Multiple Myeloma

Question 1

The median age at diagnosis of multiple myeloma is:
A. 39
B. 49
C. 59
D. 69
E. 79

Answer 1

D. 69

Question 2

True or False: MM affects men slightly more than women, and African American have twice the incidence and mortality as Caucasians.

Answer 2

True

Question 3

Which type of cells does multiple myeloma affect?

Answer 3

Terminally differentiated B cells (plasma cells)

Question 4

Interleukin-\_\_ (IL-\_\_) is a growth factor that promotes the survival of the Multiple Myeloma cell.
A. 2
B. 3
C. 4
D. 5
E. 6

Answer 4

E. 6

Question 5

Multiple myeloma cells secrete IL-__, IL-___, and the soluble IL-6 receptor that activate osteoclasts in the vicinity of the myeloma cell to cause bone resorption

Answer 5

IL-1 and IL-6

Question 6

True or False: Patients with Multiple Myeloma present with an increase in blood vessel density, with elevated basic fibroblast growth factor (bFGF) and vascular endothelial growth factor (VEGF).

Answer 6

True

Question 7

In the model of disease progression for multiple myeloma, which of the following is the correct order?
A. Multiple myeloma, smoldering myeloma, normal plasma cell, monoclonal gammopathy of undetermined significance (MGUS)
B. Normal plasma cell, smoldering myeloma, MGUS, multiple myeloma
C. Normal plasma cell, MGUS, multiple myeloma, smoldering myeloma
D. Normal plasma cell, MGUS, smoldering myeloma, multiple myeloma

Answer 7

D. Normal plasma cell, MGUS, smoldering myeloma, multiple myeloma

Question 8

True or False: Early initiation of chemotherapy in the MGUS and smoldering myeloma stages has been shown to improve outcomes.

Answer 8

False! It did not improve outcomes, so observe patient and begin treatment when symptomatic.

Question 9

True or False: With multiple myeloma, there is increased bone resorption.

Answer 9

True

Question 10

The easy way to remember how multiple myeloma patients present is by using the acronym CRAB. What does each letter stand for?

Answer 10

C = Increased calcium above 11.5
R = Renal function decrease (Scr > 2)
A = Anemia (hemoglobin < 10 or 2 g below lower limit of normal)
B = Lytic bone lesions

Question 11

________ are plasma cell tumors that arise outside the bone marrow in multiple myeloma.

Answer 11

Extramedullary plasmacytomas (EMPs)

Question 12

_______ is the most common site that extramedullary plasmacytomas (EMPs) in multiple myeloma occur, but may present in any organ.

Answer 12

Upper Respiratory Tract

Question 13

Of the initial workup for multiple myeloma, all of the following are extremely important and should be focused on EXCEPT:
A. Skeletal survey
B. Bone marrow aspirate/biopsy
C. Serum protein electrophoresis (SPEP)
D. 24-hr urine for urine protein electrophoresis (UPEP)

Answer 13

A. Skeletal survey (this is also a test that can be done, but she said to focus on the other 3).

Question 14

Which of the following types of multiple myeloma is the most common?
A. Heavy chain (IgG, IgA, IgM)
B. Light chain (Kappa or lambda)
C. Non-secretory

Answer 14

A. Heavy chain (IgG, IgA, IgM)

Question 15

Which of the following types of multiple myeloma has no detectable immunoglobulin?
A. Heavy chain (IgG, IgA, IgM)
B. Light chain (Kappa or lambda)
C. Non-secretory

Answer 15

C. Non-secretory

Question 16

Patients with which of the following types of multiple myeloma are at higher risk for hyperviscosity?
A. Heavy chain (IgG, IgA, IgM)
B. Light chain (Kappa or lambda)
C. Non-secretory

Answer 16

B. Light chain (Kappa or lambda)

Question 17

~ 20% of patients with MM produce light chains only, which are incomplete immunoglobulins. Light chain proteins can cause ______ proteinuria, which is when they are secreted in the urine and cause kidney damage as well.

Answer 17

Bence jones

Question 18

The serum protein electrophoresis (SPEP) is used in diagnosing multiple myeloma patients by assessing for a sharp peak of the gamma region called the ______.

Answer 18

M Spike

Question 19

True or False: Smoldering myeloma patients are often symptomatic, which is why we must start chemotherapy at that stage.

Answer 19

False!! Smoldering myeloma is asymptomatic so only observe patients until they become symptomatic with active myeloma.

Question 20

The M protein level for MGUS stage should be < __ g/dL

Answer 20

3

Question 21

Describe how each stage of multiple myeloma presents in terms of level of M protein, % of plasma cells, and symptomatic or asymptomatic stage.

Answer 21

MGUS = Asymptomatic, < 10% PC, M-protein < 3 g/dL
Smoldering myeloma = Asymptomatic, M-protein ≥ 3 g/dL, and ≥ 10% PC
Active Multiple Myeloma = Symptomatic (CRAB) + M spike + ≥ 10% PC

Question 22

True or False: Multiple myeloma is NOT curable.

Answer 22

True

Question 23

True or False: Lenalidomide treatment may need to be adjusted for renal dysfunction.

Answer 23

True

Question 24

With lenalidomide treatment for multiple myeloma, a decrease in CD34+ cells collected after prolonged lenalidomide treatment has been reported. Therefore, have stem cells collectedwithin the first __ cycles of therapy, if deemed transplant-eligible

Answer 24

4

Question 25

List some of the common adverse effects of lenalidomide.

Answer 25

``` Peripheral neuropathy Neutropenia Thrombocytopenia Thromboembolic clots Fatigue ```

Question 26

True or False: Bortezomib dose has to be adjusted in patients with renal dysfunction.

Answer 26

False! It has to be adjusted in patients with hepatic dysfunction.

Question 27

Which should be used in combination therapy for multiple myeloma: low-dose dexamethasone OR high-dose dexamethasone?

Answer 27

Low-dose dexamethasone

Question 28

``` Which of the following is the WORST side effect seen with the protease inhibitor bortezomib? A. Peripheral neuropathy B. Hypotension C. Fatigue D. Myelosuppression ```

Answer 28

A. Peripheral neuropathy

Question 29

Which of the following formulations of bortezomib was shown to have lower peripheral neuropathy risk: IV OR subcutaneous

Answer 29

Subcutaneous

Question 30

List some factors that would make someone NOT a candidate for transplantation in multiple myeloma.

Answer 30

Age > 77 years old Direct bili > 2.0 ECOG 3 or 4 NYHA class 3 or 4

Question 31

_____ can cause herpes zoster reactivation. A. Proteasome inhibitors (bortezomib, carfilzomib, ixazomib) B. Anti-CD20 monoclonal antibody (Rituximab) C. Immunomodulatory agents (Thalidomide, Lenalidomide, Pomalidomide) D. All of the above

Answer 31

A. Proteasome inhibitors (bortezomib, carfilzomib, ixazomib)

Question 32

For transplant eligible multiple myeloma patients, there are 3 preferred 3-drug regimens. List them.

Answer 32

Bortezomib + lenalidomide + dexamethasone Bortezomib + doxorubicin + dexamethasone Bortezomib + cyclophosphamide + dexamethasone

Question 33

For transplant eligible multiple myeloma patients, if the patient cannot tolerate a 3-drug regimen, what is an appropriate 2 drug regimen?

Answer 33

Bortezomib + dexamethasone

Question 34

When comparing high dose vs. low dose dexamethasone in multiple myeloma patients, what were 3 common adverse effects seen more frequently in patients on high dose vs. low dose? A. DVT, infections, hepatitis B reactivation B. Infections, fatigue, hand foot syndrome C. Fatigue, leukocytosis, DVT D. DVT, infections, fatigue E. Infections, leukocytosis, DVT

Answer 34

D. DVT, infections, fatigue

Question 35

``` Which of the following class of medications used for multiple myeloma requires enrollment in REMS program? A. Alkylating agents B. Proteasome Inhibitors C. Steroids D. Immunomodulatory agents E. Monoclonal antibodies ```

Answer 35

D. Immunomodulatory agents (due to embryo-fetal toxicity observed with thalidomide after it being used as a N/V agent in pregnant woman decades ago).

Question 36

True or False: Bortezomib IV has more efficacy compared to Bortezomib SQ.

Answer 36

False! They have equal efficacy with SQ having less adverse effects.

Question 37

True or False: In multiple myeloma cells, the combination of lenalidomide and dexamethasone synergizes the inhibition of cell proliferation and the induction of apoptosis.

Answer 37

True

Question 38

_________ is now the preferred immunomodulatory agent in triple drug regimens due to improved safety profile seen in multiple studies. A. Thalidomide B. Lenalidomide C. Pomalidomide

Answer 38

B. Lenalidomide