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