Extramedullary myeloma (EMM) is defined by the presence of plasma cells outside the bone marrow in a patient with multiple myeloma (MM) (Touzeau & Moreau, 2016). EMM is by itself a rare entity with cases involving central nervous system (CNS) being rarer, it has an estimated incidence of 1-1.8% of all MM cases (Majd et al, 2015). Its presentation in comparison to classical MM has an adverse prognosis including a shorter progression free survival (PFS) (Gozzetti et al, 2015) and overall survival (OS) with a mean life expectancy of 1.5-6 months (Majd et al, 2015). Currently there are not international treatment guidelines for this disease. The aim of this report is to illustrate our experience at a single institution in Mexico, presenting five cases of CNS-EMM treated with proteasome inhibitor (carfilzomib) in combination with thalidomide, dexamethasone plus radiotherapy. The patient's characteristics and the treatment regimen are shown in table 1 and 2. Within three months, following the criteria to the international multiple myeloma working group (IMMWG), all five patients accomplished a positive response (one partial response [PR] four very good partial responses [VGPR]), at sixth months two patients improved their response from previously PR to a VGPR and from VGPR to complete response (CR), one sustained its VGPR and after this period of time two patients had progressive disease (PD) and died due to infectious complications. After the tenth month a third patient also died of infectious complications. By the end of this report two patients still alive, one is being evaluated for autologous stem cell transplantation (ASCT) and the other one wasn't eligible according to European Group for Blood and Marrow Transplantation (EBMT) risk score and will continue treatment without ASCT. Previously reported cases in the literature with old chemotherapy regimens shown to have median survival of 1.5 months (Petersen et al 1999), nowadays the recommended therapy is based on triplet induction therapy followed by high-dose melphalan/ASCT, a triplet consolidation therapy and maintenance treatment with lenalidomide (Touzeau & Moreau, 2016); so far there is no evidence of proteasome inhibitors penetrating the blood brain barrier (Nooka et al, 2013) and this might be the reason why the literature strongly recommends the use of lenalidomide as this one does penetrate into the CSF after oral administration (Muscal et al, 2012), we did not use lenalidomide due to the high monetary cost of the treatment but instead we use thalidomide in combination with carfilzomib and dexamethasone with improved OS in three of our five patients (VGPR + CR). Despite the small number of patients presented in this report and the lack of cytogenetics or FISH information, we think this might be a good therapeutic approached in patients with CNS-EMM, especially in those scenarios with not accessible resources or absence of clinical trials. Further studies evaluating the addition of monoclonal antibodies (daratumumab, elotuzumab) need to be done in order to improve the OS and PFS in this group of patients. Disclosures No relevant conflicts of interest to declare.
Multiple myeloma a plasmatic cell disorder, characterized by bone marrow infiltration of clonal plasmatic cells, monoclonal immunoglobulin production and end stage organ damage. This disease has a wide range of clinical manifestations, including solitary disease or plasmacytoma. It´s the second most common hematologic disease just behind Non Hodgkin Lymphoma. More than 60% of de novo MM patients present vertebral involvement. 80% of MM patients refer pain as the first symptom of the disease, and this often leads to opioid abuse and adverse effects related to pain medication. Plasmocytoma is one of the three neoplastic lesions of the vertebra that can be susceptible of percutaneous vertebroplasty. The preferred method of treatment is a percutaneous vertebroplasty (PV), a radiologic invasive treatment that can treat multiple pathologies, and is now widely used for treatment of osteoporosis vertebral fractures. For the purpose of the study we aimed to assess functional status and reincorporation to daily living, we used the Karnofsky Performance Status; and the Barthel index. For pain improvement we used the Visual Analog Scale. The Likert satisfaction scale (introduced in 1932) measures patient satisfaction in an analog scale. The main objective of the study was to assess the repercussion of the PV in pain score modification and improvement of functional scores in patients with MM at the Pain Clinic of the Instituto Nacional de Cancerología (INCan) in Mexico City. We carried out the study between January 2004 and October 2015. We compared VP treatment to bisphosphonate (BP) and radiotherapy (RT) according to the visual analog scale; and according to Karnofsky and Barthel scales, we determined the reincorporation to daily activities. We included 119 new cases con MM, of this only 64 were included in the study. Of this 54 were female, and 65 were male with a mean age of 59 years (28-87). 88% of patients referred pain as their main symptom, and 70% presented with a vertebral fracture. 26.9% had an ECOG of 3 or more. 96% (114) received RT and 99% (118) BP. 64 (54%) of patients were treated with VP. Of this, 67% referred a VAS of 4 or more (moderate to severe pain). And 92% of the patients achieved a VAS of 4 or less. As for the Karnofsky we assessed an improvement of 50/80 points pre VP to 80/90 post VP. The same result was assessed in the Barthel scale, with an improvement of 50/80 points pre VP to 80/100 post VP. This data provides solid evidence of the importance of multidisciplinary approach, and that VP is a safe and effective treatment, coupled of course with BP and RT. Disclosures No relevant conflicts of interest to declare.
La gerencia tradicionalmente, fue envestida de una concepción un tanto retraída, asumida como una posición de autoridad, poder, orden y mando; visión trastocada por un afán de dirigir, donde la acción monocular, capacitaba todos los estratos del hecho organizacional. Razón por la cual, el auge del crecimiento social, la globalización y el enfoque sistémico, articularon una vigencia situada en la esencia humana, en la racionalidad dialógica, donde la gestión inoculaba una gerencia; esta, a su vez, constituía un liderazgo afianzado en la nuclearización del contexto, relaciones interpersonales, inteligencia emocional, escucha activa y comunicación sentida. Dimensiones de urdimbre que, al ser valoradas por el continuum orgánico institucional, permiten fecundar acciones estratégicas, equipos de trabajos bajo la disposición común. Por ello, se enmarca como objetivo, describir las relaciones entre el liderazgo y comunicación digital, como un medio de socializante de las metas, acciones y logros organizacionales, dentro de las escuelas de educación básica general de Ecuador, metaforizándolas como dos causas llamadas a coexistir en un mismo fin de convergencia laboral, apertura al cambio, adaptabilidad y conciencia colectiva; orquestada en mejorar las condiciones sociolaborales, curriculares, pedagógicas y formativas desde la ecoconvivencia interrelacional de los actores bióticos de las escuelas.
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