Outcome of Multiple Myeloma Patients Treated Across Pakistan
Hospital Record ID(File No.):
Date of Birth
Gender:
Male
Female
Hospital Name:
Patient Contact No 1
Patient Contact No 2
Date Of Diagnosis:
Weight(kg)
Height(cm)
BMI Kg/m
2
BSA
Status at diagnosis:
Transplant eligible
Transplant ineligible
Reason for transplant ineligibility
ECOG:
0
1
2
3
4
Marital status:
Married
Unmarried
Pregnancy:
Yes
No
Resource Environment:
Limited Resource
Enhanced Resource
Fraility score (IMWG)
calculator
Clinical Presentation:
Back ache
Anemia
Azotemia
Pathological Fracture
hypercalcemia
Neuropathy
Sepsis
Hyperviscosity
Plasmacytoma
Cord Compression
Others
Physical examination findings
Preceding History:
MGUS
Smouldering Myeloma
Amyloidosis
Osseous Plasmacytoma
Extra-osseous Plasmacytoma
Others
Current Diagnosis
LABORATORY DATA:
Hemoglobin (g/dl):
WBC 10
9
/l:
Platelets 10(9)/l:
ESR: mm fall
Serum LDH:
Serum Creatinine (mg/dl):
Normal
Increased
Serum Calcium (mg/dl)
Serum bilirubin umol/l
Serum B2-microglobulin (mg/l)
Serum Albumin (g/dl)
Skeletal survey:
X ray
Whole Body CT scan
MRI
PET scan
Findings on skeletal survey:
Concomittant Plasmacytoma:
Yes
No
Plasmacytoma (Single/Multiple)
Single
Multiple
Site of Plasmacytoma
Bone Marrow monoclonal plasma cell %
Cytogenetics
Serum protein electrophoresis results
Serum Immunofixation
Negative
Positive
Not Available
Heavy chain
lgG
lgM
lgA
lgD
Light Chain
Kappa
lambda
Urine Immunofixation
Negative
Positive
Not Available
Heavy chain
lgG
lgM
lgA
lgD
Light Chain
Kappa
lambda
Serum free light chain
Not Available
Serum Kappa (mg/dl)
Serum lambda (mg/dl)
Kappa: lambda
ISS Stage:
iss_stage
I
II
III
Not Available
R-ISS Stage:
I
II
III
Not Available
FISH for del17p:
Positive
Negative
NA
FISH for t(4:14):
Positive
Negative
NA
FISH for t(14:16):
Positive
Negative
NA
FISH for t(14:20):
Positive
Negative
NA
Fish for Gain 1q:
Positive
Negative
NA
Other FISH abnormalities:
CNS Involvement
Yes
No
Co-morbids at Diagnosis:
Neuropathy:
Yes
No
Grade
Renal Failure:
Yes
No
CrCl2
Dialysis done
Yes
No
Pulmonary disease::
Yes
No
Detail
Cardiac Status (EF)
H/o Stroke
Yes
No
Recurrent infections :
Yes
No
frequency per year
Site
DVT
Yes
No
Site
Date of DVT
Diabetes Mellitus:
Yes
No
Treatment
Supportive care
Anemia requiring transfusion
YES
NO
Palliative Radiotherapy
YES
NO
Pain control
YES
NO
Hypercelcemia
YES
NO
DVT Prophylaxis
YES
NO
Drug used for DVT Prophylaxis
LMWH
Warfarin
DOACS
Orthopaedic Intervention
YES
NO
Bisphosphonate
YES
NO
First Line Therapy:
Date of Starting Treatment
Date of Stopping treatment
Chemotherapy Protocol:
CyBorD
VRd
KCd
KRd
Dara-VRd
Thal-dex
Melphalan-Pred
Others
Dose reduction during first line therapy
75%
50%
Others
Reason for dose reduction
Response to first line therapy
Response assessment done
YES
NO
Date of Response assessment
Total number of cycles given before response assessment:
Response assessed by:
IMWG 2014 criteria
Bone Marrow
SPEP
Immunofixation
FLC
Others
MRD assessment :
Yes
No
Method
IMWG 2014 Response documented:
sCR
CR
VGPR
PR
SD
PD
Total no. of cycles given
Change in regimen during first line therapy
Changes Done:
Reason for Change:
Side effects of first line chemotherapy
Neuropathy
YES
NO
Grade
Cytopenias
YES
NO
Grade
Infection
DVT
Skin Rash
Bisphosphonate Induced Osteonecrosis
YES
NO
Others:
Duration of response to first line drugs (days)
Second line therapy
Date of starting second line
Date of stopping
Regimen:
Indication: Relapse/Refractory
Number of cycles given:
Best response to second line therapy:
IMWG 2014 Response documented:
SCR
CR
VGPR
PR
SD
PD
Side effects:
Duration of response to Second line drugs (days)
Subsequent therapies
Regimen used
Best Response
Radiotherapy:
Yes
No
Intent:
Curative
Palliative
Indication
Site
Total dose of RT
Date of completion of RT
Response to RT:
CR
PR
SD
PD
Post induction therapy
Autologous HSCT
Yes
No
Maintenance chemotherapy
Lenalidomide
Thalidomide
Bortezomib
PI+IMiD
Others
Lost to follow up
Yes
No
Autologous HSCT
Mobilization protocol :
GCSF
chemo-GCSF
G-plerixafor
CD34 dose:
Day Neutrophil Engraftment:
Day Platelet Engraftment:
AHSCT:
Yes
No
Date of HSCT
Response status at AHSCT:
sCR
CR
VGPR
PR
SD
PD
Conditioning regimen:
Mel 200
Mel 140
Others
Transplant complication:
Reason for not proceeding to transplant
Remission not achieved
Lack of finances
Patient not referred to transplant centre
Unwilling for transplant
Lost to follow-up
Became unfit for HSCT
Failure to mobilize stem cells
Post transplant consolidation
Yes
No
Regimen
Number of cycles
Post-transplant maintenance
Yes
No
Regimen:
Lenalidomide
Bortezomib
Carfilzomib
Thalidomide
Proteosome inhibitor +lenalidomide
Others
Post AHSCT relapse
Yes
No
Date of relapse
Management post relapse:
Palliation
Second AHSCT
Allogeneic
Others
Current Status:
Date of last assessment
Alive
Dead
Lost to follow up
Current Disease Status
IMWG 2014 Response documented:
SCR
CR
VGPR
PR
SD
PD
Alive remission:
Date of last follow-up
Date of last remission assessment
Current Treatment
Alive relapsed:
Date of last follow-up
Date of last remission assessment
Current Treatment
Dead:
Date of Death
Cause of death
Myeloma related
Others
Date lost to follow-up
Submitted by:
Name:
Email:
Phone No:
Institute/Organization:
Supervised by:
Supervisor's Name:
Supervisor's Email:
Supervisor's Phone No:
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