- Multiple myeloma (MM) is a cancer that develops in plasma cells leading to excessive production of a monoclonal immunoglobulin (M protein).
- Most patients have skeletal involvement at the time of diagnosis with associated bone pain and fractures. Anemia, hypercalcemia, and renal failure may also be present. A bone marrow biopsy with 10% or more plasma cells and a M-protein spike on plasma or urine electrophoresis confirm the diagnosis.
- Most patients will require treatment after diagnosis but treatment can be deferred in patients with smoldering (asymptomatic) MM. In patients with symptomatic disease, treatment produces benefits in various measures of survival and quality of life.
- Thalidomide, lenalidomide, or bortezomib plus dexamethasone are commonly used induction regimens. They produce higher complete remission rates as compared with the classic regimen of melphalan plus prednisone and vincristine, doxorubicin, dexamethasone. The increased response is at the risk of significant grades III and IV toxicity which can include venous thromboembolism and neuropathy depending on the regimen used.
- Bortezomib is commonly used to treat relapsed MM and increasingly as initial therapy combined with dexamethasone or chemotherapy. Bortezomib activity is maintained in patients with high-risk cytogenetics.
- Lenalidomide is more potent and better tolerated than thalidomide and is becoming the most common drug used in induction regimens.
- Melphalan plus prednisone is not used in transplant candidates as part of induction but commonly used in transplant ineligible patients combined with thalidomide, lenalidomide, or bortezomib.
- Autologous hematopoietic stem cell transplantation (autoHSCT) is used after induction in patients with reasonably good performance status to maximize complete remissions and prolong survival.
- The quality of induction responses may be important, including in those receiving autoHSCT to maximize clinical benefit.
- The use of myeloablative allogeneic hematopoietic stem cell transplantation (alloHSCT) produces high early mortality, but the use of nonmyeloablative alloHSCT may offer a chance for long-term disease-free survival.
- Bisphosphonates are used to treat bone disease associated with MM, which results in decreased pain and skeletal-related events and improvement in quality of life.
- Salvage therapy for patients with relapsed or refractory MM can include any of the prior listed therapies, depending on performance status of the patient, risk category of the patient, and prior treatments used for induction.
On completion of the chapter, the reader will be able to:
- 1. Describe the malignant cell of multiple myeloma (MM)
and the methods used to diagnose the disease.
- 2. Explain the relationship between MM pathophysiology and
- 3. Differentiate between monoclonal gammopathy of undetermined
significance (MGUS), smoldering MM, and active MM as it relates
to disease-related complications and initial treatment.
- 4. Describe those newly diagnosed patients who can defer treatment
and benefit from a strategy of watchful waiting.
- 5. Describe the options for induction therapy in patients
who are and are not candidates for autologous-hematopoietic stem
cell transplantation (auto-HSCT).
- 6. Describe the role of auto-HSCT in the initial treatment
- 7. Describe potential therapies for patients with high-risk
- 8. Compare and contrast the toxicity profiles of thalidomide, ...