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Abstract: An elderly female patient with low back pain thought to be arthritis was found to be suffering from multiple myeloma. Multiple myeloma is the most common type of plasma cell tumor . Diagnosis of the disease requires bone marrow aspiration and biopsy examination, and chemotherapy and bone marrow transplantation are the main treatment methods. In this case, the patient’s condition was well controlled after aggressive chemotherapy, bone pain disappeared, anemia and renal insufficiency improved, and survival and quality of life were significantly improved.
Basic information】Female, 67 years old
Disease Type】Multiple myeloma
Hospital】The Second Hospital of Guangzhou Medical University
Date of consultation】August 2021
Treatment plan] Chemotherapy (bortezomib + lenalidomide + dexamethasone)
Treatment period】Hospitalization once a month, 7 days each time, 21 days of outpatient follow up
Treatment effect] The disease was well controlled, bone pain disappeared, anemia and renal insufficiency improved.
I. Initial consultation
The patient is an elderly woman who came to our orthopedic surgery department with “lumbar spine pain for more than one month”. She had a history of rheumatoid arthritis and complained that she started to have left-sided lumbar pain more than one month ago, thinking that her back had flashed when she walked or she had been invaded by rheumatoid rheumatism, so she did not go to the hospital. In the past 1 week, the back pain became more and more severe, and the pain was so bad that he could not sleep at night, so he came to our outpatient orthopedic surgery clinic. The outpatient doctor found: pressure pain and percussion pain in the spinous process of 1 and 2 lumbar vertebrae; routine blood test found: severe anemia, hematocrit 76g/L; renal function impairment: blood creatinine 125μmol/L. The preliminary diagnosis was “lumbar pain investigation: lumbar spine injury?” He was admitted to the hospital.
II. Treatment history
The patient was admitted to the hospital and underwent MRI examination of the lumbar spine, which revealed “worm-like” bone destruction in each vertebral body of the lumbar spine, with attention to exclude bone metastases or plasma cell tumors. The orthopedic surgeon asked our department for consultation, and after the consultation, the possibility of plasma cell tumor was considered to be high, so the patient was transferred to our department for further consultation. After the transfer, a bone marrow aspiration and biopsy, as well as relevant flow cytology and genetic testing were performed, and the final diagnosis of “multiple myeloma” was confirmed. We informed the family of the patient’s final diagnosis and pointed out that the patient was not eligible for bone marrow transplantation and that chemotherapy was the only treatment available to prolong the patient’s survival and improve the patient’s quality of life. Both the patient and the family expressed their willingness to actively cooperate with the physician’s treatment. From August 2021 to March 2022, a total of 6 chemotherapy sessions were performed with the following regimen: bortezomib + lenalidomide + dexamethasone. after March 2022, the patient received oral lenalidomide for maintenance treatment and regular outpatient review.
III. Treatment outcome
After the patient completed 6 times of chemotherapy, whole-body bone scan examination indicated that the bone destruction of the lumbar spine was significantly smaller than before; the rest of the body bones did not show significant destruction. Blood tests showed that the hematocrit increased to 100 g/L and the blood creatinine decreased to 57 μmol/L. The bone marrow was rechecked in April 2022, and no myeloma cells were found, and no abnormal monoclonal globulin (M protein) produced by myeloma cells was detected in the blood. Based on the examination results, the patient’s outcome was evaluated as complete remission (CR). The disease was well controlled, the bone pain disappeared, and the anemia and renal insufficiency were improved.
IV. Precautions
We are glad that the patient’s condition is under control after chemotherapy. Chemotherapy is a high-risk treatment, and many side effects appear after discharge from the hospital after chemotherapy. Therefore, patients should have regular outpatient review after discharge, usually every 3 days for routine blood tests and every 7 days for liver and kidney functions. In addition, many chemotherapy drugs have special side effects, for example, bortezomib can damage peripheral nerves, causing patients to have numbness in their hands and feet. Patients can be advised to eat more red meat rich in vitamin B12 and take oral vitamin B12 tablets to nourish nerves if necessary. Dexamethasone can lead to hypertension, hyperglycemia and gastric ulcer, etc. Patients must monitor their blood pressure and blood sugar, and take some oral gastric drugs, such as aluminum thioglycollate and omeprazole, etc. under the guidance of doctors. In addition, cancer patients are prone to develop cancer-phobia and give up treatment easily, so family members are advised to build up confidence for patients to overcome the disease during the treatment consolidation period. As in this case, the patient actively cooperated with the treatment and got a good treatment effect.
V. Personal insight
Multiple myeloma is the most common plasma cell malignancy, mostly seen in patients over 60 years old. Patients often present with bone pain, renal failure and anemia as the first manifestation, which are often misdiagnosed and missed. If patients find themselves with 3 or more of the above clinical manifestations, they should pay attention to the possibility of plasma cell tumors. Since the cure rate of multiple myeloma is relatively low, patients are prone to fear or give up treatment. Therefore, psychological counseling for patients is also important, both during the treatment period and the consolidation period of treatment, and as doctors, they must always pay attention to the psychological changes of patients and urge and encourage patients to adhere to treatment.