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    What do these medical reports suggest?

Posted on Fri, 7 Jul 2017 in General Health
Question: Hello Doctor,

I have consulted before many times for my mother (Age:69) who is a Multiple Myeloma Patient. She has been gone through radiation and chemotherapy after Kyphoplasty surgery in D9 vertebra (Done in 2011). She gave complete response to chemotherapy. After chemotherapy she has been on maintenance that included Lenalidomide 10 mg daily for 20 days and then 10 days gap before continuing further and also she's taking Zoldria injection after every 3 months. She has been under remission since 2012 till now. Her Free Light Chain reports were normal till last year. But, after that Kappa lambda value started increasing. Last test was done in March 2017 which showed Kappa\lambda values as Kappa: 88.40 mg\L and Lambda 28.60 mg\L with Kappa\Lambda Ratio: 3.091. However FLC done in the month of XXXXXXX 2017 showed further increase in Kappa and Lambda Values with Kappa: 117.0 mg\ L and Lambda 49.2 mg\ L with Kappa\ Lambda Ratio: 2.378. (Both the reports have been attached). She is health wise fine except loose motions often and side effects of Leneledomide resulting numbness in her feet.

Doctor, please suggest me what exactly these reports are indicating and What options are available now for her in case abnormality in reports continues?
Can chemotherapy be advised again to bring FLC values to normal?
Answered by Dr. Indranil Ghosh 10 hours later
Brief Answer:
This looks like a relapse

Detailed Answer:
Thanks for following up.

It appears that she had an excellent remission but now FLC ratio is increasing. In the last two results, free kappa is progressively increasing but the ratio has somewhat reduced. However, both the FLC ratio values are abnormal. This indicates relapse from complete remission and needs attention.

I would do another FLC test in around 6 weeks time along with serum protein electrophoresis and 24 hr urine protein with electrophoresis. Depending on the results we can modify the treatment again to induce remission.

Hope this helps.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
Follow up: Dr. Indranil Ghosh 1 hour later
Hi, I have provided some attachments. Please review them.
Answered by Dr. Indranil Ghosh 1 hour later
Brief Answer:
Albumin globulin ratio is still reversed

Detailed Answer:
This again raises suspicion of relapse. In that case I would do the serum protein electrophoresis and 24 hr urine protein with electrophoresis right now.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
Follow up: Dr. Indranil Ghosh 3 hours later
Thanks for your valuable response doctor.

I have also attached recently arrived reports that includes Serum Protein Electrophoresis and Beta 2 Micro globulin. Her Beta 2 Micro globulin report falls under stage 1 as of now and there is no M-Spike seen.

As you said this looks a relapse. And we need to test again after 6 weeks before starting further treatment. But, Still could you please give an idea that what options does she has available to induce further remission in near future and How does such patients (Age:69) respond on further inducing remission on relapse. I would also like to know if she is still a good candidate for conventional chemotherapy or stem cell transplant.
Answered by Dr. Indranil Ghosh 5 hours later
Brief Answer:
There are many options

Detailed Answer:
M Spike is negative. beta2 microglobulin is not good marker for monitoring. It's good that it's low but doesn't carry much significance.

We have many options for relapse treatment. Bortezomib can be tried again, or even better, carfilzomib. Then there is pomalidomide. Given the long remission, response likely to be good.

Stem cell transplant will be difficult at this age but not impossible. It would depend on the judgement of the treating physician.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
Follow up: Dr. Indranil Ghosh 43 hours later
Thanks doctor,

Before I close this consultation I would like to confirm whether our current doctor has advised correctly.

We visited the OPD of our oncologist to show all the reports I have shown you. My mother is having severe pain in couple of her teeth because of which dental surgeon has suggested for extraction of teeths. Hence, our oncologist postponed zoldria injection for three months and said to first get her dental treatment completed and then visit after three months with Serum FLC reports. But, when I asked him what action we may take now on the basis of her increased FLC. He said no action as of now just continue lelneledomide for next three months and then we will proceed further based on reports at that time.

Does waiting for three months is ok for her? Or if there is any test that you may recommend for monitoring within this three months of span to avoid any latency. (Attached is latest OPD note of the doctor)
Answered by Dr. Indranil Ghosh 3 hours later
Brief Answer:
Yes we can wait

Detailed Answer:
Zoledronate should​ be avoided in case of dental problems.

Regarding the course of action, as I said we can wait. Now I said 6 weeks and your doc said 3 months, it can vary. Just to buy some more time till we start the next treatment, as she is otherwise all right and it is just the lab value that is abnormal.

It should not change the results of next line of therapy. I don't recommend any special test in the meantime.

Above answer was peer-reviewed by : Dr. Raju A.T
Answered by
Dr. Indranil Ghosh


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