Multiple Myeloma and Related Disorders

Published on 04/03/2015 by admin

Filed under Hematology, Oncology and Palliative Medicine

Last modified 04/03/2015

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Chapter 104

Multiple Myeloma and Related Disorders

Summary of Key Points

Multiple Myeloma

Diagnosis

• The most common presenting symptoms are fatigue and bone pain.

• Osteolytic bone lesions are the hallmark of the disease.

• Hypercalcemia is found in one fourth of patients; the serum creatinine level is elevated in almost one half of patients.

• Diagnosis requires 10% or more clonal plasma cells in the bone marrow and/or a biopsy-proven plasmacytoma, monoclonal (M) protein in the serum and/or urine (except in patients with true nonsecretory myeloma), and evidence of end organ damage (hypercalcemia, renal insufficiency, anemia, or bone lesions) attributable to the underlying plasma cell disorder. Patients with 60% or more clonal plasma cells in the bone marrow are considered to have multiple myeloma even in the absence of end organ damage.

• M proteins can be detected by serum protein electrophoresis (SPEP) and immunofixation in 93% of patients; addition of urine protein electrophoresis (UPEP) and urine immunofixation or the serum free light chain (FLC) assay will increase sensitivity to 97% or higher.

Treatment

• Newly diagnosed patients are categorized as having standard-, intermediate-, and high-risk myeloma based on specific prognostic factors.

• Initial therapy for patients with standard-risk disease is with regimens such as lenalidomide–low-dose dexamethasone (Rd) or bortezomib-cyclophosphamide-dexamethasone (VCD). A bortezomib-containing regimen is preferred as initial therapy for patients with intermediate- and high-risk myeloma.

• After 4 months of initial therapy, patients eligible for transplantation can pursue early or delayed autologous stem cell transplantation (ASCT). If early ASCT is used, a second ASCT is considered in patients who do not achieve a very good partial response or better with the first ASCT. If transplant is delayed, patients will continue on the induction chemotherapy drugs at lower doses until plateau or progression occurs.

• Options for relapsed disease include thalidomide, lenalidomide, bortezomib, alkylating agents, anthracyclines, and corticosteroids alone or in combination.