Dr. Ashok Raswant

1951 / Class of 2003 / Type: IgG / Spinal lesions / Radiotherapy, Chemo / Updated 9/11

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 Feb 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 10days, although MRI brain was normal. M-spike (Dtd 05/02/11) showed an increase to 4.45 from 2.19 (in Dec’ 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/cumm.

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.

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!