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Dr. Ashok Raswant

 

   Ludhiana, Punjab; araswant@yahoo.com

1951 / Class of 2003 / Type: IgG / Spinal lesions / Radiotherapy, Chemo / Updated 3/13

Radiologist by profession and a resident of Ludhiana, Punjab, was asymptomatic 8 years back when I started having low backache, not relieved with traction and medicines. Further investigations revealed Plasmacytoma of L 5 spine (IgG) type along with M protein in gamma globulin region. M spike was 1.86 g/dl, B2 microglobulin-1.9 mg/dl, IgG-2230 mg/dl. Bone marrow aspiration was normal. A biopsy from L5 spine was not attempted considering the site and type of lesion. I underwent radiotherapy for the same-received 14 fractions to spine with 250 cGy in 2003 in Ludhiana. I remained almost asymptomatic for 3 years except the persisting back pain, Follow up with CBC, RFTs, Serum Electrophoresis and skeletal survey every 6 monthly continued.

In May 2007, the localized tumor at L5 again progressed. M-spike was 1.07. I received 9 fractions of radiotherapy at same level of spine (L5) with a total dose of 2250 cGy in June 2007. Bone marrow aspiration was normal at that time. Serum electrophoresis done after 6 months in January 2008 as a follow up showed no M-spike. In September 2008 M-spike showed an increase to 2.31g/dl. Skeletal survey except the localized tumor at L4-L5 was normal. Bone marrow aspiration was also normal. I was started on Thalidomide at a dose of 100 mg/day. Serum Electrophoresis done in December 2008 showed a decrease in M-spike (1.52 g/dl). Symptomatically I was not feeling better. Malaise and back pain increased. I was running persistent low-grade fever at night for which blood, urine cultures and Widal test was also done but all were negative. Thalidomide was increased to 200 mg/day in February 2009.

In March 2009, Serum Electrophoresis showed only slight improvement with M-spike noted as 1.49. Skeletal survey showed newly developed lytic lesions in right femur (Near intertrochanteric region), 2nd rib left side and parietal bone of skull along with pre-existing collapsed L5 vertebra in LS spine. I was started on Dexamethasone (4 mg) 2 tabs twice daily for 5 days per month in continuation with Thalidomide (200 mg HS). In addition, Injection Zoledronic acid and calcium supplementation was started. Also, radiotherapy for femur was done.

Over this period, the neuropathy due to Thalidomide increased. In February 2010, M- spike rose to 1.57 (as compared to Aug 09 - 1.04). I was started on Lenalidomide (initially 10mg then 25mg) and Dexamethasone (40mg, but I actually took 16mg for 5days) since March 2010. But due to Neutropenia, Lenalidomide was discontinued off and on. MRI spine (Dtd19/05/10) showed partial collapse of D9 vertebra along with newer lesions in left pedicle of L1 vertebra, in bodies of D10, D11vertebrae and further collapse in L5 vertebra. No active intervention was done at that time.

My general condition started deteriorating in December 2010. I developed hemorrhoids. Hemoglobin dropped to 7.40, 2 units of PRCs had to be transfused. Sclerotherapy was done for hemorrhoids. I was also started on erythropoietin injection (40,000 units) s/c every 15 days. M-spike in December rose to 2.19. I was started on Bortezomib (2mg once weekly i/v for 3 weeks then 1week off), Dexamethasone (20mg once a week) and Lenalidomide (15mg for 3 weeks then 1 week off). But then I started having Thrombocytopenia. Lenalidomide was stopped. After 3 doses of Bortezomib, my CBC was Hb- 9.40, TLC- 2500 and Platelet count- 56,000/cumm.

At the start of February 2011, I got delirious for 10 days, although MRI brain was normal. M-spike (Dtd 05/02/11) showed an increase to 4.45 from 2.19 (in Decí 10). Total protein-10.8, Albumin-2.89, Gamma Globulin-5.26, A: G ratio-0.41). CBC Hb-7.9, TLC-2600 N50, L38 and Platelet count-81,000/mm3.

Bone marrow aspiration and biopsy was done which suggested hypocellular marrow.

My weakness increased, I was slightly confused and unable to walk I was given 40 mg I/V Dexamethasone for 4 days, which improved my health. Later, I was started on Liposomal doxorubicin 40mg once in every 3 weeks along with Dexamethasone 40mg once a week initially and later reduced to 20mg/week. My general condition improved except I gained lot of weight (steroid induced). In between I was given blood transfusions prior to chemotherapy cycle to maintain my Hb.

In June 2011, the M-spike was 3.11, which meant partial response (30%). So the oncologist added Endoxan 100mg for 1 week to the ongoing regime. But a week later after starting Endoxan, I started feeling very weak and tired along with profuse sweating and recurrent vomiting. I was admitted in Emergency and investigations revealed hyponatremia (Na-121mq/l)---Endoxan induced SIADH. Endoxan was discontinued. I managed some improvement with extra salt and fluid restriction.

In August 2011, M-spike showed a significant decline. M-spike-1.52. My treating doctor, Dr. Amit Dhiman insisted that the response was due to Endoxan and advised to continue it along with doxorubicin.

So, presently I have completed 7 cycles of doxorubicin along with Dexamethasone. Endoxan is restarted with close monitoring of sodium levels. Overall, with the current regime of lipodox, steroids and endoxan, my general condition is better except malaise, neuropathy and fatigue.

I completed 7 cycles of doxorubicin along with Dexamethasone. Endoxan was restarted with close monitoring of sodium levels. Overall, with the current regime of lipodox, steroids and Endoxan, my general condition got better except malaise, neuropathy and fatigue.

 

 

December 2011, I started having fever and my appetite decreased. On investigating, myelomatous deposits were found in liver. Following that the oncologist had put me on Bortezomib again (1.5mg s/c every week for 16 weeks) along with Melphalan 8 mg andwysolone 60 mg for 5 days, every 28 days cycle. I responded initially but later liver lesions showed progression.

 

February 2012, I was detected two lesions in liver which is very rare and for that I was given 16 injections ofVelcade, 1.5 mg once a week along with Dexona 20 mg tablet once in a week along with pyricontin for my neuropathy which was really troublesome.

 

October 2012, I was put on Melphalan 8mg tablet daily for 7days a month, Prednisone 60mg tablet daily for 7 days in a month. My Hb remained between 9.4 to 11.2 g/dl, albumin 3.34, gamma globulin 2.1g/dl, A:G ratio 92, M spike 1.93g/dl. However, I experienced terrible neuropathy, pain in back and insomnia.

 

November 2012, I started having excessive dry cough and low-grade fever. X-ray showed a broad pleura based soft tissue density mass lesion abutting lateral aspect of third and fourth left sided rib without definite bony erosion in the region. Dose of Bortezomib was increased to 2.5mg s/c every week along with Dexamethasone 40 mg i/v every week. Melphalan (8mg for 5 days every 28 day cycle) was continued. M-spike in November 2012 was 3.09.

 

December 2012, I improved symptomatically, fever and cough settled but I had lot of pain over left side of chest along with left shoulder. A repeat X-ray was done which showed same lesion in the chest. The lesion didnít show any regression.


February 2013, My general condition has deteriorated. I have lot of bony pains especially over the left side. M-spike has increased to 4.44. Chest X-Ray is showing increase in the lesion. Velcade has been discontinued.


The oncologist advised to give palliative radiotherapy for the chest lesion but it could not be given due to bone marrow suppression. Further it was planned to start chemotherapy with Bendamustine after blood transfusion.
 

March 2013, my oncologist is still undecided whether I should go for regime of Bendamustine, Velcade and Dexamethasone because overall Bendamustine is not the drug of choice and due to financial condition I am unable to start Pomalidomide and Carfilzomib which are new drugs and so far not available in India. My pain on the left side has further increased and not subsided by tablet Tramadol and for that I am likely to start tablet morphine though it has more side effects than others.

 

Thankfully with grace of God I have completed 10 years of my MM life. 

Being a doctor by profession, I advise all those people who are suffering due to Multiple Myeloma and their families that there is nothing to fear. This is a chronic disease and lot of research is going on so do not get disheartened. Try to live LIFE day to day. God Bless!

 

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