highly recommended

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Confirmation

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