Done serum electrophoresis, taken injection of Zoledronic acid, have metastatic carcinoma. Suggest further treatment

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Posted on Fri, 7 Sep 2012 in Cancer
Question: I have some urgent query regarding my mother's serum electrophoresis report. She previously had a fracture in spine vertebrae D9. After biopsy of D9 vertebrae doctors found it to be a metastatic carcinoma with primary in kidney. Orthopaedics doctors suggested for kyphoplasty of D9 vertebrae which was successfully done in XXXXXXX 2011. A biopsy again was also done simultaeneously while operation of kyphoplasty from D9 vertebrae, reports of biopsy showed no malignancy. Blood report of Seum electrophoresis revealed M-spike 1.5 gm/dl in fast gamma region. After all that doctors advised for Radiation therapy. Which was given in 44 gray quantity on same vertebrae. Further after completion of radiation therapy given in 22 fractions. Doctor said to revisit after six weeks with report of Skeletal survey and Serum electrophoresis. Skeletal survey showed no bony lesion except cemented collapsed D9 vertebrae body. But SE report showed Mspike to be 1.55 gm\dl i.e. 0.5 greater then last diagnosis. Doctor advised to follow again after 4 weeks with again report of Serum Electrophoresis and also advices a monthly injection of Zoledronic Acid. A plasma cells to be 7%. After 4 weeks SE report showed Mspike to be 1.66 gm\dl. We further advised by doctor to follow after 4 weeks with same tests done. In month of December 2011 SE report showed a decrease in value of M-spike which was 1.37 gm\dl. Doctor said that its good indication and said to visit after 3 months, but also advised for injection of Zoledronic acid monthly. Now in month of March 2012 (3 months) after last visit we got SE done again and Report showed a jump in M spike to 3.02 g\dl with hypogammaglobulineamia present. Please suggest further ASAP by considering this case very important. Latest and previous SE reports are attached. Questions were asked by me before in Nov 2011 and answered by Dr. Indranil XXXXXXX Old reports are still in my dashboard.
doctor
Answered by Dr. Indranil Ghosh 4 hours later
Hello XXXXXXX,

I do remember your mother's history. I felt that she was having a monoclonal gammopathy but not myeloma.

Now the M-spike has increased to 3 gm/dl, which qualifies it as smoldering myeloma. We should repeat the skeletal survey (X-rays of whole body), serum haemoglobin, creatinine and calcium to ascertain whether it is full-blown myeloma. A repeat bone marrow may also be needed if any of these is abnormal.

If it is only smoldering myeloma (no drop in haemoglobin, normal calcium/creatinine and no bone disease elsewhere), then the treatment remains observation. In any other scenario it becomes active myeloma and needs anti-myeloma treatment.

Hope I have answered your query. Let us know of any follow-up queries. If you do not have any follow-up query, then please accept my answer.

Above answer was peer-reviewed by : Dr. Shanthi.E
doctor
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Follow up: Dr. Indranil Ghosh 2 days later
Hello Dr. Indranil,
Thanks for your response. Doctors here suggested for Bone marrow aspiration, Skul X-ray Lateral view and Blood tests (CBC, RFT, Ca). I got these test done.New Reports are uploaded. Skul X-ray is normal as per doctor. However Bone marrow aspiration shows plasma cells increased to 18%. I am consulting with two oncologists. One of doctor has given prescription (After going through recent reports) to take medicines like Thalidomide 100g, Decdak 4g, Forcen 200g etc. for 1 month and then after that adviced to show up again. Whereas one of doctor has a plan of Chemotharapy to be given in 3 cycles. But before giving a XXXXXXX signal for chemotherapy he advised for blood test to check Hemoglobin, platlet count and Serum Creatinine etc...reports of those I'll be showing him tommorow... Please suggest what would be the appropreate and effective treatment at the moment (Medicines or Chemotherapy)? And does chemotherapy includes medicines like Thalidomide & dexamethasone. Does these medicines helps to reduce plasma cell in bone marrow?
doctor
Answered by Dr. Indranil Ghosh 13 hours later
Hi and thanks again,

As hemoglobin, Creatinine / calcium and X rays are normal, this is smoldering myeloma.

The treatment of smoldering myeloma (according to all international guidelines like NCCN, ASCO, ASH) is observation 3-6 monthly OR enrolment into clinical trials. Unfortunately we do not have too many trials going on in India. Hence I would recommend observation only.

She will need anti-myeloma treatment in near future for sure; but there is no point starting it now.

I suggest you take another opinion from AIIMS, New Delhi.

Hope this answers your query. Let me know if you have any further concerns.
If all your queries are answered, please accept the answer and close the discussion.

Regards

Above answer was peer-reviewed by : Dr. Prasad
doctor
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Follow up: Dr. Indranil Ghosh 23 hours later
Hello Doctor,
I would like to show you the attached prescription of doctor for medicines to treat myeloma at the moment. Please check the newly added file Doctors prescription.jpg. Also recently we got a report of full skeletal survey (uploaded).

Kindly suggest if is it ok to start the medicines prescribed at the moment? Doctor, I am very sensitive regarding my mother's problem and would never like to see a moment in future, where I may feel that "The other alternative (treatment) could have proven better".
doctor
Answered by Dr. Indranil Ghosh 55 minutes later

Hi and thanks again,

I was able to view your report. Your doctor has mentioned Xray skul "+". I don't know what he means by that as the report of skull Xray is mentioned as normal. It is probable that he had seen something on the Skull Xray film.

If the vertebral lesion is the only bone lesion we may just follow her up (because it may be osteoporotic and not related to myeloma). If there are other lesions then definitely immediate treatment is required.

If treatment is required then I would prefer bortezomib-dexamethasone as it is more effective and less toxic.

Hope this answers your query.

Best Wishes

Above answer was peer-reviewed by : Dr. Prasad
doctor
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Follow up: Dr. Indranil Ghosh 27 hours later
Hello Doctor,

Thanks for your reply. You are right, Doctor said that there are small lesions on skull xray. according to him its myeloma. But still he said to wait for one month and advised to come with reports of CBC, RFT & Ca, SE again.
He said she'll be surely requiring treatment soon. But, not now as currently blood CBC. RFT and CA are on normal levels and patient is not having any symptoms.

I don't know why they are regreting to begin treatment ASAP when they know that plasma cell count is increasing and lesion can be seen in skull x-ray.

At last I would like to ask, Are they doing the right thing? otherwise I'll get the treatment started from somewhere else.
doctor
Answered by Dr. Indranil Ghosh 9 minutes later
Hi again,

The prescription you uploaded probably advised to start the drugs right away; but you are saying that it would be started after one month. It is not clear to me what the exact advice of the doctor is.

Treatment can decrease plasma cells, but not eliminate completely. That is why we want to wait as long as there is no urgency. However if there are skull X XXXXXXX abnormalities, then treatment should be started immediately. Otherwise you can wait.

Hope it clear to you.

Thanks again and Best Wishes

Above answer was peer-reviewed by : Dr. Prasad
doctor
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Dr. Indranil Ghosh

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