Mayo
Clinic in Arizona
CLINICAL NOTES
Patient
Name:
Malkiewicz, Judith Ms. Service Date:
11/20/2012
Medical Record Number: 76943760
DOB:
December 08, 1950
Age:
61
Service:
Hematology
Facility Name: MCA
Provider
Name:
Rafael Fonseca, M.D.
Visit Type: Consultation
CHIEF
COMPLAINT / REASON FOR VISIT:
I am seeing Ms. Malkiewicz in consultation
this afternoon for a second opinion regarding further management of multiple
myeloma.
HISTORY
OF PRESENT ILLNESS:
Ms. Malkiewicz is a delightful 61-year-old
woman who has a history of multiple myeloma who has received multiple
treatments and comes here for further treatment recommendations.
Past Myeloma History: Ms. Malkiewicz was
diagnosed with IgG kappa multiple myeloma on May 24, 2011. At that time, the
patient was obtaining a routine physical examination which revealed anemia. A
bone marrow showed that she had 80% plasmacytosis with the presence of a t4,14
translocation and deletion of chromosome 13. She had an M-spike of 3.0. The
patient received induction therapy with the VRD regimen. She started on June
13, 2011, and did three-and-a-half cycles. Interestingly, the patient had no
evidence of lytic bone lesions as is commonly seen in patients with a t4,14
translocation. She also had no evidence of hypercalcemia and had normal renal
function. The patient subsequently received treatment at the University of
Colorado Hospital with a four-day course of VDT-PACE chemotherapy. The thought
behind this was that the patient was showing evidence of a cytogenetic progression
with gains of chromosome 1q21. The patient collected stem cells and underwent
an autologous stem cell transplant on September 13, 2011. The patient was said
to be in a stringent complete response by a bone marrow donor 50 days post her
transplant November 2, 2011. At the time, she had an M-spike of 0.1. The
patient had a TriFusion Hickman catheter and developed deep venous thrombosis
in her atrial appendage as well as the venous system. She had both removed and
was placed on low-molecular-weight heparin. Maintenance chemotherapy post the first
stem-cell transplant. The patient received treatment with Velcade,
dexamethasone, and Revlimid, and also was started on treatment with zoledronic
acid which she first received in January of 2011. The patient spent 7 months in
Colorado and finally returned home to Mackay, Idaho.
By February of 2011, the patient had a rise
in M-spike at 0.59 and was seen back at the University of Colorado Hospital. A
biopsy confirmed that she had 50% plasmacytosis with the bone marrow donor in
March of 2012. The patient was treated again with VDT-PACE chemotherapy in
March of 2012 and received the second cycle in April of the same year. At this
point, she had 1% plasmacytosis although she had persistence of genetic changes
with 1q21 and t4,14. The patient underwent a second autologous stem-cell
transplant May 11, 2012, with beam-induction chemotherapy. The patient returned
back home on day 28. Follow up on day 55 on July 12, 2012, showed an M-spike of
less than 0.1. The patient, however, still showed abnormal cytogenetics with
t4,14 and 1q21 amplification. The patient started, again, chemotherapy with
Velcade and dexamethasone on August 20, 2012. The patient did develop
peripheral neuropathy which extended at least up to her knees and sometimes she
had symptoms up to her groin region. Subsequently, the patient had vorinostat
(Zolinza) added to her regimen. The patient did have quite significant toxicity
and had to stop the medication. She was also concerned that she had a mild rise
in her creatinine which she attributed to the Zolinza. The patient had a repeat
bone marrow biopsy done on October 17, 2012. At this point, the patient showed
a 60% plasmacytosis. Patient then started with carfilzomib, dexamethasone, and
Revlimid at 10 mg on October 30, 2012. The patient comes here for additional recommendations
for treatment.
ALLERGIES:
Patient has multiple allergic reactions:
1. Cephalosporin antibiotics which gave her
hives. Okay to take penicillin.
2. Quinolones. Severe dizziness and
jitteriness.
3. Propofol, cardiac arrhythmias.
4. Latex, skin rash.
5. Tape, severe adhesive allergy.
6. Miconazole, rash and swelling.
7. Clotrimazole, rash and swelling.
8. Vicodin, GI upset.
9. Zyrtec, extreme dizziness.
10. Neurontin, facial and body swelling,
prolonged sedation.
11. Benadryl, prolonged sedation.
12. Wools, trees, grasses, and evergreens.
PAST
MEDICAL/SURGICAL HISTORY:
Medical
History:
1. Myeloma as above.
2. Pneumonia.
3. Hypothyroidism.
4. Elevated cholesterol.
5. Deep venous thrombosis as mentioned
before.
6. Peptic ulcer disease.
Surgical
History:
1. Fracture of the left humerus in 2002.
2. Sinus surgery times three in 1990s and
2007.
3. Hysterectomy 1978.
4. Right knee times two in 1978 and 2002.
5. Femoral hernia 1978.
SOCIAL
HISTORY:
Tobacco: Never.
Alcohol: None.
Recreational drug use: None.
Referring Physician: Dr. Clay Smith from
the University of Colorado Hospital in Aurora, Colorado, and Dr. Phatama
Padavanija who is at St. Luke's Mountain States Tumor Institute. This is in
Twin Falls, Idaho.
FAMILY
HISTORY:
Father is alive with heart disease and
spinal stenosis at the age of 88 and 91.
Mother died at the age of 80 from heart disease, diabetes, and she passed away from lung cancer. The patient has
one brother who is alive with high cholesterol
and Meniere's disease. One sister who is alive with high cholesterol, and also otosclerosis. She has no children.
REVIEW
OF SYSTEMS:
As above.
PHYSICAL
EXAM:
Not done during this visit.
IMPRESSION/REPORT/PLAN:
I spent the best part of our visit, 70
minutes, talking about the current status
and options for treatment for Ms. Malkiewicz. I believe she still has a few options available for her
treatment but at this point I have recommended
that she continues in treatment with one more cycle of carfilzomib, Revlimid, and dexamethasone. Unfortunately, it seems
like there is a discordance between
the level of her protein markers in her blood and the amount of plasmacytosis that she has exhibited. This points
toward either a nonsecretor or hyposecretory
myeloma. I have told her that I would like for her to complete two cycles and then we can gauge her results.
Recently, she has had some drop in her
platelet count and her white count so it would be important to know rather soon if she is responding to the
treatment or not.
This might only be possibly assessed by
repeating a bone marrow examination because
her M-spike is currently 0.3 and she has not had elevated serum free light chains. The patient agreed to
have laboratory draws done during this visit.
Given the nature of Ms. Malkiewicz's
myeloma, I see that she is most afflicted
because of the cytopenias at this point. She is at very low risk for renal damage because of a low serum
free light chain and she also has no evidence
of bone disease. Accordingly even if we had a difficult time controlling her plasmacytosis, she has
the possibility of perhaps enjoying some
quality time if we could support her with an aggressive transfusion strategy. I told her that I would
recommend that she receive both packed red
cells and platelet transfusions as needed.
Other options for Ms. Malkiewicz would
include clinical trials although that might
be difficult for her given that she would have to relocate to the treatment center and she lives in a small,
rural community. Another option might
be the use of pomalidomide which hopefully will be available in the beginning of 2013.
I believe Ms. Malkiewicz and her sister,
who accompanied her during this visit,
had ample opportunity to ask questions and they were addressed.
