MIELOM MULTIPLU
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MIELOM MULTIPLUMIELOM MULTIPLU
ASPECTE DE ASPECTE DE DIAGNOSTIC,TRATAMENT SI DIAGNOSTIC,TRATAMENT SI
EVOLUTIEEVOLUTIE
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Pacient de sex masculin in Pacient de sex masculin in varsta de 70 ani, provenind din varsta de 70 ani, provenind din mediul urban, fost mare fumator , a mediul urban, fost mare fumator , a fost internat la sectia Pneumologie fost internat la sectia Pneumologie acuzand astenie fizica, fatigabilitate, acuzand astenie fizica, fatigabilitate, tuse seaca, subfebrilitati, scadere tuse seaca, subfebrilitati, scadere ponderala, dureri toracice si la niv ponderala, dureri toracice si la niv coloanei lombare.coloanei lombare.
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DIAGNOSTIC LA INTERNAREDIAGNOSTIC LA INTERNARE
Suspiciune TBC pulmonarSuspiciune TBC pulmonarDiscopatie lombaraDiscopatie lombara
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LABORATORLABORATOR
Hb-4,7; Ht-0,244; Hb-4,7; Ht-0,244; VSH=40/75VSH=40/75GGT=79GGT=79Rtg pulmonar: discreta fibroza.Rtg pulmonar: discreta fibroza.
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Pe parcursul internarii pacientul Pe parcursul internarii pacientul a prezentat o criza epileptica cu a prezentat o criza epileptica cu durata de aprox 3 minute, stare de durata de aprox 3 minute, stare de prostatie, agitatie, agresivitate prostatie, agitatie, agresivitate verbala si progresiv a devenit verbala si progresiv a devenit paraplegic motiv ptr care s-a cerut paraplegic motiv ptr care s-a cerut consult neurologic cu transferarea consult neurologic cu transferarea acestuia pe sectia Neurologie.acestuia pe sectia Neurologie.
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CONSULTURI CONSULTURI INTERDISCIPLINAREINTERDISCIPLINARE
Ex gastroenterologic: ulcer duodenal Ex gastroenterologic: ulcer duodenal cronic, gastrita eroziva, esofagita cronic, gastrita eroziva, esofagita recenta.recenta.
Ex urologic prostata normala fara Ex urologic prostata normala fara suspiciune de transformare suspiciune de transformare neoplazica.neoplazica.
Ex ortopedic: fracturi patologice la Ex ortopedic: fracturi patologice la niv L1,2,4 si suspiciune de niv L1,2,4 si suspiciune de osteoporoza avansata.osteoporoza avansata.
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CT coloana vertebrala CT coloana vertebrala
corpi vertebrali lombari moderat tasati;corpi vertebrali lombari moderat tasati;multiple zone de osteoliza de pana lamultiple zone de osteoliza de pana la
4,5cm diametru la niv oaselor bazinului 4,5cm diametru la niv oaselor bazinului si desi de
pana la 2,5cm la niv corplilor vertebralipana la 2,5cm la niv corplilor vertebrali
lombari, unele cu intreruperea conturuluilombari, unele cu intreruperea conturului
osos.osos.
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CONFIRMAREA CONFIRMAREA DIAGNOSTICULUI DIAGNOSTICULUI
electroforeza peak monoclonal,electroforeza peak monoclonal,VSH=125/152,VSH=125/152,prezenta paraproteinei urinare Bence prezenta paraproteinei urinare Bence
Jones, Jones, Hb=4,7; Ht=0,245Hb=4,7; Ht=0,245Fe=3,01Fe=3,01rtg craniana leziuni osteolitice. rtg craniana leziuni osteolitice.
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TRATAMENTTRATAMENT
Melphalan si PrednisonMelphalan si Prednison Bonefos in pev,Bonefos in pev, roborante,roborante, protectoare gastriceprotectoare gastrice anticonvulsivanteanticonvulsivante
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EVOLUTIEEVOLUTIE
dupa a 2-a cura remiterea dupa a 2-a cura remiterea paraplegiei si diminuarea paraplegiei si diminuarea simptomatologiei si ameliorarea simptomatologiei si ameliorarea rezultatelor biologice (Hb=6,4)rezultatelor biologice (Hb=6,4)
dupa a 4 a cura mai acuza dureri dupa a 4 a cura mai acuza dureri osoase difuze dar biologic se osoase difuze dar biologic se constata diminuarea sdr inflamator constata diminuarea sdr inflamator (VSH=24/50), iar electroforeza nu a (VSH=24/50), iar electroforeza nu a mai evidentiat peak monoclonal.mai evidentiat peak monoclonal.
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Pacient de 55 ani care a fost Pacient de 55 ani care a fost indrumat spre sectia Chirurgie indrumat spre sectia Chirurgie pentru excizia chirurgicala a unei pentru excizia chirurgicala a unei formatiuni tumorale craniene, formatiuni tumorale craniene, aderenta de tesuturile profunde, aderenta de tesuturile profunde, nedureroasa,cu evolutie lenta, nedureroasa,cu evolutie lenta, astenie fizica, fatigabilitate.astenie fizica, fatigabilitate.
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DIAGNOSTIC LA INTERNAREDIAGNOSTIC LA INTERNARE
TUMORA CRANIANATUMORA CRANIANA
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PARACLINICPARACLINIC
Creatinina=1,51Creatinina=1,51uree=10,71uree=10,71Glicemie=7,79Glicemie=7,79VSH=100/125VSH=100/125
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RTG CRANIANARTG CRANIANA
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TRATAMENTTRATAMENT
excizia formatiunii tumorale excizia formatiunii tumorale
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LABORATORLABORATOR
electroforeza – peak monoclonal electroforeza – peak monoclonal ionograma, ionograma, paraproteina urinara pozitiva paraproteina urinara pozitiva creatinina=1,53creatinina=1,53uree=10,71uree=10,71
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TRATAMENTTRATAMENT
fortarea diurezeifortarea diurezei initierea terapiei cu Alkeran, initierea terapiei cu Alkeran,
Prednison, BonefosPrednison, Bonefoshepatoprotectoarehepatoprotectoareprotectoare gastriceprotectoare gastrice
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EVOLUTIEEVOLUTIE
a treia cura PCT bolnavul nu prezinta a treia cura PCT bolnavul nu prezinta acuze acuze
paraclinic - prezenta sdr inflamator paraclinic - prezenta sdr inflamator VSH=90/116VSH=90/116probe renale normaleprobe renale normale
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DISCUTIIDISCUTII
Tetrada clasica :Tetrada clasica :Calcium elevatedCalcium elevatedRenal failureRenal failureAnemieAnemieBone lesionBone lesionManifestari neurologice:astenie fizica, Manifestari neurologice:astenie fizica,
fatigabilitate, cefalee, retinopatie, sdr fatigabilitate, cefalee, retinopatie, sdr de tunel carpian, neuropatii iar in de tunel carpian, neuropatii iar in cazurile care s-au prezentat tardiv cazurile care s-au prezentat tardiv paraplegie.paraplegie.
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PARACLINICPARACLINIC
anemii de etiologie neprecizata, anemii de etiologie neprecizata, insuficienta renala, insuficienta renala, VSH crescut,VSH crescut,niv mari ale imunoglobulinelor niv mari ale imunoglobulinelor prezenta zonelor de osteoliza prezenta zonelor de osteoliza
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TRATAMENTTRATAMENT
Depinde de:Depinde de:varsta pacientului varsta pacientului afectiunile asociateafectiunile asociate
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Tratamentul pacientilor sub 65 Tratamentul pacientilor sub 65 aniani
Initiere tratamentului Initiere tratamentului cura Alexaniana (VAD)cura Alexaniana (VAD) melphalan-prednisonmelphalan-prednison thalidomide-dexametazona, thalidomide-dexametazona, lenalidomide-lenalidomide-
dexametazona,urmat dedexametazona,urmat detransplantul de celule stem transplantul de celule stem autolog cel mai frecvent utilizat autolog cel mai frecvent utilizat
allogenic allogenic
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Tratamentul pacientilor peste 65 Tratamentul pacientilor peste 65 aniani
Initiere tratament cu Initiere tratament cu SCHEMA SCHEMA STANDARDSTANDARD
care consta in Melphalan si Prednison care consta in Melphalan si Prednison Transplant de celule stemTransplant de celule stem
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EVOLUTIEEVOLUTIE
RECADERI RECADERI -tratamentul depinde de:-tratamentul depinde de:conditia pacientuluiconditia pacientuluidurata remisiei durata remisiei include adm agentilor utilizati in faza include adm agentilor utilizati in faza
de inductie urmata apoi de de inductie urmata apoi de transplant de cellule stem.transplant de cellule stem.
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EVOLUTIEEVOLUTIE
REZISTENTA LA TRATAMENT-REZISTENTA LA TRATAMENT-proces proces reversibil.reversibil.
Noile preparate farmaceutice par a sensibilizaNoile preparate farmaceutice par a sensibiliza
celulele tumorale la terapia standard fiindcelulele tumorale la terapia standard fiind
reprezentate de: reprezentate de: Bortezomid care a intrat in arsenalul Bortezomid care a intrat in arsenalul
terapeuticterapeutic
din 2005 si este uninhibitor de protozomidin 2005 si este uninhibitor de protozomi Lenalidomid analog de thalidomide dar cuLenalidomid analog de thalidomide dar cu
efecte adverse mai putin numeroase. efecte adverse mai putin numeroase.
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CONCLUZIICONCLUZII
Repartitia pe sexe arata la nivelul Repartitia pe sexe arata la nivelul judetului Covasna o usoara judetului Covasna o usoara preponderenta a afectiunii la sexul preponderenta a afectiunii la sexul femininfeminin
Tratamentul de prima linie consta din Tratamentul de prima linie consta din adm de Alkeran- prednisonadm de Alkeran- prednison
In cazurile de recadere sau raspuns In cazurile de recadere sau raspuns partial la terapia standard se obtin partial la terapia standard se obtin rezultate satisfacatoare prin adm curei rezultate satisfacatoare prin adm curei AlexanieneAlexaniene
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• Tratamentul de ultima generatie cu VELCADE nu a fost aplicat deoarece acest produs a intrat recent pe piata farmacologica a tarii iar primul caz va beneficia de administrare in luna noiembrie