Category: Myeloma

Myeloma

MRI

I called my doctor this morning and made an appointment to have him schedule an MRI for me. My right leg has been hurting for a few weeks, and I’m now having to take pain meds a few times a day. I had some xrays last week, which didn’t show any lesions. Hopefully, there’s nothing wrong, but an MRI has a better chance of showing anything else that could be causing the pain. Mostly, I worry about AVN. I also need to have him check my HGB A1C to make sure it’s not off the charts from all the dex.

In my 3 years since dx with MM, I have never had to take pain meds on regular basis. It’s just been on an as-needed basis, such as when I have a BMB.

Big Report

I have a lot to report tonight. First, my IgA has gone down more from the Revlimid/dex trial. Today’s result was 584 mg/dL. It’s never been that low since my diagnosis. You can see all the results I have back so far by clicking on “My Labs” above.

Once my MM is at an acceptable low level, we will harvest my stem cells. The way it works there at Wake Forest, is like this: They are going to contact my insurance company to make sure they will pay for a harvest and store. Once I have that approval, they will have me in the hospital for 2 days while they administer a fairly powerful dose of Cytoxan. Then they will start me on Neupogen for 10 days, which I will inject at home. I’ll have blood tests here at home to make sure my counts reflect the administration of the Neupogen. It’s supposed to mobilize the stem cells by producing so many that they spill out of the bone marrow into the blood stream. It can cause bone pain when it starts to crowd the marrow. It can be managed with pain meds, which I already have. I’ll return to WFUBMC and have my stem cells harvested through a process called pheresis, where the blood will be drawn out through an IV in one arm, the stem cells removed and the blood returned through an IV in the other arm.

I had an xray to look for lytic lesions. The doc said that AVN is painful when active and at rest, so he didn’t believe it was that. No lesion was found. That was good news. It’s probably the sciatic nerve or some inflammation somewhere.

I lost 4 more lbs between my last appointment 2 weeks ago and today. Seems weird, being on so much dex! But I’m glad. I’m not even trying. I think it’s probably the GI problems I have. Also when I’m on the dex, I don’t have much of an appetite. I’m very thirsty though. It’s when I’m off the dex that I have a ravenous appetite. I just don’t let myself have anything that’s bad for me. During dex days, I stay off carbs as much as I can & sugar (always off sugar, for that matter).

I am going to a different dex schedule. Since I’m so miserable on my days off (exhausted!), I am going to do a tapered dose that goes like this:

Day 1: 40 mg
Day 2: 40 mg
Day 3: 40 mg
Day 4: 24 mg
Day 5: 12 mg
Day 6: 6 mg
Day 7: 2 mg
Days 8-14 off
Day 15 – 21: same as days 1-7
Days 23-29 off

Survivors

This evening I was calling cancer survivors to let them know about the annual Relay for Life. I made about 30 calls and got in touch with about 20 people, I think. Everyone I talked to was looking forward to attending. It was good talking to them. We all have something in common. I got to talk to a few people who were at or near their 5 year anniversary of being cancer-free. I had to call one man back to ask one of my required questions because I lost track of what I was supposed to be doing.

Tomorrow I see Dr. Hurd at Wake Forest. I have to make some notes about what I need to discuss with him. Right after I went of dex last week (for the week off), I had a lot of pain in my right leg. I worry about AVN, having been on steroids for so long, and so much. I just have to have it checked out, because I’d rather complain about something that turns out to be nothing than end up having to have hip replacement surgery.

There’s also been a lot of buzz about Zometa and ONJ lately. I don’t think I should be having it any more than every 3 months anymore. I’ve been having it every month for 3 years now. Some doctors stop it for their patients after 2 years.

Next appointment

My next visit with Dr. Hurd at Wake Forest will be on Wednesday, March 8th. I’m hoping for continued good results from the Rev/dex EAP. The dex is a wicked drug though, and I’m beginning to doubt my ability to stick it out at this high dose for 2 more months. I’m on my rest week now, and am recovering, so I may feel differently in a day or so. As soon as I can, I am going to see about having my stem cells harvested. If you’ve read my blog much, you know I’m not in favor of having a stem cell transplant at this time, but I DO want to have my stem cells frozen so I can have more treatment choices.

Cancer Stem Cells

Read through this and let me know what you think. A lot of folks believe that there are cancer stem cells, and those need to be the target of research.

> Dear Friends,

> Dr. Matsui sent this wonderful reply to me late this evening.
> Describing the difficulties of getting people to believe the findings
> and then to test appropriate agents, he supports Dr. Richardson
> description of Matsui’s work as “preliminary.” I think he’d like
> the patient community to spread the word. (Or I would. Probably just
> reading between his lines!)
> His message clarifies (for me) why Hopkins is using Rituxan despite
> the fact that it will likely affect all B cells. They feel they can
> support those whose immune systems are suppressed as is already done
> for persons with genetic disorders that prevent normal development of
> antibodies. He is testing many other agents. He also mentions that
> proteasome inhibitors may attack cancer stem cells. This raises both
> velcade and NPI-504 in my mind. (Recall, taking Rituxan could
> disqualify one from the NPI-504 trial, as it does the PR-171 trial.)

> Finally, I note that he thinks that the active ingredient in fever
> few would be a good agent to test. Since I can buy some form —
> probably not strong or pure enough to matter — nonetheless, I’m
> giving it to my guy NOW.

> What an amazingly generous communication from such a busy, high-
> powered researcher! (Nick, thank you for helping refine the
> questions!)

> Best wishes,
> D.

> Begin forwarded message:

>> From: William Matsui
>> Date: February 22, 2006 10:53:50 PM EST
>> Subject: Re: Follow-up questions?

>> Dr. Wicha passed this message on to me and I had a few thoughts…

>>

>> Like our colleagues at Michigan, we (at Hopkins) believe that cance
>> stem cells lie at the heart of developing effective therapies that
>> can truly result in long-term remissions. The cancer stem cell
>> hypothesis currently is just that, a hypothesis. We believe that we
>> have solid evidence that specific cell populations (stem cells) are
>> able to give rise to myeloma in the laboratory, but the ultimate
>> proof will come from finding effective stem cell targeting agents,
>> then testing them in patients and showing that they can prolong their
>> lives. As you might imagine, this is a formidable task…. Using
>> acute leukemia (AML) as an example, the stem cells in this disease
>> were first identified in the early 90’s. Potential leukemic stem
>> cell targets (the interleukin-3
>> (IL-3) receptor and proteosomes) were described a few years later,
>> but neither of these targets have been seriously studied in the
>> disease (Velcade is a proteosome inhibitor and should have activity
>> against the cells, and has been tested only in a limited fashion in a
>> single published study). So AML (in which few would argue the
>> existence of stem
>> cells) illustrates the difficulties decscribing the laboratory
>> findings, getting people to believe the data, then carrying out a
>> clinical trial that would ultimately prove the point. Hopefully,
>> trials that suggest that the theory is correct, like our Rituxan
>> trial or the Michigan Bexxar trial (that would hopefully extend the
>> length of remissions, but are not likely to cure myeloma-since each
>> agent has curative benefit in only limited cases of lymphoma) will
>> give us the evidence we need to perform future clinical trials using
>> drugs that we think may truly eliminate myeloma stem cells.

>> For our trial at Hopkins, we chose to use Rituxan largely because of
>> its lack of serious side effects and our data from the laboratory.
>> I do
>> not know whether any other investigators have repeated our
>> experiments, but I do know many researcher have asked me to help them
>> with the laboratory assays to detect growth of the stem cells (so
>> maybe confirmatory results are coming). I agree that parthenolide is
>> a promising drug in leukemia and would certainally make sense to test
>> in MM. We are looking at several agents in the lab to test their
>> anti- stem cell activity. Some are focused on agents that can
>> inhibit B cells (regardless if they are myeloma derived or not),
>> others on pathways that we think are shared my stem cells from many
>> different tissues and organs. For the latter set of drugs, there is
>> certainally concern that they will affect normal stem cells so much
>> testing is likely needed prior to their standardly being used. As
>> for myeloma, my hope is that we can eliminate most all B cells since
>> the greatest risk of this approach would likely be a period of
>> immunodeficiency (due to the loss of normal antibody production).
>> But there are individuals with genetic defects that lead to
>> immunodeficient states that can really lead normal lives with
>> antibodies given every 1-2 weeks, and I would expect that the B cell
>> pool to be “replenished” by new B cells made from hematopoietic stem
>> cells.

>> Hope that this answers a few questions. Please don’t hesistate to
>> contact me if you have any others.

>> Bill

>> William Matsui, MD
>> Assistant Professor of Oncology
>> Division of Hematologic Malignancies
>> The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins The
>> Bunting Blaustein Cancer Research Building Room 245 1650 Orleans
>> Street Baltimore, MD 21231

Results!

Here’s what I just received by email:

Got your phone and e-mail, just been very busy with patients this am. Your values are much better. M-spike in beta 2 region is 0.29 G/dl, Gamma region is 0.18 G/dl. Your IGA is 1132, IGG 310, and IGM 37

My IgA was 2245 mg/dL when I started. My IgM is in the normal range for the first time ever! IgG still low.

Starting second cycle

I started my second cycle of Rev/dex yesterday. So far, nothing bad! Just the dex sleeplessness and a bit of a headache. Normal dex stuff. Just 3 more months to go, and then I go to dex just 4 days a month and the Revlimid 21 days, like now. I had the quantitative Ig’s and SPEP done, as well as CBCs. The CBCs were all in the normal range. The RBC, HGB and HCT are all at the low end, but still in the normal range!