La p or a nk a s u s

SEORANG PENDERITA DENGAN LEUKEMIA MIELOID KRONIK DAN MIELOMA MULTIPEL

Ke t u tS u e g a Di v i s iHe ma t ol og i On k ol og i Me d i k , Ba g i a n / S M FI l muP e n y a k i tDa l a m F K Un u d / RS UPS a n g l a hDe n p a s a r Ema i l : k s u e g a @y a h oo.c om
ABS TRACT Ch r on i cM y e l oi d Le u k e mi a( CM L)a n dM u l t i p l eM y e l oma( M M )a r et wo c h r on i cp r og r e s s i v ed i s e a s e sc h a r a c t e r i z e d b yn e op l a s t i cp r ol i f e r a t i onofmy e l oi dc e l l a n dmon oc l on a l p l a s mac e l l . Ch r on i cmy e l oi dl e u k e mi awa sr e c og n i z e da sad i s t i n c t e n t i t y ,a s s oc i a t e dwi t hma s s i v es p l e n ome g a l ya n da sr s t ma l i g n a n t d i s e a s ef ou n dt ob ec on s t i t u t i v e l ya s s oc i a t e dwi t hs p e s i c c y t og e n e t i ca b n or ma l i t yt h eP h i l a d e l p h i aon c og e n e . Wh e r e a sM M i sf r e q u e n t l yr e c og n i z e db ymon oc l on a lp r ot e i np r od u c t i on a n de i t h e r d i f u s eos t e op or os i sor l y t i cb on el e s i on . Cl i n i c a l ma n i f e s t a t i ona r ec on s e q u e n c eof ma r r ow i n l t r a t i onof p l a s mac e l l s , p r od u c t i onof Mp r ot e i ni nb l oodor u r i n ea n di mmu n ed e c i e n c y . Coi n c i d e n c eof t h e s et wo d i s e a s e si non ep a r t i c u l a r p a t i e n t i sa v e r yr a r eoc c a s i on . He r e wi t hwer e p or t e dawoma n4 2y e a r sol dBa l i n e s ep r e s e n t e dof a b d omi n a l e n l a r g e me n t wi t h ou t s y mp t om ofb on ep a i n ,a n e mi cs y n d r ome . Af t e rc omp l e t ee x a mi n a t i on s u p p or t i n gb y n d i n g on b on ema r r ow e x a mi n a t i on t h i sp a t i e n t n a l l yd i a g n os e d ofh a v i n gc h r on i cp h a s eofCM L a n dM M s t a g eI I I Ba swe l l .T r e a t me n twa sg i v e n wi t hh y d r ox yu r e aa n d ot h e rs u p p or t e dme a s u r e sa n dwep l a n n e dt oc on t i n u ewi t hme l p h a l a na n dp r e d n i s on e . Th e r ewe r en oc l e a re x p l a n a t i onf ort h i s c on d i t i onwh e t h e r i t oc c u r c on c omi t a n t l yor on ed i s e a s ef ol l ow wi t ht h eot h e r .S e v e r a l r e p or t sf ou n dt h a t i nq u i t es i mi l a r oc c a s i on Me l p h a l a n wa st h ea g e n tofs u s p e c t e d wi t hi n d u c e ds e c on d a r y ma l i g n a n c y . Ot h e r sa l s of ou n dt we n t y M DS p a t i e n tt og e t h e r wi t hl y mp h oi dma l i g n a n c ya n dp l a s mac e l l .T a n a k aet.al., n ot e dt h a t amor es a t i s f a c t or ye x p l a n a t i oni st h a t b ot hd i s or d e r sa r e f r om ma l i g n a n t t r a n s f or ma t i onofap r e c u r s orc e l l c a p a b l eofd i f f e r e n t i a t i n gi n t ob ot hl y mp h oi da n dmy e l oi dl i n e s .I nou rc a s e mor el i k e l yt h a tCM L c on c omi t a n t l yf ou n d wi t hMM b e c a u s et h e r e we r en op r e v i ou sh i s t or y ofh a v i n gc h e mot h e r a p yn or r a d i ot h e r a p y . Ke y wor d s : c h r on i cmy e l oi dl e u k e mi a , mu l t i p l emy e l oma ,c oe x i s t e n c e

P ENDAHULUAN Le u k e mi a Mi e l oi d Kr on i k ( LM K) a d a l a h l e u k e mi ak r on i kd e n g a ns e l s e ly a n gd omi n a na d a l a h 1,2 s e ls e r imi e l oi d . Da r is e mu ak a s u sl e u k e mi a , LM K me n c a k u p 20 %. I n s i d e n n y a1 p e r10 0 .0 0 0p e n d u d u k . P r e d omi n a np a d al a k i l a k i d i b a n d i n g k a nwa n i t ad e n g a n r a t i o 1,4 :1. Le u k e mi ami e l oi dk r on i kb i s ame n g e n a i s e mu au mu rd e n g a np u n c a kk e j a d i a np a d ad e k a d e50 182

6 0t a h u n .3 S e b a g i a nb e s a r k a s u s( 9 5%) me n u n j u k k a n 15 k r omos om p h i l a d e l p i a p os i t i f . Ab n or ma l i t a s i n i a d a l a h t r a n s l ok a s ib a g i a n l e n g a n p a n j a n g a n t a r a k r omos om 9d a n22, u mu my ad u ad e r i v a t 9q+ d a n22 q.3 Ge j a l ap e n y a k i ti n ia d a l a hb a d a nl e ma h ,n a f s u ma k a n me n u r u n d i s e r t a ip e n u r u n a n b e r a tb a d a n , s p l e n ome g a l i , p u c a td a nn y e r is t e r n u m, n a mu n4 0 % p e n y a k i t i n i a d a l a ha s i mt oma t i ss e h i n g g ap a d ak e a d a a n i n id i a g os i sd i b u a th a n y ab e r d a s a r k a np e me r i k s a a n

J Peny Dalam, Volume 11 Nomor 3 September 2010

s e ld a r a hy a n ga b n or ma lb e r u p al e k os i t os i sb e r a td a n g a mb a r a nd a r a ht e p iy a n gk h a s . P e r j a l a n a np e n y a k i t i n id a p a td i b a g ime n j a d id u af a s ey a i t uf a s ek r on i k d a nt r a n s f or ma s i a k u t ,p e r j a l a n a n n y ab e r s i f a t p r og r e s i f y a n gd i a wa l id e n g a nf a s ek r on i ky a n gj i n a kb e r j a l a n p e r l a h a n l a h a ns e k i t a r46b u l a ns e l a ma3 5 t a h u n , d a nd a p a tb e r k e mb a n gd e n g a nc e p a td a l a m mi n g g u k e a r a hk r i s i sb l a s t i ky a n gb e r s i f a t f a t a l d a nme n y e r u p a i 6 9 g e j a l ak l i n i kl e u k e mi aa k u t . Mi e l omamu l t i p e la d a l a hs u a t up e n y a k i tk r on i k p r og r e s i fy a n gf a t a ly a n gd i t a n d a i ol e hp r ol i f e r a s i n e op l a s t i k d a r i s e l p l a s ma mon ok l on a l y a n g me n g h a s i l k a ni mu n og l ob u l i ny a n gs p e s i k d i s e b u t p r ot e i nmon ok l on a l ( p r ot e i nmi e l omaa t a up a r a p r ot e i n 11 a t a up r ot e i nM ) .10P r ol i f e r a s id a r is e l s e lp l a s mai n ime n i mb u l k a n b e r b a g a i k e l a i n a n or g a nd a nma n i f e s t a s i k l i n i ks e p e r t i n y e r it u l a n g ,a n e mi a ,i n f e k s ib e r u l a n g ,h i p e r k a l s e mi a , f r a k t u rp a t ol og i s , g a n g g u a nf u n g s ig i n j a l , g a n g g u a n 12,13 n e u r ol og i sd a ns e b a g a i n y a . An g k ak e j a d i a nmi e l omamu l t i p e l a k h i r a k h i r i n i me n i n g k a t ol e hk a r e n ap e n i n g k a t a ns a r a n ad i a g n os t i k . Umu mn y ap r i al e b i hb a n y a k me n d e r i t ad i b a n d i n g k a n wa n i t a , p e n y a k i ti n it e r u t a ma p a d au s i at u ad a n me n i n g k a ts e s u a id e n g a np e r t a mb a h a nu mu r . An g k a k e j a d i a np a n y a k i t i n i d i AS2 3 p e r 10 0 .0 0 0p e n d u d u k p e r t a h u nd a nb e r v a r i a s i d i b e b e r a p an e g a r al a i n n y a . Di 14 ,15 I n d on e s i ab e l u ma d aa n g k ay a n gp a s t i . Be r i k u td i l a p or k a n k a s u sj a r a n gp a d as e or a n g wa n i t ay a n g me n d e r i t a LM K d a n me n d e r i t aM M , j u g ak a i t a na n t a r aLM K d a nM M ma s i hb e l u mb a n y a k d i b i c a r a k a n . KAS US S e or a n g wa n i t a4 2t a h u n ,S u k u Ba l i ,p e k e r j a a n p e t a n i d a t a n gk eRS UPS a n g l a hd e n g a nk e l u h a nt i mb u l b e n j ol a np a d ap e r u tb a g i a nk i r is e j a k 6 mi n g g uy a n g l a l u . Be n j ol a ni n i t e r u sme mb e s a r s e h i n g g ap e r u t t e r a s a p e n u h . Be n j ol a ni n i t i d a kd i r a s a k a nn y e r i . Ke l u h a nl a i n b e r u p ab a d a nl e ma h , mu a l , mu n t a h , ma t ab e r k u n a n g S e or a n gP e n d e r i t ad e n g a nLe u k e mi aM i e l oi dKr on i kd a nM i e l omaM u l t i p e l Ketut Sueg a

k u n a n g , t e l i n g a me n d e n g i n g , s a k i tk e p a l a , n a f s u ma k a n me n u r u n ,p a n a sb a d a n ,b e r a tb a d a n me n u r u n , b e r k e r i n g a t ma l a m, n a f s u ma k a n me n u r u ns e j a k5 mi n g g uy a n gl a l u . Di j u mp a ik e l u h a nn y e r i n y e r ip a d a t u l a n gk a k i d a nb e n g k a ks e h i n g g ap e n d e r i t at i d a kb i s a b e r j a l a n ,t i d a kd i s e r t a in y e r ip a d ap i n g g a n gd a nn y e r i t u l a n gb e l a k a n g . BAB d a nBAK d a l a mb a t a sn or ma l . Ri wa y a tp e n y a k i ts e b e l u mn y a t i d a k p e r n a h me n d e r i t a p e n y a k i ty a n g s a ma . Ri wa y a tk e n c i n g ma n i s , t e k a n a nd a r a ht i n g g i , ma l a r i a , s a k i tk u n i n g d i s a n g k a lol e hp e n d e r i t a .P e n d e r i t as u d a hb e r ob a tk e d ok t e ru mu mk a r e n ap a n a s ,s e t e l a hmi n u m ob a t p a n a s me n u r u nt a p is e t e l a h ob a th a b i sp a n a sb a d a n mu n c u l l a g i . P a d a p e me r i k s a a n s i k d i d a p a t k a n k e a d a a n u mu m l e ma h , k e s a d a r a n k omp os me n t i sd e n g a n t e k a n a nd a r a h9 0 / 50mmHg ,n a d i 10 8x / me n i t ,r e s p i r a s i o 20 x / me n i t ,d a nt e mp e r a t u ra k s i l a38 C. P e me r i k s a a n ma t ad i d a p a t k a nk on j u n g t i v aa n e mi s , s k l e r at i d a k a d ai k t e r u s , r e e kp u p i ln or ma l . P e me r i k s a a nl e h e r t i d a kd i d a p a t k a np e mb e s a r a nk e l e n j a rd a nJ VP P R+ 2c m H2O. P e me r i k s a a n THT t i d a kd i d a p a t k a nu l k u s d i mu l u t , f a r i n gt i d a kh i p e r e mi sd a nt on s i ld a l a m b a t a sn or ma l ,t e l i n g ad a nh i d u n gt i d a ka d ag a n g g u a n . P e me r i k s a a np a r ud a nj a n t u n gt i d a kd i d a p a t k a na d a n y a k e l a i n a n .P e me r i k s a a na b d ome nd i d a p a t k a nl i e nt e r a b a S c h u f f n e r VI , h e p a rt i d a kt e r a b a , a s i t e st i d a ka d a , k ol a t e r a lt i d a ka d a ,t i d a kd i s t e n s i ,b i s i n gu s u sd a l a m b a t a sn or ma l . P e me r i k s a a n e k t r e mi t a sd i d a p a t k a n e d e ma mi n i ma lp a d ae k t r e mi t a sb a wa h .P e me r i k s a a n p e n u n j a n gs a a t M RS d i d a p a t k a np a d aT e h n i c on H 1a d a l a h W BC 22,10 k / u l , RBC 2,4 6k / u l , Hb 6 ,4 g / d l , HCT 22,3% , M CV 9 0 ,7 , M CH 26 ,1p g , M CHC 28,8g / d l , p l a t e l e t4 82 k / u l , d i f fc ou n t :n e u t r ol17 ,6 k / u l , l i mf os i t2,39 k / u l , mon os i t1,7 1 k / u l , e os i n ol 0 ,0 2k / u l ,b a s ol0 ,0 6k / u l . Re t i k u l os i t3,2%, LED 15 me n i td a n4 5 me n i t ,S I17 mg %d a n TI BC 4 5 mg %. P e me r i k s a a n ma l a r i an e g a t i f , BUN 25 mg / d l ,S C 2,4 5 mg / d l ,S GOT 21 u / l ,S GP T 28 u / l ,a l b u mi n 3,0 6g / d l , g l ob u l i n5,4 5g / d l ,b i l i r u b i nt ot a l 0 ,55 mg / d l ,b i l i r u b i n d i r e k0 ,16mg / d l ,a s a mu r a t 11,9 8 mg %, LDH 321 u / l . 183

P a d ap e me r i k s a a nu r i n ed i d a p a t k a nP H6 ,0 ,l e u k os i t + 10 0 / u l ,p r ot e i n+ 10 0mg / d l ,r e d u k s in e g a t i f ,b i l i r u b i n n e g a t i f ,u r ob i l i n og e nn e g a t i fd a ns e d i me nl e u k os i t+ b a n y a k ,e r i t r os i t +p e n u h ,s i l e n d e r g r a n u l a rp os i t i f .P a d a h a p u s a nd a r a ht e p id i d a p a t k a ne r i t r os i tn or mok r om n or mos i t e r ,a n i s os i t os i s ,p oi k i l os i t os i s . Le u k os i t k e s a n j u ml a h me n i n g k a tr e l a t i fn e u t r ol i a , me t a mi e l os i td a n me i l os i t p os i t i f ,t i d a kd i d a p a t k a nb l a s t .T r omb os i t k e s a n j u ml a hn or ma l . Ke s i mp u l a nh a p u s a nd a r a ht e p i s e s u a i d e n g a ng a mb a r a nLM K. P e me r i k s a a nEKG d i d a p a t k a n s i n u st a k i k a r d i , HR 10 8 x / mn t . P e me r i k s a a nt h or a k f ot o g a mb a r a np a r ud a nj a n t u n gd a l a mb a t a sn or ma l . P e me r i k s a a n US Gy a n gd i b a wa p e n d e r i t ad i d a p a t k a n h e p a rn or ma l , k ol e s i s t i t i sk r on i s , h e p a t ome g a l id a n h i d r on e f r os i sk a n a nd a nk i r i . Be r d a s a r k a nd a t ak l i n i sd a nd a t ap e n u n j a n g t e r s e b u t ,d i a g n os i sk e r j ad a r ip e n d e r i t aa d a l a hs u s p e k LM K d e n g a nd i a g n os i st a mb a h a ns u s p e kI S K d a n i n s u s i e n s i r e n a l ol e hk a r e n ar e n a lDD/p r er e n a l . P e n d e r i t ad i b e r i k a nt e r a p i d i e tT i n g g iKa l or i T i n g g iP r ot e i n( TKTP ) , i n f u s Na Cl0 ,9 %, d e k s t r os e 5% d e n g a n30t e t e s / me n i t ,a n t i b i ot i k ac e f ot a x i m 3 x1 g r a m, v i t a mi nC d a nB k omp l e k3 x1 t a b l e t . Da l a mp e r j a l a n a np e r a wa t a np e n d e r i t ad i l a k u k a n mon i t or i n g d a r a h r u t i n d e n g a n h a s i lh e mog l ob i n me n g a l a mip e n u r u n a n me n j a d i6 ,0 g / d l , W BC t u r u n j u g ame n j a d i 17 ,8 K/ u l ,P L T4 6 5 K/ u l ,r e t i k u l os i t 0 ,6 %. Di l a k u k a nb i op s is u ms u mt u l a n gs e p e r t it e r l i h a tp a d a g a mb a r 1d e n g a nh a s i l d i d a p a t k a ns e l u l a r i t a s me n i n g k a t , s i s t e me r i t r oi dn or ma l ,s i s t e mg r a n u l op oe t i k mi e l oi s i t d omi n a nd a nn e u t r ol d omi n a n ,d i t e mu k a ns e l p l a s ma a b n or ma l12%, s e h i n g g ad i s i mp u l k a nd e n g a n LM K d e n g a np l a s ma s i t os i s . P e n d e r i t ad i c u r i g a ime n d e r i t a mi e l oma mu l t i p e ls e h i n g g ad i l a k u k a np e me r i k s a a n l e b i h l a n j u t . Di l a k u k a n p e me r i k s a a n e l e k t r of or e s i s p r ot e i nd i d a p a t k a na l b u mi n 1,4 g / d l ,a l p h a1 g ob u l i n 0 ,5 g / d l ,a l p h a2 g l ob u l i n 1,2 g / d l ,b e t ag l ob u l i n0 ,5 g / d l ,g a mmag l ob u l i n 3,7 g / d l( s pi k e) ,k e s i mp u l a n n y a p a r a p r ot e i n( monoc lonal g ammopath y) ,a s a mu r a t 8,7 7 mg % ( 2,4 5,7 mg %) , LDH 382 u / d l( 210 4 25u l ) , p r ot e i nBe n c eJ on e sn e g a t i f ,k a l s i u m 11,2 mg / d l ( 8,10 184

10 ,4mg / d l ) , I gA 553 mg / d l ( 85 4 50mg / d l ) , I gG 30 11 mg / d l ( 80 017 0 0mg / d l ) , BUN 27 ,0 7mg / d l ,S C 0 ,9 6mg / d l ,p e me r i k s a a nf e s e s l e n g k a pd i d a p a t k a nt e l or d a nl a r v aa n c y l os t omap os i t i f . Di l a k u k a np e me r i k s a a n s u r v e it u l a n gp e l v i s , f e mu r , d a ns k u l ld i d a p a t k a n t u l a n g t u l a n gd a l a m k e a d a a nn or ma l . P e me r i k s a a n US Gu l a n g a nd i d a p a t k a n h e p a rd a nl i e n me mb e s a r , e c h on or ma l d a np e mb e s a r a nk e l e n j a r p a r a a or t ap os i t i f . Di l a k u k a np e me r i k s a a nk r omos om P h i l a d e l p h i ad i S u r a b a y an a mu nh a s i l n y ai n k on k l u s i fk a r e n ab a h a n y a n gk i t ak i r i mt e r c e ma r .

Ga mb a r 1. Bi op s i s u ms u mt u l a n gd i s i mp u l k a nd e n g a nLM K d e n g a np l a s ma s i t os i s

Be r d a s a r k a nd a t a d a t at e r s e b u tp a d ap e n d e r i t a i n id i s i mp u l k a nd e n g a n LM K d e n g a np l a s ma s i t os i s DD/ mi e l omamu l t i p e l +a n c y l os t omi a s i s . T e r a p iy a n gd i b e r i k a np a d ap e n d e r i t ai n id i e t t i n g g ik a l or id a nt i n g g ip r ot e i n , t r a n f u s iP RC t i g a k a n t on g ,h i d r ok s i u r e a( h y d r e a ) , 2 x 50 0 mg ,v i t a mi n Cd a nB c omp l e k3 x1 t a b l e t , me b e n d a z ol e2 x 10 0 mg s e l a ma t i g ah a r i . P a d ah a r ik e 29 p e r a wa t a n p e me r i k s a a nd a r a hl e n g k a pd i u l a n gl a g id e n g a nh a s i l W BC 8,1 k / u l , HB 8,3 g / d l , p l a t e l e t27 7k / u l , p a d a p e me r i k s a a n f e s e sl e n g k a p t i d a k d i d a p a t k a n t e l or ma u p u nl a r v aa n c y l os t oma . Ob a t h i d r ok s i u r e a( h y d r e a ) d i h e n t i k a n .P e n d e r i t ad i p u l a n g k a np a d ah a r i p e r a wa t a n k e 32 d e n g a nr e n c a n aa k a nd i a wa s ik e a d a a n n y ad i p ol i k l i n i k .

J Peny Dalam, Volume 11 Nomor 3 September 2010

P EM BAHAS AN Le u k e mi ami e l oi dk r on i ka d a l a hl e u k e mi ak r on i k y a n g k a r a k t e r i s t i k d e n g a n d i d a p a t k a n p e n i n g k a t a n j u ml a hl e u k os i t d a np e n u mp u k a ns e mu ab e n t u kma t u r d a ni mma t u rd a r ig r a n u l os i t , n a mu ny a n gd omi n a n a d a l a hs e l s e ld a r is e r i mi e l oi d . Wa l a u p u nk a d a n g k a d a n gp a d al i mf os i t T . LM K a d a l a hp e n y a k i tp a d a ma n u s i ay a n gp e r t a ma d e n g a na b n or ma l i t a ss p e s i k d a r ik aryotype y a i t ua d a n y aP h i l a d e l p h i ak r omos om, mu n g k i n k a r e n a k e a d a a n li nk ed to path og eneti c 3 of leuk emog enes i s . Di a g n os i sd a r i LM K a d a l a h d i d a p a t k a n d e n g a n i d e n t i k a s is i t og e n e t i k a t a u a d a n y ae k s p a n s ik l on a lmol e k u l e rd a r ih ematopoi eti c s tem c ell me l a l u ip r os e s rec i proc al trans loc ati on a n t a r ak r omos om 9 d a n 22. Ha s i lt r a n s l ok a s ii n ip a d a k e p a l a e k or g e nb a g i a nd a r i break poi nt c lus ter reg i on ( BCR)d a r ik r omos om 22 p a d ac a b a n g q 11 d e n g a n l ok a s ig e nABL p a d ak r omos om 9 p a d ac a b a n gq34 , s e c a r as i mu l t a ng e n CCi sd a r ik r omos om 22 p i n d a h 9 k ek r omos om 9 .2Kr omos om P h i l a d e l p h i ame n g k od e p r ot e i n l e u k e mi a s p e s i k y a n g d i n a ma k a n P 210 . Ad a n y ap r ot e i ni n i me mb u a ts e lt i d a kt e r g a n t u n g d a r is t i mu l a s if a k t orp e r t u mb u h a ne k s t r a s e l , mu n g k i n me n y e b a b k a na k t i v a s it r a n s k r i p s id a r ig e ns e h i n g g a 5 s e l t e r l i n d u n gd a r i k e ma t i a n . I n s i d e n LM K d i p e r k i r a k a n1 2 k a s u sp e r 10 0 .0 0 0p e n d u d u kp e r t a h u n , 15% d i t e mu k a nd a r i l e u k e mi a , i n s i d e n me n i n g k a t p e r l a h a n d e n g a n me n i n g k a t n y au mu rd a ns a mp a i p e r t e n g a h a n4 0t a h u n , 12 30 %p a s i e na d a l a hu mu r6 0t a h u na t a ul e b i hi n i s a n g a t p e n t i n gu n t u kp e mb e r i a ns t r a t e g it e r a p i s e p e r t i t e r a p it r a n s p l a n t a s id a ni n t e r f e r on a l f a , i n s i d e nl e b i h t i n g g i p a d al a k i l a k i d i b a n d i n g k a nwa n i t a .6,7 Ma n i f e s t a s ik l i n i kd a r iLM K d a p a td i b e d a k a n me n j a d i2 y a i t uf a s ek r on i kd a nf a s ea k u t .P a d af a s e k r on i kd i d a p a t k a ng e j a l ah i p e r k a t a b ol i kb e r a tb a d a n me n u r u n ,l e ma h ,a n or e k s i a ,d a nb e r k e r i n g a t ma l a m,r a s a s a k i t d a nr a s at i d a ke n a kp a d ap e r u t k i r i a t a s ,d a ng e j a l a y a n gt i d a ks e r i n gy a n gb e r h u b u n g a nd e n g a np e n i n g k a t a n j u ml a hg r a n u l os i td a nf u n g s ip l a t e l e ta d a l a hi n f e k s i ,
S e or a n gP e n d e r i t ad e n g a nLe u k e mi aM i e l oi dKr on i kd a nM i e l omaM u l t i p e l Ketut Sueg a

t r omb os i s d a np e r d a r a h a ns e p e r t i v as ooc c lus i v ed i s eas e, c erebrov as c uler ac c i d ent, myoc ard i al i nf ac ti on, v enous th rombos i s ,p r i a p i s mu s ,g a n g g u a nv i s u s ,i n s u f s i e n s i p u l mon a l . Ka d a n g k a d a n gd i s e r t a i k e l u h a nn y e r i s e n d i d a nn y e r ip a d at u l a n g . P r og r e s i v i t a sd a r i LM K i n i d i h u b u n g k a nd e n g a ns e ma k i n me mb e r a t n y ag e j a l a . P a d af a s et r a n s f or ma s ia k u td i d a p a t k a ng e j a l aa n e mi a d a nd e ma ns e ma k i np r og r e s i f ,r e s p onp e n u r u n a nl e k os i t t e r h a d a pk e mot e r a p ia wa l n y ab a i k me n j a d ime n u r u n , s p l e n ome g a l ik a mb u h l a g id a n r e f r a k t e rt e r h a d a p k e mot e r a p i , a n e mi as e ma k i np r og r e s i fd a nt i mb u l t r omb os i t op e n i a ,d a np a d aa k h i r n y at i mb u lg a mb a r a n 1,2,4 ,5 k l i n i ky a n gme n y e r u p a i l e u k e mi aa k u t . P a d a p e me r i k s a a n s i k d i t e mu k a n s p l e n ome g a l il e b i hd a r i10 c m d i b a wa hk os t a , p e mb e s a r a n l i e n b e r h u b u n g a n b a i k d e n g a n j u ml a h l e u k os i t , h e p a t ome g a l i , a n e mi a , k a d a n g k a d a n g g ou t d a n p r i a p i s mu s , l i mp a d e n op a t i t a p i j a r a n g me l e b i h i d i a me t e r1 c m, p e n i mb u n a nl e u k e mi ke k s t r a me d u l a r ( Ch loromas ) , p u r p u r a . Ga mb a r a n l a b or a t or i u m l e u k os i t os i s , b i a s a n y a > 50 .0 0 0 / mm3, s e r i n g > 10 0 .0 0 0 / mm3, a n e mi ab i a s a n y ar i n g a np a d af a s ea wa l , s i f a t n y a n or mok r omi k n or mos i t e r , t r omb os i tp a d a f a s ea wa lma l a h a ns e r i n g me n i n g k a t . Ha p u s a nd a r a h t e p ime n u n j u k k a nl e u k os i t os i sb e r a t , t e r l i h a ts e mu a s p e k t r u ms e r i mi e l oi d ,d a r i b l a s t s a mp a i n e u t r ol . Ya n g p a l i n gd omi n a na d a l a hmi e l os i t d a nn e u t r ol ,g a mb a r a n s u ms u mt u l a n gs a n g a th i p e r s e l u l a rd e n g a nh i p e r p l a s i a mi e l oi d ,g a mb a r a n n y ai n i s a n g a t mi r i pd e n g a nh a p u s a n d a r a ht e p i . Me g a k a r i os i ts e r i n g me n i n g k a td e n g a n mi k r ome g a k a r i os i t . S k or f os f a t a s en e u t r ol r e n d a h s a mp a in e g a t i f . P e me r i k s a a ns i t og e n e t i kl e b i hd a r i 9 5% k a s u sd i j u mp a i Kr omos om P h i l a d e l p h i a( P h l ) y a n gme n u n j u k k a nrec i proc al trans loc ati on k r omos om 1,2,4 ,5 9d a n22. P a d a p e n d e r i t a d i a t a s d i d a p a t k a n g e j a l a h i p e r k a t a b ol i k , s i n d r om a n e mi a , s p l e n ome g a l i , p a d a p e me r i k s a a n l a b or a t or i u m d i d a p a t k a n l e u k os i t os i s , a n e mi a n or mok r omn or mos i t e r , t r omb os i tn or ma l , h a p u s a nd a r a ht e p i s e s u a i d e n g a nLM K. T a p i g a mb a r a n s u ms u mt u l a n gd i d a p a t k a ns e s u a i d e n g a nLM K d e n g a n 185

t a mb a h a nb a n y a kd i j u mp a i s e l . Da r i d a t a d a t at e r s e b u t d i a g n os i sd a r iLM K d a p a td i t e g a k k a n . Na mu np a d a p e me r i k s a a n s i t og e n e t i k Kr omos om P h i l a d e l p h i a h a s i l n y ai n k on k l u s i f k a r e n a b a h a ny a n gd i k i r i m t e r c e ma r . Ga mb a r a n s u ms u m t u l a n g p a d a k a s u s i n i b a n y a kd i j u mp a i a d a n y as e l p l a s ma ,s e t e l a hd i l a k u k a n p e me r i k s a a n l e b i h l a n j u ta k h i r n y a p e n d e r i t a i n i d i d i a g n os i sj u g ad e n g a n mi e l omamu l t i p e l . Di a g n os i s mi e l oma mu l t i p e lp a d ak a s u si n id i t e g a k k a n ol e h k a r e n ame me n u h i k r i t e r i ad i a g n os t i kmi e l omamu l t i p e l me n u r u t Wi n t r ob e ,s e p e r t i p a d at a b e l . Kr i t e r i aM M y a n g d i p e n u h ib e r u p a , 1a p os i t i fy a i t ua d a n y as e lp l a s ma s u ms u m t u l a n gy a n gl e b i hd a r i10 % d a n 2a p os i t i f y a i t ud i j u mp a ip r ot e i n mi e l oma s e c a r ae l e k t r of or e s i s d a l a ms e r u m.

T a b e l 1. Kr i t e r i ad i a g n os t i k mi e l oma mu l t i p e l me n u r u t 10 13 Wi n t r ob e 1. Kr i t e r i as i t ol og i k a . S e l p l a s mas u ms u mt u l a n gl e b i hd a r i 10 % b . Bi op s i j a r i n g a ns u ms u mt u l a n gme n u n j u k k a na d a n y a p l a s ma s i t oma a . Di j u mp a i p r ot e i nme i l omas e c a r ae l e k t r of or e s i sd a l a m s e r u m b . Di j u mp a i p r ot e i nmi e l omad a l a mu r i n e c . Di j u mp a i l e s i os t e ol i t i k d . Di j u mp a i s e l p l a s map a l i n gs e d i k i t d a l a md u ah a p u s a nd a r a ht e p i . Di a g n os i sd i b u a t j i k a: 1. Di j u mp a i1ad a n1bp os i t i f 2. Di j u mp a i1aa t a u 1bp os i t i fd i t a mb a hs a l a hs a t ud a r i 2 p os i t i f 3. S e l p l a s mad a l a ms u ms u mt u l a n g> 30 %d i t a mb a hl e s i os t e ol i t i kl u a s .

Mi e l omamu l t i p e l s e r i n gd i j u mp a i p a d au mu r t u a d a nl e b i hb a n y a kp a d al a k i l a k i d i b a n d i n gp a d awa n i t a . Ke l u h a nu t a may a n gs e r i n gi a l a hn y e r i t u l a n gb e l a k a n g , p a n g k a lt u l a n gp a n j a n g , d a nt u l a n gr u s u k . S e r i n g t e r j a d if r a k t u rp a t ol og i sy a n g me n y e b a b k a np e n d e r i t a p a r a p l e g i a , me n u n j u k k a ng e j a l aa n e mi a ,s e r i n gt e r d a p a t i n f e k s iy a n gb e r u l a n g , s e r i n gd i s e r t a id e n g a ng e j a l a g a g a lg i n j a l , g e j a l ah i p e r k a l s e mi a , g e j a l ap e r d a r a h a n 186

k u l i td a n mu k os a , g e j a l ah i p e r v i s k os i t a sd a ng e j a l a a mi l oi d os i s . P a d ag a mb a r a nl a b or a t or i u m d i d a p a t k a n a n e mi an or mok r om n or mos i t e r , LED y a n gme n i n g k a t , p a d ag a mb a r a nd a r a ht e p i d i j u mp a i g a mb a r a nroeleaux , k a d a n g k a d a n gs e lp l a s ma ,k a d a n g k a d a n gg a mb a r a n l e u k oe r i t r ob l a s t i k .14 P a d as u ms u m t u l a n gd i d a p a t k a ns e lp l a s ma a b n or ma lme n i n g k a tl e b i hd a r i10 %, s e b a g i a nb e s a r M M me n g h a s i l k a np r ot e i ny a n gs p e s i k i mu n og l ob u l i n mon ok l on a ly a n gd i s e b u td e n g a np r ot e i nM a t a u 16 18 p a r a p r ot e i n . P a d a p e me r i k s a a n e l e k t r of or e s i s p r ot e i nd i d a p a t k a ns pi k e p a d af r a k s ig a ma g l ob u l i n . P a d ap e me r i k s a a n i mu n oe l e k t r of or e s i sa k a n d a p a t d i t e n t u k a n j e n i s i mu n og l ob u l i n mon ok l on a ly a n g me n i n g k a t . Ad a p u nj e n i s i mu n og l ob u l i ny a n gd i j u mp a i : I g G( 55%) ,I g A( 27 %) ,I g D( 1,5%) ,I g M ( 0 ,2%) .P a d a p e me r i k s a a nu r i n es e r i n gd i j u mp a i p r ot e i nb e n c ej on e s , p a d ap e me r i k s a a nf u n g s i g i n j a l s e r i n gj u g ad i d a p a t k a n k a d a rk r e a t i n i nd a nu r e u m d a r a h me n i n g k a t . Ka d a r LDH d a n beta 2 mi c rog lobuli n s e r i n g me n i n g k a t , v i s k os i t a sd a r a h me n i n g k a t .P a d a p e me r i k s a a n bone s urv ey ( t e n g k or a k ,c ol u mn av e r t e b r a l i st or a k ol u mb a l , p e l v i s ,f e mu r d a nh u me r u sp r ok s i ma l ,t or a k s ) d i j u mp a i l e s i os t e ol i t i ky a n gk h a s( punc h edout les i ons ) ,k a d a n g k a d a n gb e r u p a os t e op or os i su mu m. Da p a td i j u mp a i 13,19 g a mb a r a nf r a k t u rp a t ol og i k . P e n y a k i tmi e l omamu l t i p e lmu l a mu l ab e r l a n g s u n ga s i mt oma t i ks e l a mab e b e r a p ab u l a na t a ub e b e r a p a t a h u n . An e mi ad i t e mu k a np a d a6 2% p e n d e r i t ap a d as a a t d i a g n os i s ,t e r d a p a th u b u n g a na n t a r ab e r a t n y aa n e mi a d e n g a nma s s at u mor .P a d ak a s u si n i d i t e mu k a nHb6 ,4 g / d l . An e mi ap a d ap a s i e ni n is e l a i nk a r e n a mi e l oma mu l t i p l e n y aj u g ab i s ad i p e r b e r a t ol e h LM K. Ny e r i t u l a n gd i t e mu k a np a d ak i r a k i r a7 0 % p e n d e r i t ap a d a s a a t d i a g n os i s t e r u t a map a d ad i p i n g g a n gd a nd a d a ,n y e r i 20 b i a s a n y ab e r t a mb a hp a d ap e r g e r a k a nb a d a n . P a d a p a s i e ni n i d a r i a n a mn e s i st i d a kk a mi d a p a t k a nk e l u h a n n y e r i p a d at u l a n g t u l a n g . Ga n g g u a nf u n g s i g i n j a l p a d a p e n d e r i t aM M s e r i n gd i t e mu k a ns a a td i a g n os i s .P a d a mi e l oma mu l t i p e lg a n g g u a nf u n g s ig i n j a ld i s e b a b k a n ol e h myeloma k i d ney, a mi l oi d os i s , p i e l on e f r i t i s ,
J Peny Dalam, Volume 11 Nomor 3 September 2010

renal tubuler as i d os i s , h i p e r k a l s e mi a , h i p e r u r i s e mi a , s i n d r oma h i p e r v i s k os i t a s ,d a ni n l t r a s is e lp l a s ma .11 P a d ak a s u si n it e l a hd i t e mu k a n n y ag a n g g u a nf u n g s i g i n j a l . Ad a n y a a n e mi a , g a n g g u a n f u n g s ig i n j a l , wa l a u p u nb e l u m d i t e mu k a n n y ak e l u h a nn y e r it u l a n g p e n d e r i t at e r s e b u td a p a td i c u r i g a i me n d e r i t aj u g a mi e l omamu l t i p e l . P e me r i k s a a n e l e k t r of or e s i s p r ot e i n d a r a h , s u ms u m t u l a n gd a nr a d i ol og i ka ma tp e n t i n gu n t u k me n e g a k k a nd i a g n os i s mi e l oma mu l t i p e l . Ke l a i n a n d a l a ms u ms u mt u l a n gb i a s a n y at e r s e b a r d i f u s , wa l a u p u n k a d a n g k a d a n g p e n y e b a r a n n y ab e r s i f a tl ok a ld e n g a n d a e r a hn or ma l d i a n t a r a n y a ,s e lp l a s mad a p a t me n c a p a i l e b i hd a r i30 %. P a d ak a s u si n is e lp l a s ma s u ms u m t u l a n gs e b a n y a k12%. Ke l a i n a nr a d i ol og i kt u l a n gu mu mn y ab e r s i f a t l e s il i t i k ( punc h ed out les i ons ) , wa l a u p u n d a p a t os t e op or ot i ka t a ua d a n y af r a k t u rp a t ol og i s .P a d ak a s u s i n it i d a kd i t e mu k a na d a n y ag a mb a r a n os t e ol i t i kp a d a p e me r i k s a a nbone s urv ey. M u n g k i nk a r e n at i d a ka d a n y a k e l a i n a np a d at u l a n g t u l a n gi n is e h i n g g ap e n d e r i t a t i d a kme n g e l u hn y e r i n y e r i p a d at u l a n g n y a . Be r d a s a r k a n k r i t e r i a d a r i Wi n t r ob e , ma k a p a d ak a s u si n id i t e g a k k a n mi e l oma mu l t i p e l . Ka r e n a d i j u mp a i 1a p os i t i fd a n 2a p os i t i f . Kr i t e r i ad e r a j a t 13,19 mi e l omamu l t i p e l d i p a k a i k r i t e r i aDu r i ed a nS a l mon P a d ak a s u si n i me me n u h i d e r a j a t I I IB, k a r e n aa d a n y a Hbk u r a n gd a r i 8,5 g / d l ,d a nk r e a t i n i nd i a t a s2 mg / d l . P a d ap e me r i k s a a ne l e k t r of or e s i sp r ot e i nd a r a h d i d a p a t k a ns pi k e p a d af r a k s ig a mma g l ob u l i n( M s pi k e ) . Ad a n y a Ms pi k e i n i me r u p a k a ns a l a hs a t u b u k t ia d a n y ap r od u k s ip a r a p r ot e i n( p r ot e i n M )y a n g me n i n g k a tol e hs e lp l a s mag a n a s .P a d ak a s u si n ih a l t e r s e b u ts e s u a id e n g a na d a n y ap e n i n g k a t a nI g G 30 11 mg / d l( 80 0 17 0 0 mg / d l )a t a u I g A 553 mg / d l( 85 4 50mg / d l ) .J u g ap a d ap e me r i k s a a nh a p u s a nd a r a ht e p i t i d a kd i t e mu k a nb e n t u k rouleaux . Ad a n y ab e n t u k rouleaux me n g i s y a r a t k a nh i p e r g a mma g l ob u l i n e mi a ( b a i k mon ok l on a lp a d a mi e l oma mu l t i p e l ma u p u n 10 ,19 p ol i k l on a l ) . P e me r i k s a a n p r ot e i n Be n c e J on e s d a l a m u r i n ed i l a k u k a n me l a l u i me t od ep e ma n a s a n ,
S e or a n gP e n d e r i t ad e n g a nLe u k e mi aM i e l oi dKr on i kd a nM i e l omaM u l t i p e l Ketut Sueg a

e l e k t e r of or e s i sd a ni mu n oe l e k t r of or e s i s u r i n ey a n g d i k on s e n t r a s i k a n . P e me r i k s a a nu r i n ed e n g a n me t od e p e ma n a s a n b u k a n l a h s u a t u me t od e y a n g d a p a t d i p e r c a y au n t u kme n d e t e k s i r a n t a i r i n g a nd a l a mu r i n e . De n g a n me t od ei n ih a n y ad a p a tme n d e t e k s ip r ot e i n Be n c eJ on e sp a d ak i r a k i r a 50 % p e n d e r i t a . De n g a n me t od ee l e k t r of or e s i s ,p r ot e i nBe n c eJ on e sd i t e mu k a n p a d ah a mp i rs e mu ap e n d e r i t at a n p ap a r a p r ot e i nd a l a m 20 s e r u m. P a d ak a s u si n id e n g a nd i t e mu k a n n y a M s pi k e p a d ae l e k t r of or e s i sp r ot e i nd a r a hn a mu nt i d a k d i t e mu k a np r ot e i nBe n c eJ on e sd a l a mu r i n e . Da r iu r a i a nt e r s e b u td i a t a s p a d ak a s u si n i d i d i a g n os i sd e n g a n l e u k e mi a mi e l oi d k r on i k f a s e k r on i kd a nj u g ad e n g a n me i l oma mu l t i p l ed e r a j a tI I I Bd a p a td i t e g a k k a n . Di a g n os ek a s u si n ime n j a d is u l i t , a p a k a hk a s u si n i t e r d a p a t d u ap e n y a k i t y a n gb e r s a ma a n a t a u k a hs a l a hs a t ud a r i p e n y a k i t i n i me r u p a k a nt u r u n a n d a r i p e n y a k i t y a n gl a i n n y a . Da l a ml i t e r a t u ry a n gl a ma s e r i n gd i j e l a s k a nh u b u n g a nmi e l omad e n g a nl e u k e mi a a k u t( b i a s a n y a mi e l omon os i t i k ) . Ka s u s k a s u ss e p e r t i i n i d i j e l a s k a nd e n g a nb a i kol e h Ros n e r d a nGr a u n wa l d , y a n g me n e mu k a n4 6k a s u sd a r il i t e r a t u rd a n 12 k a s u s t a mb a h a ny a n gd i l a p or k a n n y a s e n d i r i .Me s k i p u nma r e k a me n e k a n k a n a t a u me n c u r i g a ip e r a n a n me l p h a l a n d a l a m me n g i n d u k s it e r j a d i n y al e u k e mi aa k u t ,n a mu n d a r ik a s u s k a s u s y a n gd i t e mu k a nt e r s e b u t , t e r d a p a t 10 k a s u s mi e l oma d a n2 k a s u s ma k r og l ob u l i n e mi a y a n gd i t e mu k a ns e c a r ab e r s a ma a nd e n g a nl e u k e mi a a k u t( s e c a r as i mu l t a n ) , d a np a d as a t uk a s u sl a i n n y a t e r j a d il e u k e mi aa k u tp a d as e or a n gp a s i e nd e n g a n ma k r og l ob u l i n e mi ay a n gt i d a k me n d a p a tr a d i ot e r a p i ma u p u nob a t s i t ot ok s i k . P a d ab e b e r a p ap a s i e nd e n g a n mi e l oma y a n g b e r k e mb a n g me n j a d il e u k e mi as e t e l a hk e mot e r a p i , t e l a hd i ob s e r v a s ia d a n y af a s e mi e l od i s p l a s t i ky a n g 21 j e l a s . Mu l et al. me l a p or k a nl i ma p a s i e ny a n g s e c a r as i mu l t a n d i d i a g n os i sd e n g a n mi e l oma d a n M DS ( 3 RAEB, 1 RAEBt , 1 RARS ) .P a d at i g ak a s u s M DS me n g a l a mi t r a n s f or ma s i me n j a d iAM L, y a n g ma n ad u ad i a n t a r a n y at a n p ai n t e r v e n s ik e mot e r a p i . Ke mu d i a n Coop l e s t on e me l a p or k a n 20 k a s u sa t a u 187

p a s i e nd e n g a n M DS b e r s a ma a nd e n g a nk e g a n a s a n l i mf oi dd a ns e lp l a s ma .P a d ap a s i e ny a n gd i t e mu k a n d e n g a n n e op l a s ma l i mp oi d , 8 k a s u s d i d i a g n os i s s e b a g a i mon ok l on a l g a mmop a t i ,3k a s u sd e n g a nCLL, 2 k a s u sd e n g a nf oli c ular lymph oma, 1 k a s u sd e n g a n P l a s mos i t i k Li mf oma ,d a n2 k a s u spleomorcT -Cell lymph oma. Da r i 18 k a s u st u mor BCe l l , 14d i a n t a r a n y a d i d a p a t k a np a r a p r ot e i np a d as e r u md a ns a l a hs a t u n y a 22 a d a l a hd e n g a nt u mors e lp l a s ma .T a n a k aet al. j u g a me l a p or k a na d a4k a s u sd i ma n ak e j a d i a nLM K t e r j a d i b e r s a ma s a ma d e n g a n M M . Koe k s i s t e n s ia n t a r a a b n or ma l i t a smi e l oi dd a nl i mf oi dme n u n j u k k a na d a n y a k e l a i n a np a d as u mb e ry a n gs a ma . Be b e r a p ak on d i s i a n t a r al a i na d a n y ad e s i e n s ii mu na k i b a tM M a k a n me mi c ut i mb u l n y aLM K, a k a nt e t a p i h a l i n i s a n g a t k e c i l k e mu n g k i n a n n y a .P e n j e l a s a ny a n gp a l i n gb a i k ,d i d u g a b a h wa k e d u ak e l a i n a ni n ib e r a s a ld a r is e lp r e k u r s or y a mg ma mp ub e r d i f e r e n s i a s ime n j a d is e ll i mf oi dd a n mi e l oi d .S e h i n g g ad i h i p ot e s i s k a nb a h was e lp r e k u r s or y a n g me n g a l a mik e l a i n a nt e r s e b u ta k a n me n u r u n k a n b a i ks e l l e u k e mi kma u p u ns e l mi e l oma .P a d ak a s u si n i k e a d a a n LM K k e mu n g k i n a nk oi n s i d e nd e n g a n MM. F a k t orp e n y e b a by a n gd i c u r i g a id a l a ml i t e r a t u r ,p a d a p e n d e r i t ai n ib e l u mk a mid a p a t k a na d a n y ap e mb e r i a n k e mot e r a p i d a nr a d i ot e r a p i s e b e l u mn y a . T e r a p iu n t u k LM K p a d af a s ek r on i ka d a l a h k e mot e r a p i , i n t e r f e r on a l p h a , t r a n p l a n t a s is u ms u m t u l a n g . Ke mot e r a p iy a n gd a p a td i b e r i k a n Bu s u l p h a n d os i s0 ,1 mg / k g / h a r i p e r or a l a t a uh i d r ok s i u r e ad e n g a n d os i s0 ,5 3 g r a ms e c a r ak on t i n y ud e n g a nt i t r a s i d os i s . I n t e r f e r on a l p h ad os i s5 10 j u t au n i t / h a r id i b e r i k a n s e l a ma 5 h a r id a l a ms e mi n g g u .T r a n p l a n t a s is u ms u m t u l a n ga l og e n i ka d a l a h me r u p a k a n mod a l i t a st e r a p i y a n gd a p a tme mb e r i k a nk e s e mb u h a n .P a d ap e n d e r i t a i n id i b e r i k a nh i d r ok s iu r e a( h y d r e a )2 X 50 0 mg d a n p e n g ob a t a ni n ik e mu d i a nd i h e n t i k a ns e t e l a h 4h a r i k a r e n aW BC t u r u nme n j a d i 8,3 g / d l . T e r a p iu n t u k me i l oma mu l t i p e lt e r d i r id a r i k e mot e r a p i , r a d i ot e r a p i , t e r a p is u p or t i f . Ke mot e r a p i u n t u kr e g i me ns t a n d a ra d a l a h Me l p h a l a n 6 9 mg /

m2/ h a r i , d i b e r i k a n or a ls e l a ma 4 7 h a r i . P r e d n i s on 6 0 10 0 mg / h a r ip e r or a ls e l a ma 4 7 h a r i . S i k l u s d a p a td i u l a n gt i a p 4 mi n g g ud i b e r i k a n 6 12 s i k l u s . Ra d i ot e r a p id i b e r i k a nu n t u k me n g u r a n g in y e r ih e b a t p a d at u l a n gb e l a k a n g .T e r a p i s u p or t i fu n t u kme n g a t a s i u r e mi a ,h i p e r k a l s e mi aa k u t ,p a r a p l e g i a ,a n e mi ab e r a t 13 d a n i n f e k s i . P a d a p e n d e r i t a i n it i d a k d i b e r i k a n k e mot e r a p iu n t u k me i l oma mu l t i p e l ,h a n y ad i b e r i k a n t e r a p i s u p or t i f . RI NGKAS AN Di l a p or k a n s e b u a hk a s u sj a r a n g ,p a d as e or a n g wa n i t a ,4 2t a h u nd e n g a nk e l u h a ns i n d r om a n e mi ad a n d i s e r t a ib e n j ol a np a d ap e r u tk i r ia t a ss e j a k 6 mi n g g u y a n gs e b e l u m M RS . P a d ap e me r i k s a a nd a r a ht e p i d i d a p a t k a ng a mb a r a nl e u k e mi a mi e l oi dk r on i k , p a d a b i op s is u ms u mt u l a n gd i d a p a t k a ng a mb a r a nl e u k e mi a mi e l i od k r on i kd e n g a np l a s ma s i t os i s . P e me r i k s a a n k l i n i sd a nl a b or a t or i u m me n d u k u n gk ea r a hl e u k e mi a me i l oi dk r on i kd a n mi e l oma mu l t i p e l . Di a g n os i sd a n t e r a p ime n j a d is u l i ta p a k a hp a d ak a s u si n ime ma n g t e r j a d il e u k e mi a me i l oi dk r on i kd a n me i l oi d mu l t i p e l p a d as a t up a s i e na t a ua p a k a h me r u p a k a nk omp l i k a s i d a r i s a l a hs a t up e n y a k i t i n i . DAF T AR RUJ UKAN 1. Ba k t aI M, S u e g aK, Dh a r ma y u d aTG. Le u k e mi a mi e l oi dk r on i k( c h r on i cmy e l oi dl e u k e mi a ) .I n : Ba k t aI M, S u e g a K, Dh a r ma y u d a TG, e d i t or s . P e d oma nd i a g n os i s d a nt e r a p i h e ma t ol og i . Di v i s i He ma t ol og id a n On k ol og i Me d i k La b / S MF P e n y a k i t Da l a m F K UNUD/ RS UP De n p a s a r : 20 0 0 .p .24 6 . At h e n sJ W. Ch r on i cmy e l i od l e u k e mi a .I n :Le e GR, Bi t h e l lTC, F oe r s t e rJ , At h e n sJ W, Lu k e n s t J N, e d i t or s . Wi n t r ob e sCl i n i c a l He ma t ol og y . 9h e d .P h i l a d e l p h i a :Le a& F e b i g e r ;19 9 3.p .19 6 9 9 0 .

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Hu g h e s TP , Gol d ma n J M . Cr on i c my e l i od l e u k e mi a .I n :Hof f ma n R, Be n z EJ ,S h a t t i lS J , F r u i e B, Coh e n HJ , S i l b e r s t e i n LE, e d i t or s . n d He ma t ol og y :b a s i cp r i n c i p l e sa n dp r a c t i c e . 2 e d . Ne w Yor k : Ch u r c h i l l Li v i n g s t on e ; 19 9 5. p .114 26 0 . Mc La u g h l i n CJ . Cr on i cl e u k e mi aI n :Ca me r on s t RB, e d i t or . P r a c t i c a l on c ol og y . 1 e d . Los An g e l e s : Ap l e t on& La n g e ; 19 9 4 .p .529 36 . De i s s e r ot h AB, An d r e e f f M , Ch a mp l i n R, Ke a t i n g MJ , Ka n t a r j i n H, Kh ou r iI F , e ta l . Ch r on i cl e u k e mi a s . I n :Ca n c e rp r i n c i p l e sa n d p r a c t i c eofon c ol og y .4 t he d .P h i l a d e l p h i a :J .B. Li p p i n c ot t Comp a n y ; 19 9 3.p .19 6 583. F a d e r iS , T a l p a z M , Es t r ov Z, O Br e i nS , Ku r z r oc k R, Ka n t a r j i n HM . Th eb i ol og y of c h r on i c my e l oi d l e u k e mi a . N En g l J Me d 19 9 9 ; 34 1: 16 4 17 2. We t z l e rM , Bl oome l d CD. Ac u t ea n dc h r on i c my e l oi dl e u k e mi a .I n :F a u c i AS , Br a u n wa l d E, I s s e l b a c h e rKJ , Wi l s on J D, M a r t i nJ B, Ka s p e r DL, e t a l ,e d i t or s . Ha r r i s on sp r i n c i p l eof i n t e r n a l t h me d i c i n e . 14 e d . Ne w Yor k :Mc Gr a wHi l l ; 19 9 8.p .6 84 9 4 . Le Be a u M , La r s on RA. Cy t og e n e t i ca n d Ne op l a s i a .I n :Hof f ma n R, Be n z EJ ,S h a t t i lS J , F u r i eB, Coh e nHJ ,S i l b e r s t e i nLE, e t a l ,e d i t or s . n d He ma t ol og y Ba s i cP r i n c i p l e sa n dP r a c t i c e .2 e d .T ok y o:Ch u r c h i l lLi v i n g s t on e ;19 9 5.p .87 89 15. Gol d ma n J M . Ch r on i c my e l oi d l e u k e mi a . I n : Gol d ma nJ M, e d i t or . Ba i l l i e r e sc l i n i c a l h a e ma t ol og y .v ol10 .T ok y o:Ba i l l i e r e st i n d a l l WBS a u n d e r sComp a n y ; 19 9 7 . S a l ma nS E, Ca a s s a d yJ R. P l a s mac e l l n e op l a s ma . I n : De v i t a VT , He l l ma nS , Ros e n b e r gS A, e d i t or s . h Ca n c e r p r i n c i p l e s& p r a c t i c e of on c ol og y . 5t e d . P h i l a d e l p h i a : Li p p i n c ot Ra v e n ; 19 9 7 .p .234 4 7 9 . F oe r s t e r J . P l a s ma c e l ld y s c r a s i a g e n e r a l

12. 13.

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c on s i d e r a t i on sI n :Le e GR, F oe r s t e rJ , Lu k e n J N, P a r a k e v a sF , Gr e e r J P , Rod g e r sGM , e d i t or s . t h Wi n t r ob e sc l i n i c a lh a e ma t ol og y.Vol2. 10 e d . Ba l t i mor e : Wi l l i a ms& W i l k i n s ; 19 9 9 .p .26 1253. Ba t a i l l e R, Hor ou s s e a uJ L. M u l t i p l e my e l oma . N En g l JM e d19 9 7 ; 336 : 16 57 6 4 . Ba k t aI M, S u e g aK, Dh a r ma y u d aTJ . Mi e l oma mu l t i p e l ( Mu l t i p l e My e l oma ) I n : Ba k t a I M,S u e g a K, Dh a r ma y u d aTJ ,e d i t or s .P e d oma nd i a g n os i s d a nt e r a p ih e ma t ol og i . Di v i s iHe ma t ol og id a n On k ol og i Me d i k La b / S MF P e n y a k i t Da l a mF K UNUD/ RS UPDe n p a s a r : 20 0 0 .p .4 550 . Lon g o DL. P l a s ma c e l ld i s or d e r s . I n :F a u c i AS , Br a u n wa l d E, I s s e b a c h e rKJ , Wi l s on J D, Ma r t i nJ B, Ka s p e rDL, e t a l ,e d i t or s . Ha r r i s on s t h p r i n c i p l e s of i n t e r n a lme d i c i n e . 14 e d . Ne w Yor k : Mc Gr a wHi l l ; 19 9 8.p .7 1218. F a c h r u d d i n A, T a u q G. Ga mb a r a n mi e l oma mu l t i p e ld ib e b e r a p ar u ma hs a k i tp e n d i d i k a n Uj u n gP a n d a n g s e l a ma 3 t a h u n . Ac t aM e d i c a I n d on e s i a n a19 9 6 ; 28( s u p p l 2) : 39 7 4 0 3. S mi t hLS .P l a s mac e l lmy e l oma .I n : We i s sGR, e d i t or . Cl i n i c a lon c ol og y . US A:P r e n t i c e Ha l l I n t e r n a t i on a l ; 19 9 3.p .257 6 2. Ba i n BJ , Cl a r k DM , La mp e rI A. M u l t i p l e my e l oma a n d ot h e rp l a s ma c e l ld y s c r a s i a s .I n : Ba i n BJ , Cl a r k DM , La mp e rI A, e d i t or s . Bon e ma r r ow p a t ol og y . Ox f or d :Bl a c k we l lS c i e n t i c P u b l i c a t i on s ; 19 9 2.p .18820 3. Ky l e RA. M u l t i p l e my e l oma a n d ot h e rp l a s ma c e l ld i s or d e r s .I n :Hof f ma n R, Be n zEJ ,S h a t t i l S J ,F u r i eB, Coh e n HJ ,S i l b e r s t e i n LE, e d i t or s . He ma t ol og yb a s i cp r i n c i p l e sa n dp r a c t i c e . 2nd e d . Ne w Yor k : Ch u r c h i l l Li v i n g s t on e ; 19 9 5.p .1354 7 1. F oe r s t e rJ . Mu l t i p l e my e l oma . I n : Le e GR, Bi t h e l lTC, F oe r s t e rJ , At h e n sJ W, Lu k e n sJ N, t h e d i t or s . Wi n t r ob e sc l i n i c a lh e ma t ol og y .9 e d . P h i l a d e l p h i a : Le a& F e b i g e r ; 19 9 3.p .2219 4 0 .

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20 .

21.

Al b a rNA, S a l on d e rH. M i e l omamu l t i p l es u a t u k a s u sn ons e k r e t or i ( l a p or a nk a s u s ) . Ac t aM e d i c a I n d on e s i a n a 19 9 5; 27 ( s u p p l 1) : 26 27 . Ha mb l i n T . I mmu n ol og i c a b n or ma l i t i e s i n my e l od y s p l a s t i c s y n d r ome s . He ma t ol og y / On c ol og yCl i n i cOfNor t hAme r i c a19 9 2; 6 : 37 .

22.

T a n a k a M , Ki mu r a R, M a t s u t a n i A, Za i t s u K, Ok a Y, Oi z u miK. Coe x i s t e n c e ofc h r on i c my e l og e n ou sl e u k e mi aa n d mu l t i p l e my e l oma . Ac t aHa e ma t o 19 9 8; 9 9 : 2213.

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J Peny Dalam, Volume 11 Nomor 3 September 2010