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Case #816
Multiple Myeloma

A 71-year-old African-American male with multiple myeloma and jaundice

Release Date: July 15, 2009
Expiration Date: July 14, 2010

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Chief Complaint

Abdominal pain and icteric sclerae

History of Present Illness

Darryl is a 71-year-old African-American male initially presented to the emergency department with pain in his upper back and was diagnosed with a T7 compression fracture on plain radiographs of the thoracic spine. Subsequently a bone scan showed bony metastasis of multiple ribs and thoracic vertebrae. A CT-guided biopsy of the thoracic spine lesion confirmed plasmacytoma, which was negative for CD20 but positive for CD38 with lambda light chain restriction. The patient received thalidomide (100 mg daily) and dexamethasone (20 mg daily on days 1–4, days 8–11, days 15–18, every 28-day cycle) for 7 cycles, and then received high-dose melphalan (200 mg/m²) with autologous stem-cell rescue 8 months after initial diagnosis. Four cycles of bortezomib/dexamethasone were administered because of a partial response, resulting in further decrease of his monoclonal gammopathy but not eradication. Less than 2 years after primary therapy and bone-marrow transplantation, serial serum protein and urine protein electrophoresis showed persistent low but stable IgA levels (total IgA 489 mg/dL (normal levels 70–386 mg/dL).

The patient presents now with yellow discoloration to his eyes for one week and a decreased appetite for the past month. He also notes that his stool is light in color and his urine has been a dark orange for the past week. He has mild right upper quadrant abdominal pain the last two days but no vomiting, fever, flank pain or rectal bleeding.


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Disclosures and Important Information

Supported by an educational grant from Millennium Pharmaceuticals, Inc.

Release Date: July 15, 2009

Expiration Date: July 14, 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

Professor of Medicine
University of Texas
MD Anderson Cancer Center
Member, Scientific Advisory Board
International Multiple Myeloma Foundation
Houston, TX

Independent Reviewer

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

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 staging studies for multiple myeloma
Execute appropriate diagnostic protocols for refractory multiple myeloma
Implement newly emerging therapies for refractory myeloma

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
Raymond Alexanian, MD	Indicated he has not received financial support for consultation, research or evaluation or has a financial interest relevant to this activity

Independent Reviewer
Carol Ann Huff, MD	Advisory Board: Amgen Inc., Celgene Corporation Royalties: Syndax

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.

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Hardware/Software Requirements and Technical Assistance

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128 MB RAM
Windows 98 or newer
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Audio playback with speakers for programs that have video content
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1024 x 768 resolution
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Confirmation

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