Multiple Myeloma Flashcards
disease progression
MGUS->smouldering myeloma->intramedullary myeloma->extramedullary myeloma->myeloma cell line
signs and symptoms -2
- CRAB - calcium >11.5, renal dysfunction (SCr >2), anemia (hgb), bone
- presents as HA, blurred vision, epistaxis, oral bleeding, AMS, confusion->start plasmapheresis to tx
diagnosis - MGUS -2
m-protein <10%
no related orgain impairment
diagnosis - asymptomatic myeloma -3
m-protein >30g/L
bone marrow plasma cells >10%
no related orgain impairment
diagnosis - symptomatic myeloma -2
m-protein 10%
orgain impairment = CRAB
staging - ISS -3
stage I: B2M 3.5 =OS 62 mo
stage II: neither I or III =OS 44 mo
stage II: B2M >5.5 =OS 29 mo
staging - mSMART - high risk -3
FISH del 17p, t14;16, t14;20
staging - mSMART - intermediate risk -3
FISH t4;14, cytogenetic del 13q OR hypoploidy
staging - mSMART - standard risk -3
hyperploidy, FISH t11;14 OR t6;14
response criteria - CR -3
- serum and urine immunofixation (-)
- no soft tissu plasmacytomas
- <5% plasma cells in BMBx
- *this will not be on test
how do you decide if autoSCT eligible? -3
age, PS, co-morbidity
if potential autoSCT candidate should you use melphalan? -1
Don’t use alkylator (melphalan) based chemo in induction. melphalan at high doses is toxic to stem cells
induction tx - non-HSCT - preferred regimens -5
bortezomib-dex lenalidomide-low dose dex melphalan-pred-bortezomid melphalan-pred-thalidomide melphalan-pred-lenalidomide
induction tx - non-HSCT -MP vs MPT
OS 64 vs 84% @3yr
CR 7 vs 28%
PFS 27 vs 54% @2yr
induction tx - non-HSCT -MP vs b-MP
OS not reported
CR 4 vs 30%
induction tx - non-HSCT -are 4 drugs better than 3 drugs? VMP vs VMPT
NO.
OS 89 vs 87% @3yr
CR 24 vs 38%
induction tx - HSCT candidates- concepts of dex, L, and T combo’s -
- low dose dex-L >high dose dex-L: CR+VGPR 50 vs 40%
- dex-T > dex alone: CR+VGPR 44 vs 16%
- VAD (vinc-doxo-dex) used previously->CR 28%, replaced by DvD (peg doxo-vinc-dex)
lenalidomide and autoSCT -2
lenalidomide->cummalitive tox to bone marrow, collect cells prior to 4-6 cycles of tx
induction tx - HSCT candidates- preferred regimens -9
bortezomib-dex bortezomib-dex-cyclophos bortezomib-doxo-dex bortezomib-lenalid-dex bortezomib-thalid-dex lenalid-dex OPTIONAL DvD (liposomal doxo-vinc-dex) thalid-dex dex
What is the effect of induction regmen on OS post HSCT?
higher CR in induction = higher CR post HSCT; choose induction regimen that obtains highest CR in induction as has implications post tx
DVT risk - T, L, dex -
T, dex D1-4,9-12,17-20: 17%
L, dex D1-4,9-12,17-20: 26%
L, weekly dex: 12%
thromboembolism px -T, L, dex -3
- first 6 mo: ASA 6.4%, warf 8.2%, lmwh 5%
- entire f/u: ASA 8.6%, warf 10%, lmwh 7.8%
- NO CLEAR BEST CHOICE
nuances of HCT -4
-2x10^6 CD34+/kg (watch melphalan, lenalidomide)
-inc harvest with cyclophos+gcsf
chemo-mobilization with cyclophos MAY overcome lenalid TOX (use if >4cycles L)
-if >65y->red cyclophos OR plerixafor
HCT priniciples ???
benefit to 2nd autoSCT if less than VGPR to 1st
lack of convincing data to support using autoSCT -> reduced intensity chemo vs tandem autoSCT
do NOT use alloSCT as 1st line
