Living in Relapse - January 31 2013

First, a little history - I was diagnosed with high risk monoclonal IgG Kappa multiple myeloma (4:14, 1q21 and other cytogenic changes) when I was 60 years old on 24 May 2011. Aside from anemia and 80% plasma cells in my bone marrow, I was in pretty good shape with normal kidney function and no lytic bone lesions. I was still pretty active, walking the dog in the mountains daily and doing anything I wanted – I was just SLOWER. I had recently turned 60 years old and I thought needing a daily nap might be just a part of aging.

I was prepared for an autologous stem cell transplant (ASCT) with both Velcade and Revlimid which didn’t quite get me to remission, so I required a 4-day hospitalization for VDT-PACE (Velcade, Dex, Thalidomide, Cisplatin, Adriamycin, Cytoxan and Etoposide) prior to donating my stem cells for the transplant which I had on 13 Sept 2011. After my transplant, I had TERRIBLE gastritis for months and developed a blood clot in my heart and it wasn’t as “easy” as it could have been…yet, I kept smiling.

I was so hopeful that I would achieve remission and 50 days post-ASCT my bone marrow did reflect remisson with an M-Spike of 0.1. Immediately, went on weekly maintenance Velcade and Revlimid, which didn’t feel like remission since I had to go for treatment twice a week and it wasn’t long before I relapsed in Feb 2012. Back to 60% plasma cells in my bone marrow and my high risk cytogenetic changes 4:14 and 1q21 persisted.

I was re-admitted for 2 courses of VD-PACE (Velcade, Dex, Cisplatin, Adriamycin, Cytoxan and Etoposide) and prepared for a second ASCT (autologous stem cell transplant), which I had on 18 May 2012. I never achieved remission afterwards and have been living in relapse ever since.

After my failed 2^nd ASCT, I’ve been treated unsuccessfully with Zolinza which did nothing for my myeloma and gave my kidneys a workout. My bone marrow plasma cell percentage went up to 60%.

Being run down from the 2 failed autologous stem cell transplants and no immunoglobulins,  it seems that I react to chemotherapy more deeply than most.

I was started on Carfilzomib, Dex, and Revlimid in Oct 2012.  My bone marrow plasma cells went down to 40% with persistent cytogenetic changes by the end Dec 2012. Added Cytoxan to my chemo plan and my counts plummeted, so that’s in a holding pattern for now.

In addition, I have non-secretory or hypo-secretory myeloma, which means the usual myeloma SPEP (serum protein electrophoresis) blood tests are not reflective of my bone marrow plasma cell percentages. This requires that I be followed by frequent bone marrow biopsies – I’ve had 9 in 19 months. Eight of the 9 bone marrow biopsies have been done without conscious sedation and I have finally convinced the powers to be that I REQUIRE conscious sedation for any future bone marrow biopsies.  Yippee.

So, back to living in relapse!  I'm been doing it for a year now. It is hard knowing each day that you have relapsed myeloma – constantly wondering how your bone marrow is doing, trying to stay off the internet surfing myeloma sites and blogs, yet worrying you might miss some new treatment for high risk myeloma…and simply wondering how much time I might have left. My oncologist already told me that I’ve lived longer than might be expected with my cytogenetic changes, but he added, no one knows. I’m lucky as the approval of new myeloma drugs seem to be coming along just as I need them. So, I keep smiling.

My continuing, weekly chemotherapy keeps me tired, but I try to keep up with my daily activities. I’m best after a dex day. Unlike many, I like dex – seems to give me energy and clarity of thinking that I don’t have otherwise. Unfortunately, the effect does not last.

I worry about getting something from others and I am good about wearing a mask around groups of people and always washing my hands. I have not been sick at all.  I have never been re-hospitalized for any infection. My kidney function returned to normal once all the Zolinza passed through my system and I’m careful to drink plenty of water each day. If I’m going to die, I want it to be of myeloma and not some dumb infection.

I’ve been in a rush to get my family genealogy organized and completed before my time is up. This project is huge and I enjoy it so much. While on the other hand, organizing my medical deductions for my 2012 Taxes is not much fun at all.

Walking my dog, Kemmer, is important to me and I try to do this daily. I like to shovel snow and I’ve been able to do some of that too. I take care of my own house and get my own meals. Trying to fight fatigue with activity, which helps. But, to be honest, right now, the thing I’m best at is “being one with my sofa” working on my laptop and watching television (I’ll miss football and I love golf)…so unlike my active pre-myeloma self.

I have no desire to travel out of Idaho, but do so for my transplant follow-up visits in Colorado. Plus, these trips give me a chance to visit with my former work colleagues. I love when my sister visits in Idaho and I hope she’ll come again soon.

I miss going to the Mackay School to volunteer and watch sporting events. If my Absolute Neutrophil Count (ANC) ever comes up near normal, I’ll return to the school, because I love the children. I’ve tried to keep up my Mackay Food Bank volunteer duties, but I let my Presidency in the South Custer Historical Society go along with my Secretary duties in the Mackay Women’s Club. I keep my Mackay Idaho 83251 blog going http://mackayidaho1.blogspot.com and my jm’s Adventure With Multiple Myeloma blog updated http://jmmultiplemyeloma.blogspot.com 

My mood is good. I don’t suffer from depression. I go to town each day and get the mail for my 92 year-old father. During this trip, I always visit with someone at the Post Office and I like that! Friends have been good about watching Kemmer while I need to away from Mackay. Driving 135 miles each way for my weekly 2 days of chemo is almost relaxing depending on the weather. I like to drive and it is a good thing since I spent 18,701 miles in the car during 2012 JUST for MEDICAL CARE. I’m retired with a monthly income and I have excellent heath insurance, so money has not been an issue.

So, I continue to live in relapse and for the most part – I’m doing a million!

2nd ASCT - Day 70 - July 27 2012

Han Myint, MD from the University of Colorado Hospital called me late this afternoon with my bone marrow biopsy results from 12 July 2012. The biopsy smear showed 1 percent plasma cells which is "really good" according to Dr. Myint. The core sample showed an aggregate of IgG Kappa cells less than 10 percent (but, this is only an estimate). The cytogenetics showed no 4:14, however in the FISH results 4:14 represented 1 percent ("almost nothing") and 1q21 up to 2.5 percent of the cells.

Bone Marrow Biopsy Surgical Report for 12 July 2012 (3 pages).

Bone Marrow Biopsy Genetics Report for 12 July 2012 (2 pages)

All this means that I will need to continue chemotherapy to hold the cancer at bay, but I knew that. Dr. Myint will call my oncologist in Twin Falls, Idaho with his recommendations for chemotherapy which will need to be approved by my medical insurance. I will also need to continue Aredia for bone building. IF all goes well, I will return to UCH in Colorado mid-October 2012.

Dr. Wolfel, the cardiologist has not yet returned Dr. Myint's request for more information related to my echocardiogram done on 12 July 2012. I want to stop the daily blood thinning injections, Fragmin and only Dr. Wolfel can make this decision.

The hearing loss and roar in my right ear seems to be some better this evening. My throat is a tad sore on the right side...so, maybe it was an eustachian tube issue.

Bone Marrow Surgical Pathology Report from March 9 2012

Finally remembered to get a hard copy of my March 9 2012 Bone Marrow Biopsy Surgical Pathology Report. Shows that more than 50 % of my bone marrow had been replaced with multiple myeloma plasma cells at the time of my RELAPSE and demonstrates the abnormal cytogenetic change of 1q21 which I had pre-autologous stem cell transplant too. Oh joy~

Bone Marrow Biopsy Cytogenetics Report from March 9 2012

The cytogenetics report from my 9 March 2012 Bone Marrow Biopsy. I have a mere 16 (SIXTEEN) cytogenetic abnormalities this time, but not the 4:14 that I had prior to my stem cell transplant on 13 September 2011.

Day 57 - The NEWS - November 9 2011

Jani took me to the University of Colorado Hospital today for my blood draw and appointment with transplant doctor, Han Myint, MD. We were both anxious as we waited in the exam room for my appointment. I wore my lucky Mackay t-shirt today~

 Reading over the list of questions that I have for Dr. Myint.

Then, Dr. Myint came in and I received my bone marrow biopsy of 11/2 results.

I am in Stringent Complete Remission!!!!!!!  No cytogenetics (abnormal DNA) and less than 0.01 plasma cells (anything less than 0.05 plasma cells is considered remission) done with the CD138 stain for myeloma cells.

If I didn't have the blood clot in my heart, Dr. Myint would have started me on maintenance chemotherapy of Velcade (IV) and Revlimid (pills by mouth). AND, if I didn't have a blood clot in my heart, I could have headed home to Mackay, Idaho tomorrow with return visits to UCH every 3 months.

Click on images below to enlarge:

Day 50 - Bone Marrow Biopsy Number 4 - November 2 2011

We checked in for my bone marrow biopsy at noon. Hank, the medical technician, came for me early. The pre-medication of liquid morphine and ativan didn't seem to be doing anything for me - but, I was brave. UCH doesn't use conscious sedation for bone marrow aspirations because they don't want to have to recover you afterwards.

The procedure is uncomfortable and painful at times. I'm just glad it is over. They were able to get a good sample.

 I still think the bone marrow samples look like tiny Shay Railroad spikes.

I won't have the results of the bone marrow biopsy with cytogenetics until next Wednesday, November 9 2011.  Below, Hank and I after the bone marrow biopsy procedure, November 1 2011



Day 35 - M Spike Values are back from October 12 2011

My M Spike values done on October 12 2011 were sent to me today. No change from pre-stem cell transplant and post-stem cell transplant. I don't really know how to interpret the "no change", but I don't think it is anything to be concerned about at this point. I'll know more after I have the bone marrow biopsy on November 2 2011. I think the cytogenetics are more important than the M Spike value.

Day 29 - Update - October 12 2011

Jani drove me to UCH in Aurora, Colorado for my follow-up appointment with Dr. Han Myint. We went early, so we could have a chance to visit with another multiple myeloma patient, Shawn Egle, who had her stem cell transplant yesterday, making today Day 1 for her. It was wonderful to see Shawn and she is doing well. However, she had have an x-ray procedure and they arrived to take her down for it just minutes after we arrived. So, Jani and I walked along with the wheelchair transport for Shawn to the basement where radiology is located so we could visit a few minutes longer.

Got my blood drawn, the dressing over my Trifusion Hickman Catheter changed (needs to be changed weekly), and my Bard Power Port flushed for the month (if not used, needs to be flushed and heparin locked once each month).

Jani and I checked in early for my 4:05 PM appointment with Dr. Myint and to our surprise they took us back to an exam room about 20 minutes early. Nurse Practitioner Diana Vurcurevich met with us and examined me. Then, Dr. Myint came in and joined us. Both Dr. Myint and Diana said my nausea and epigastric pain should have resolved by now since the transplant. Easy for them to say....I'm still suffering....We went over my medications and they said I could double my dose of Prilosec to 40 mg twice a day along with 150 mg of Zantac twice a day (recommended that I take the Prilosec and Zantac together on an empty stomach 1 hour before I eat. They also said I could take liquid Mylanta in between.

We discussed the possibility of having an EGD scope (swallow the camera test), but when I told them that I just had an EGD on May19 2011 with normal results (nothing visualized, no H. Pylori and no Celiac Disease) they decided a scope was not necessary at this time.

My blood values are okay and unremarkable. My platelets are in the normal range at 174 (norm is 150-400), my hemoglobin is a tad lower than a week ago at 11.5 from 11.8, but okay, and my white blood cell count is slightly lower at 2.6 from 2.8 a week ago. Dr. Myint says this is all normal, but he does expect my white blood cell count to rise to normal limits.

My ANC (Absolute Neutrophil Count) is fine at 1.5 - just need to be cautious and stay away from groups of people and to wear my mask when I am around people. That 3.1 value on Oct 1st is a neuopogen effect from an injection on Sept 29 2011.

I asked Dr. Myint why I'm having a bone marrow biopsy at Day 60 vs Day 100 and he said it is because of my cytogenetics (bad DNA findings) and he wants to see if the stem cell transplant put my cytogenetic findings into remission. If the bone marrow on November 2 2011 is clear of cytogenetic findings, then I will not need a 2nd transplant. However, if abnormal cytogenetics are found, then I'll have the 2nd transplant mid-November. Dr. Myint reminded me that the stem cell transplants are not a cure for my multiple myeloma - just a method to get my myeloma into remission. After the 1 or 2 transplants, I will have to be on maintenance chemotherapy of Velcade, Decadron, and Revlimid for 2-3 YEARS~! Oh Joy~

Jani didn't have to wear a mask, but she wanted to. I have to wear a mask any time I am at UCH for any thing.

They decided that I didn't need to return to see them for 2 weeks. So, Jani and I went back up to the BIC (blood draw area) and asked the nurse to give us the supplies to change my Trifusion Hickman Catheter at home next week, since the dressing needs to be changed weekly. The nurse reminded us that it needs to be done with sterile technique and we assured her that we could get it done.

Day 16 - Dr. Han Myint Appointment - September 29 2011

Jan Martin drove me to my first out-patient appointment since the Stem Cell Transplant with Dr. Han Myint on September 29 2011. My appointment was scheduled for 3 PM and they actually had us in an exam room right at 3 PM.

However, we sat and sat in the exam room for more than hour before Nurse Practitioner Denise came and showed me the lab work results from this morning and asked me a few questions. Denise noted my serum protein and albumin levels and was impressed that Jani had maintained my diet so well since discharge - making sure I was eating adequate levels of protein each day despite my continued nausea. If you look at the values over time chart below, you can see, I never ate enough protein while I was hospitalized with the Protein value ranging between 4.8 and 5.1. Now 2 days post hospital discharge, my protein level still is not in the normal range of 6.4 to 8.3, but much closer at 6.2.

Around 4:30 PM, Dr. Myint came in and said I was doing fine. He decided to give me a Neupogen injection to stimulate my new bone marrow into action since my white blood cell count had dropped from 2.8 on Day 14 to 1.3 on Day 16.

I'm scheduled for a bone marrow biopsy on November 2 2011, just prior to my Day 60 when the decision will be made on whether I will require a tandem (2nd) stem cell transplant. If that bone marrow biopsy shows any abnormal cytogenetic (DNA changes), I will need the tandem transplant. If the cytogenetics are normal and I'm in the top 3 categories of remission, then I would not require the tandem stem cell transplant. If I need the tandem transplant, it would be done right after all of the bone marrow biopsy results are done and finalized. My insurance company, Anthem, has already approved the tandem stem cell transplant.

We were still waiting for the neupogen injection when the nurse poked her head in the room and said they were waiting for insurance approval. Neupogen costs about $250 per one 300 g dose. Not long after, an obviously pregnant nurse came in the room with the neupogen and I asked her if there was a another nurse who could give the injection. The nurse looked so hurt and said, "Yes, there is." I quickly told the pregnant nurse that I had shingles and then she understood. The 2nd nurse came and gave me the injection and I took a Claritin tablet that I brought with me.

Now 5:00 PM, we went downstairs to schedule future appointments. Jan Martin waited at the desk with the scheduler and I went through a door to the Apheresis Department which has temporarily moved to the 1st Floor while the new space is being remodeled. Jessica Jones from Apheresis was there and we had a good visit.

With appointments in hand by 5:35 PM, Jan Martin drove us back to The Timbers. I told Jan that if I had to wait all afternoon by myself at the University of Colorado Hospital Outpatient Cancer Clinic - it would have been miserable - but visiting with Jan was wonderful and the 2 1/2 hour appointment didn't seem that LONG~

I collapsed into the bed for a 2 1/2 hour nap. Jan Martin made me mashed potatoes, fried chicken, and canned spinach for dinner and I ate it all - so yummy and loaded with protein.

Summary Report August 30 2011

I was admitted to University of Colorado Hospital for 4 days (8/23-27/2011) receiving the VDT-PACE Regimen of Velcade IV, Dex IV, Thalidomide Oral, Cisplastin IV, Adriamycin IV, Cytoxan IV, and Etoposide IV.

I went yesterday for a blood test and my blood is fine – being stimulated by daily Neupogen injections (total of 780 mg in 2 injections). I’m also giving myself a daily Fragmin (anti-clotting) injection. I’m taking many oral medications too including Claritin (decreases Neupogen bone pain), Ciprofloxacin (antibiotic), Acyclovir (anti-viral), Fluconazole (anti-fungal), Omeprazole (GI distress).

I will have my 3^rd (whose counting?) bone marrow biopsy on 9/1/2011. They are going to try harder to get the results including the cytogenetics back more rapidly, so they will know if my scheduled stem cell harvest will be warranted beginning on 9/6/2011.

If so, I’ll harvest until I give them 10 million cells. (My 1^st harvest yielded about 8 million cells over 3 days which contain 0.8 to 1.2 percent plasma cells – they have saved those cells, but we are hoping for plasma free cells in the 2^nd harvest period).

I will need IV Velcade/Dex on 9/9/2011and will take oral Dex 9/10 and 9/11.

Then, I’m scheduled to be admitted to University of Colorado Hospital on 9/12/2011 for pre-transplant Melphalan IV and Velcade IV with stem cell transplant on 9/13/2011. The medicine on 9/12/2011 wipes out my bone marrow and any cancer that might be hiding and then they give you the stem cells that I harvested the second time.

I’ll be in the hospital at least 2-3 weeks and maybe longer after the stem cell transplant while my bone marrow recovers. After I’m discharged from the hospital, I will have to stay in hotel near the hospital for another 2 weeks, returning to the hospital for frequent tests.

Transplant doctor, Han Myint, MD and Dana Godec, RN Visit August 18 2011

Before I left the Apheresis Department today, the UCH Transplant Doctor, Dr. Han Myint, and my Transplant Coordinator, Dana Godec, RN came to visit with my bone marrow results which were finally completed late yesterday. As predicted by the preliminary results, my bone marrow has reduced from 80 percent cancer to between 5 and 10 percent cancer with the Velcade and Revlimid chemotherapy I've received.

However, the cytogenetics of my bone marrow (the chromosomal studies) show that my remaining cancer cells have mutated and I have many additional chromosomal changes that I did not have at the time of diagnosis. Dr. Myint said the cancer is smart and is trying to mutate and continue growing around my Velcade chemotherapy. 

I asked Dr. Myint if more chemotherapy would be in line to try to get me in complete remission. He said the cytogenetics of my cancer made the probability of complete remission (CR) with Velcade not promising. In fact, my cancer has mutated from diagnosis of 4/14 translocation and deletion of 13 to a whole string of new chromosomal defects.

I asked Dr. Myint what he would do if he had my type of multiple myeloma and he said he’d do more chemotherapy to try to achieve CR and attempt harvest again. He wants to hospitalize me this coming Tuesday, August 23^rd for 4 days and give me:

·         Thalidomide po

·         Velcade IV

·         Decadron IV

·         Adriamycin IV

·         Cytoxan IV

·         Etoposide IV

·         Cisplatin IV

After that I would be discharged and give myself Neupogen 780 mcg each day for 9-10 days and somewhere in there – I'd have another bone marrow biopsy.

Then, re-harvest my stem cells on September 6^th for Transplant on September 13^th. They won't throw the stem cells I've already harvested out (estimated to have at least 1 percent cancer in them), but they will save those too.

Canceled my Stem Cell Harvest Day 4 for tomorrow. 

Bone Marrow Biopsy of August 10 2011 Results

Dana Godec, RN brought me the chromosome results of my bone marrow biopsy which was done on August 10 2011.  The results are not good and at least 3 times in the report indicate that I have poor prognosis based on my cytogenetic chromosomal changes. I started out with only 2 chromosomal changes, translocation of 4/14 and deletion of 13. I still have the deletion of 13, but the translocation of 4/14 is gone. However, I have several more now. If you understand this, you're smarter than me.

However, the references for the poor prognosis listed on the back page of the results are from 2000 and 2003. The chemotherapy I've been on, Velcade and Revlimid, weren't available back then, so I'm taking the POOR PROGNOSIS with a grain of salt for now.

Here is the whole report if you want to wade through it.

I still don't have the bone marrow results for myeloma load. Remember, my initial myeloma load at diagnosis was 80 percent. They are forecasting the load as of August 10 2011 to be between 5 and 10 percent, but I don't have the official report yet. I also don't have my free light test results along with the latest M Spike value from the blood drawn August 10 2011 at UCH. I had blood drawn for free lights, immunoglobulins, and M Spike (that will be done at the Mayo Clinic) yesterday at Dr. Moore's office.

Dr. Moore Appointment and PET Scan Result June 13 2011

We saw Dr. James Moore before my 1st chemotherapy infusion. I really like Dr. Moore and he always gives us all the time we need to have our questions answered. He never acts rushed and thoughtfully provides responses to our inquiries.

We told him how prepared we were with Bart and the cooler of food and he said he liked that because he was an Eagle Scout - I liked that about him!

I asked Dr. Moore to look in my right eye because it felt like it had something in it ever since we left post-op for the port placement. He looked and could not find anything. Jani had some eye drops and we put those in a couple of times which helped.

Dr. Moore asked me today about my emotional health and I told him I was fine. He wondered since the poor chromosomal studies (cytogenetics) were mostly the topic of my last visit with him. I told him I was going to see Dr. Myint at the University of Colorado Bone Marrow Transplant Clinic on Wednesday and he was pleased at how quickly his office had gotten me an appointment there. Dr. Moore thinks I have had multiple myeloma for some time.

Despite not wanting to take aspirin because of my prior history of a peptic ulcer, he wants me to give 81 mg enteric coated baby aspirin (ASA) by mouth a try. I will need to thin my blood when I  start on the chemotherapy agent, Revlimid, because it can cause deep vein thrombosis and/or pulmonary embolus.

Dr. Moore gave me a referral prescription to the Rocky Mountain Cancer Rehab Center at the University of Northern Colorado for an individualized exercise program to combat fatigue with my cancer and chemotherapy.

Dr. Moore gave me the results of my PET Imaging that I had done on June 9 2011. Perfectly Normal.

Dr. Moore explained that the dark area on my brain were from using my brain and the other dark area are normally seen in the kidney's and the bladder.

The radiologist who read my PET Scan was Peter D. Koplyay, MD

Diagnosis, Staging, and Treatment Plan June 6 2011

My multiple myeloma is officially diagnosed as Stage 1 IGG Kappa Myeloma complicated by two significant cytogenetic DNA chromosomal changes 4/14 and deletion of a part of 13. This combination of chromosomal changes usually predicts an unfavorable prognosis.

However, my oncologist, Dr. James Moore,  is very optimistic and wants to aggressively treat the 80 percent neoplastic cell involvement in my bone marrow at present.

I will have a PET Scan of my whole body this week – results will help in following the improvement with chemotherapy.

I will have a port surgically implanted in my chest this week (they put you to sleep) so they will not have to access my blood via my arms and hands and have a port to give the chemotherapy through.

I will begin chemotherapy on Monday, June 13^th (most probably). It will consist of intravenous Velcade and Decadron. I’ll also be given an intravenous dose of bone strengthening medication called Zometa once a month. The Velcade and Decadron schedule of medications will be intravenous on day 1, day 4, day 8, and day 11 of each 30 day period.

Hopefully, I’ll be taking Revlimid in pill form after my medical insurance approves the very EXPENSIVE drug. The insurance paperwork for the Revlimid could take up to 2 weeks. However, Dr. Moore does not want to wait for the Revlimid to begin the Velcade and Decadron. I would take the Revlimid day 1 to 14 each 30 day period.

These chemotherapy agents do not cause hair loss and are generally well tolerated – mostly make you tired. He said many of his patients on these drugs drive themselves to their chemo appointments.

I will also have to take Acyclovir 400 mg by mouth twice a day to prevent a recurrence of the shingles I had in August 2009. 

I will continue the chemotherapy agents twice a week for 2-4 months (30 day periods) and then have a autologous bone marrow stem cell transplant (where you donate your own bone marrow stem cells for the transplant) at the Anschutz Cancer Center at the University of Colorado in Aurora, Colorado.

My kidney function is fine for now and I have no known fractures.

I will plan to stay here in Greeley, Colorado with my sister, Jani and Robbyn. They are both very supportive. I will have all my chemotherapy treatments in Ft. Collins at Dr. Moore's office and the port  procedure at Poudre Valley Hospital in Ft. Collins.

So, that is what I know for right now. Thanks for your concern.

Here is Team jm at the appointment.with Dr. James Moore -  Jani, jm, and Dr. Nancy White. I'm lucky ro have so much support.

Here is the official bone marrow biopsy results from a lab in California called Genoptix. Click twice on it enlarge for reading.

1st Bone Marrow Biopsy done 24 May 2011 and resulted at GENOPTIX in Carlsbad, California on 3 Jun 2011.

CLINICAL DATA:

60-year-old female with anemia and monoclonal gammopathy. Evaluate bone marrow for multiple myeloma.

Accompanying CBC report date 5/24/11, indicates WBC 3.4, RBC 3.20, Hgb 10.3, MCV 93.2, MCH 32.2, MCHC 34.5, RDW 15.9%; platelets 174 with a differential count of neutrophils 41.3%, lymphocytes 47.9%.

FINAL DIAGNOSIS: Plasma Cell Myeloma with Unfavorable Prognostic Factors

Comprehensive Assessment:

Review of the bone marrow study shows hypercellular marrow with sheets of neoplastic plasma cells seen (approximately 80%) replacing the marrow elements. The plasma cells are, by flow cytometry and IHC staining, kappa light chain restricted. The plasma cells show atypical morphology, and occasional plasma cells show plasmablastic morphology, however, significant plasmablastic cells are not seen on the aspirate smears. Cytogenetics show norma female karyotype. Myeloma FISH shows t(4:14) and deletion 13. t(4:14) is associated with an unfavorable prognosis in plasma cell myeloma.  The presence of these risk factors for plasma cell myeloma should be interpreted in the context of all other established prognostic clinical and laboratory parameter.

Morphology:

Bone marrow aspirate, core biopsy, and clot sections:

-Plasma cell myeloma (approximately 80% marrow involvement)

Peripheral Blood:

-normocytic/normchromic anemia

-mild leukopenia

Flow Cytometry:

Monoclonal plasma cells detected (~20% of the nucleated cells), consistent with plasma cell myeloma.

Cytogenetics/FISH:

Cytogenetic analysis reveals a NORMAL female karyotype without apparent clonal aberrations.

Myeloma FISH reveals ABNORMAL results with t(4:14) and -13. FISH analysis utilizing probes specific for aberrations commonly associated with myeloma including t(4:14), +5, +7, +1 1q, t(11:14), -13, 13q-, t(14:16) and TP53 (17p-) is performed. These studies detect monosomy 13 in 23.5% 947/2000 and FGFR3-IGH @ fusion signals in 12.5% (25/200) of nuclei examined. An extra IGH signal is seen in an average of 9.75% (39/400) of nuclei examined, which supports the t(4:14) findings. The t(4:14) is associated with an unfavorable prognosis in myeloma.  The remaining probes do not detect aberrations in the 200 nuclei/probe examined.