Case MM PIT Edit
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Case Interactive Discussion
Rematologi
Hematologi OnkologiMedikGeriatri
Laki-laki, 65 tahun dengan Low
Back Pain
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Kasus
Laki-laki 65 tahun rawat inap dengan keluhanditemukan jatuh di samping tempat tidur,badan lemas tidak bisa berjalan sejak 2 harisebelum MRS.
Sejak 4 bulan yang lalu, pasien seringmengeluh nyeri pinggang kumat-kumatan,membaik dengan obat-obat nyeri dari doktermaupun yang di beli bebas.
Sejak 1 bulan sebelum MRS pasien tidak maumaka, keluarga mengatakan lebih kurus
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Pemeriksaan Fisik
Dari hasil pemeriksaan di dapatkan
Pasien tampak kurus
Pain intensity : VAS 7 Konjungtiva anemis
Penurunan ROM
Kemampuan dalam menjalankan aktifitassehari-hari: terbantu sebagian
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Pemeriksaan Laboratorium
Hb : 9,0mg/dL
Leukosit : 7300/uL
Hematokrit : 27,0 % Trombosit : 206.000/uL
Ur/Cr : 79/2.4
Albumin : 2.88 g/d
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Apa Masalah Pada Pasien Ini?
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Masalah
Low Back Pain
Jatuh
Hipoalbuminemia
Anemia
Gangguan Fungsi Ginjal
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Back Pain
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DISTRIBUSI NYERI
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Sindrom kauda equina (retensi urin, gejala dan tanda
neurologi bilateral, anastesi sadel)
Tanda atau gejala defisit neurologis ( parastesi,paresis
dan tanda neurologis yang lain)
TraumaPenurunan berat badan
Demam
Pemakaian obat-obat intravena
Pemakaian steroid
Usia lebih dari 50 tahun
Nyeri berat yang tidak berkurang waktu malam
Nyeri memberat saat posisi tidur
RED FLAGS
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Pemeriksaan SLR (straight leg raising test)
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Nyeri pinggang mekanik
(97%)
Kelainan spinal non-
mekanik(1%)
Penyakit organ dalam(2%)
Strain dan sprainlumbal
(70%)Proses degeneratif diskus
dan sendi facet(10%)
Herniasi diskus (4%)
Stenosis spinal (3%)
Fraktur kompresif
osteoporotik (4%)
Spondilolistesis (2%)
Fraktur akibat trauma (< 1%)
Penyakit kongenital (< 1%) :
kifosis berat
skoliosis berat
tulang belakang
transisional
Spondilolisis
Disrupsi diskus internal ataunyeri pinggang diskogenik
Kemungkinan instabilitas
Neoplasia (0,7 %)
Myeloma multipelMetastasis
Limfoma dan leukemia
Tumor korda spinalis
Tumor retroperitoneal
Tumor tulang belakang
primer
Infeksi (0,01 %)
Osteomielitis
Septic diskitis
Abses paraspinosus
Abses epidural
Shingles
Artritis inflamasi (sering
berkaitan dengan HLA-B27)
(0,3 %)Spondilitis ankilosa
Spondilitis psoriatik
Sindrom Reiter
Inflammatory bowel
disease
Penyakit Scheuermann
(osteokondrosis)
Penyakit Paget
Penyakit organ dalam pelvis
ProstatitisEndometriosis
Radang pelvis kronis
Penyakit ginjal
Nefrolitiasis
Pielonefritis
Perinephric abscess
Aneurisma aorta
Penyakit gastrointestinal
Pankreatitis
Kolesistitis
Ulkus yang dalam
(penetrating ulcer)
DIAGNOSIS BANDING NYERI PINGGANG
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Anemia, Back Pain, GangguanGinjal, Fraktur patologis
Suspect Multiple Myeloma
Bagaimana cara Menegakkan diagnosis
Multiple Myeloma
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Diagnostic criteria
Durie Salmon criteria
Dx : 1 major & 1 minor or 3 minor criteria Major criteria
- Plasmacytoma on tissure biopsy
- BM plasmacytosis with > 30%plasma cell- Monoclonal globulin spike on serum electrophoresis 3.5
g/dl for Ig G ,> 2g/dl for IgA
- Or urine Bence Jones > 1g/24 hr
Minor criteria
- Marrow plasmacytosis 10-29 %- Monoclonal globulin spike present ,but less than above
- Lytic bone lesion
- Normal Ig M< 0.05g/dl , IgA
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BMP
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Pemeriksaan Foto polosRadiologi
Cardiomegali
dengan Paru
emphisematous
Mineralisasi tulang
berkurang dengan
lesi punched out
Lesi Litik
Multiple pada
tulang pipih
skul l
Mineralisasi
tulang
berkurang & lesi
punched out di
internal nebula
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Hasil Scan
Lesi osteolitikmultiple berukuran
pada calvarial dan
basis cranii
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Elektroforesa
Protein Serum
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Diagnosis Multiple Myeloma
Calsium : 11,4g/dL
Ur/Cr : 79/2.4
Hb : 9,0mg/dL
Leukosit : 7300/uL
Hematokrit : 27,0 % Trombosit : 206.000/uL
Albumin : 2.88 g/d
Tetrad multiple
myeloma CRAB
C= Calcium
R= Renal failure
A = Anemia
B= Bone lesions
M Spike
Multiple Myeloma
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Apa masalah Lain Pada PasienIni?
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Jatuh/Fall
Kejadian jatuh muncul jika terdapat
kegagalan tubuh dalam
mempertahankan stabilitas postural,
baik karena faktor intrinsik maupunfaktor ekstrinsik/lingkungan
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Proses Penuaan dan Kejadian Jatuh
Faktor Kontributor Perubahan Klinis
Perubahan kontrol postural Menurunnya propioseptif, melambatnya
refleks, menurunnya tonus otot,
meningkatnya ayunan postural, hipotensi
ortostatik
Perubahan gaya berjalan : postur tubuh membungkuk, dengankedua kaki melebar dan langkah pendek-
pendek, : kedua kaki menyempit dengangaya berjalan bergoyang-goyang
Adanya komorbiditas yang lain Penyakit sendi degeneratif, patah tulang
panggul dan femur, stroke dengan gejala
sisa, sarkopenia dan deconditioning,
neuropati perifer, deformitas sendi diekstemitas bawah, ggn
penglihatan,pendengaran, pelupa dan
demensia, peny,kardiovaskuler, parkinson, dll
Iatrogenik terkait farmasi dan polifarmasi Nokturia, hipotensi ortostatik, ggnkeseimbangan, dll
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Penilaian dan Faktor Resiko
Lingkungan saat jatuh sebelumnya dan evaluasi bahaya
lingkunganKonsumsi obat-obatan (benzodiazepine, antikonvulsan,
antidepresi, neuroleptik, antiaritmia kelas 1A)
Perbaiki visus
Evaluasi hipotensi ortostatikEvaluasi keseimbangan dan gaya berjalan (uji get up and
go test) : gaya berjalan dan keseimbangan
Pemeriksaan fisologis (propioseptif, kognitif, kekuatan
otot)
Pemeriksaan muskuloskeletal (sendi : ROM, deformitas,kelemahan)
Pemeriksaan kardiovaskuler : sinkop, aritmia
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Time Up and GoTest
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Hipoalbumin terkait Malnutrisi
Penilaian Status Nutrisi (SGA, MNA)
Penyebab Malnutrisi
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Subjective
Globalassessment
Mi i N t iti l A t
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Mini Nutritional Assesment
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Penyebab Malnutrisi
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Malnutrisi (undernutrisi) padakasus ini
Sumber bahan makanan/Lack of food: income yangrendah, homeless.
Gangguan mengunyah dan menelan
Hilangnya nafsu makan: Keganasan, depresi,penyakitkronis, dll
Tinggal bersama/sendiri: Kesulitan memasak, variasimakanan, food skill
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Bagaimana Terapi pasien ini?
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Hal-hal yang perludipertimbangkan Pada Pasien Ini
Management
Tujuan Terapi
Pilihan terapi
Simptomatis untuk
back pain
Imobilisasi, Gangguan Nutrisi
Underlying Disease
Efek samping obat karena kondisi comorbid :
1. Usia Tua
2. Gangguan fungsi ginjal
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Questions when faced witha newly diagnosed elderly
patient
Are they likely to benefit from treatment?
How can I assess the patient? How much is reversible due to myeloma and how
much pre existing?
How can I predict toxicity?
How can I modify treatment and supportive careto gain maximum efficacy without toxicity?
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Pragmatic patient assessment
Frailty grade Description
Fit/ moderately fit Active
Vulnerable Limited activity butindependent
Mildly frail Need help for householdtasks eg shopping, finances
(IADL)
Moderately frail Partial help for personal care
eg dressing, bathing,toileting (ADL)
Severely frail (NOT poor
PS due to myeloma)
Completely dependent for
personal care (ADL)
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Do elderly patients wanttreatment?
Majority do
Emphasis on quality of life (QoL) vs
increased survival Dependent upon the attitude of the
physician (ageism??)
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QoL studies in myeloma
QoL is worse when disease activity is high
QoL improves as the disease comes under control Physical aspects of QoL especially pain and fatigue
Psychosocial issues may be more important than physical ones for
prognosis
If the aim is QoL, trial of treatment is likely to be beneficial
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Avoiding toxicity
Dose reduction Patients want QoL rather than survival
Increase the dose if well tolerated
Toxicity assessment after each cycle
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Supportive care
Most important in elderly Medical aspects eg.
- High infection rate, higher rate herpes zoster,
thromboembolism
Psychosocial support
Need the help of the geriatricians
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Bagaimana Management Pasien ini ?
1. Menyembuhkan ?
2. Memperpanjang
OS/PFS &
MeningkatkanKualitas Hidup
TujuanTerapi
apa yang dapat kita lakukan untuk mencapai hal ini?
Dibutuhkan Penatalaksanaan YangInteraktif & Multidisiplin
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Pilihan Terapi Multiple Myeloma
Regimen chemotherapy : VMP Protocol :
Velcade 1,3 mg/m2 on day 1,4,8,11; cycle27,10,14,17
Melphalan hari 1-4
Prednison 60mg/hari hari 1-4
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Velcade activity on bone
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Currently used combinations: PFS and OS data
7Wijermans et al. J Clin Oncol 2010; 28:3160-68Beksac et al. Eur J Haematol 2011;86:16-22
9Morgan et al. Blood 2011;118:1231-8
10San Miguel et al. N Engl J Med 2008; 359(9): 906917; Suppl. App.11San Miguel et al. J Clin Oncol 2012 Dec 10. [Epub]
1MTCG. J Clin Oncol 1998;16(12):3832-422Pnisch et al. J Cancer Res Clin Oncol. 2006;132:205-12.3Palumbo et al. Blood 2008; 112:310731144Facon et al. Lancet 2007; 370:12091218
5Hulin et al. J Clin Oncol 2009; 27:3664-706Waage et al. Blood 2010; 116:1405-12
Median PFS (months) Median OS (months)
MP1 1120 29
BP2 14* 32
MPT3-8 1527.5 2951.6
CTDa9 13 33.2
VMP10,11 21.727.4 56.4
*TTF: time to treatment failure
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Minimal Residual Disease monitoring
BM plasma cells
M-band Immunofixation
exposedsurface
hiddensurface
hinge region
carbohydrate
Previously
hiddensurface
Lambda
Kappa
Intact Immunoglobulin Free Light Chain
Bradwell,Serumfree light chainassay
Free Light Chains ImmunophenotypePCR
PR VGPR StringentCR
CR Immuno-phenotypic
CR
Molc
CR
negative negative negative negative negative
MR
PR
VGPRnCR
CRsCR
Progression
TimeDepth of response is related to TTP
Depth of Response is related to TTP(time to progression)
B t ib R l f R l I i
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Bortezomib Reversal of RenalImpairment
Reversal of RI was documented in 41% of patients after a
median of 2.3 months (range 0.47.9)
Patients with newly diagnosed MM had a higher rate ofrenal reversal vs. relapsed patients (61% vs. 37%,
p=0.014)
3/14 patients receiving dialysis became dialysisindependent after 1, 1 and 4 months of therapy
Mild RI
CrCl 51-80 ml/min
Moderate RI
CrCl 30-50 ml/min
Severe RI
< 30 ml/min
Reversal of renal
failure67% 78% 27%
Morabito et al. Eur J Haem 2009; 84: 223-228
Terapi Suportif Lesi Litik
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Terapi Suportif Lesi Litik
Ibandronat 6 mg iv setiap 28 hari
Diel I, et al. Eur J Cancer 2004;40:170412
Waktu (minggu)
p
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Take Home Masage Case Discussion
Assesment Low Back Pain
Jatuh
Malnutrisi
Keluhan & Gejala yangtumpang tindih dengan
penyakit Orang Tua
Management Tujuan Terapi
Pilihan terapi
Simptomatis untuk
back painImobilisasi
Underlying Disease
Efek samping obat karena
kondisi comorbid :
1. Usia Tua2. Gangguan fungsi ginjal
Kurang Kewaspadaan
terhadap Diagnosa
Multiple Myeloma
Eld l MM ti t h t
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Elderly MM patients are an heterogeneous group
Very fit:active, who exercise
regularly
Moderatelyfit: Not regularlyactive but Routinely
walking
Vulnerable:
Mildly frail:Help for household
tasks
Moderately frail:
Severely frail:Dependent on other
people
Thank You