Standard of Care

From Standard of Care

Estimated 21,700 new cases will be diagnosed in 2012, and an estimated 10,710 deaths.

Incidence about 5.6 cases per 100,000 people, and mortality rate 3.6 cases per 100,000 persons (SEER).

Second most common hematologic cancer after NHL.

Accounts for 10% of malignant hematologic neoplasms.

Incidence and mortality 2-fold among Blacks than Whites.

Age adjusted incidence in African-Americans 9.5 per 100,000 per year and 4.1 per 100,00 per year in whites.

Accounts for 1% of new cancers.

Accounts or 2% of all cancer deaths in the U.S.

Median age at diagnosis 65-70 years.

75% of men and 79% of affected women are older than 70 years.

37% of patients younger than 65 years of age.

26% are diagnosed by between ages 65 and 74 years.

37% 75 years or older at diagnosis.

If untreated, median survival for symptomatic patients is approximately 12 months.

In patients under 60 years of age median 10 year survival approximately 30% (Kumar SK et al).

Overall survival is greater than 8 years currently (2013).

There has been an increase in the incidence in patients younger than 55 years of age over the past several decades.

Male to female ratio approximately 3 to 2.

Does not occur in children.

Evolves from a monoclonal gammopathy of undetermined significance (MGUS).

Arises from premalignant proliferation of monoclonal plasma cells derived from post-germinal B cells, that undergo genetic amd microenvironmental changes leading to transformation of these cells into a malignant process.

A disorder of the terminally differentiated B lymphocytes, called plasma cells.

Plasma cells secrete monoclonal immunoglobulin, IgG in about 60%, IgA in about 20%, for light chains.

Chromosome abnormalities detected with cytogenetics or fluoresence in situ hybridization in more than 90% of cases and includes deletions, trisomies, and translocations.

At least 50% of patients with clonal plasma cell proliferation in monoclonal gammopathy of unknown significance (MGUS) translocations involving the immunoglobulin heavy chain (IgH) locus on chromosome 14q32 evolve into myeloma.

Hyperdiploidyand IgH translocations are early events in disease pathogenesis, and del(17p13) and translocations of MYC locus are late events.

Hyperdiploidy and is observed in 50-60% of patients, while monosomy is seen in 45% of cases.

Recurrent structural rearrangements are seen in the IGH gene mapped as 14q32.

Early translocations in chromosomes occur at immunoglobulin switch region on chromosome 14(q32,33), and this most commonly juxtaposed to MAF (t[14:16][q32,33:23] and MMSET on chromosome 4p16.3.

The above causes deregulation of 2 adjacent chromosomes MMSET, in all cases and FGFR3 in 30% of cases.

Abnormalities in t(4;14) and t(14;16), and loss of 17p13 confirmed poor prognosis with high dose therapy.

Hyperdiploidy associated with better outcomes to treatment, with older age at presentation, with IgGkappa protein and with more indolent forms of myeloma.

Hypodiploid subtypes are related to more aggressive disease, to younger age at presentation, and IgA lambda proteins secretion.

With light chain myeloma immunofixation electrophoresis (IFE), and quantitative serum assays for immunoglobulin free light chains (FLC) increased diagnostic sensitive for the diagnosis exists and can identify 100% of patients with this disorder.

About 2% of patients do not secrete any immunoglobulin-non-secretory multiple myeloma.

Response in patients with oligo-secretory or non-secretory myeloma may be assessed using the sensitive free light chain assay.

Exposure to ionizing radiation, benzene, solvents and occupational links such as farming associated in the etiology of myeloma.

Prognostic factors B2 microglobulin, LDH, serum albumin, CRP are less discerning compared with genetic aberrations.

Mayo Stratification of Myeloma and Risk Adapted Therapy (mSMART)use combination of metaphase cytogenetics, FISH, and plasma labeling index to separate standard risk from high risk patients (Kapoor P).

Median survival time of approximately 7 years, with 20% of patients living for more than 10 years.

With new therapies survival increased by 50% longer than patients treated with older treatments.

5-year survival rate is 30% with younger patients having improved outcomes compared to elderly.

5 year survival rate is approximately 34% (American Cancer Society).

Five-year survival rate reported by SEER results increase from 24% in 1975 to 34% in 2003 because of newer and more effective treatment options.

Poor prognosis associated with decreased serum albumin, increased beta 2 microglobulin, the presence of abnormal cytogenetics, increased interleukin 6, increased C reactive protein, high lactate dehydrogenase, extra medullary disease, renal insufficiency, high serum free light chains, abnormal kappa/lambda ratio, increased plasma cell labeling index, cytogenetic changes and the presence of circulating plasma cells.

Almost all patients have abnormal chromosomes by fluorescence in situ hybridization including translocations, deletions, and aneuploidy but with standard metaphase analysis only 18-30% have abnormal karyotypes and is explained by low proliferative rate on multiple myeloma cells needed for conventional cytogenetics.

Cytogenetic abnormalities on conventional studies indicates the presence of a high proliferative rate malignancy with poor prognosis.

Smoldering myeloma defined as an asymptomatic process with an M protein in serum of greater than 3 g per liter or greater than 10% clonal plasma cells without organ or tissue impairment or symptoms.

Patients with smoldering multiple myeloma developed symptomatic myeloma at a rate of 10% per year for the first 5 years of followup.

In smoldering myeloma the M protein must be IgG or IgA subtype and the plasma cells must be clonal.

Smoldering myeloma evaluation requires followup every 3-6 months.

Smoldering multiple myeloma risk factors for progression of disease include plasma cell mass, M protein size, percentage of bone marrow clonal plasma cells, abnormal free light chain ratio, evolutionary pattern and pattern of magnetic resonance imaging abnormalities (Blade J).

Smoldering multiple myeloma must be distinguished from monoclonal gammopathy of unknown significance, symptomatic myeloma, and primary systemic amyloidosis.

Smoldering myeloma is now known as asymptomatic multiple myeloma and represents a progression of MGUS with a greater burden of plasma cells in the bone marrow, that is greater than 10%, and a higher annual risk of transformation to multiple myeloma, 10% for the first five years with subsequent reduction.

Patiens with a free lght chain ratio of <0.125 or >8 have an increased progression to symptomatic myeloma.

Smoldering will evolve into symptomatic disease in a range between 2 and 3 years.

In smoldering the risk of progression is increased in the presence of light chain proteinuria of greater than 50 mg per 24 hours and findings of IgA monoclonal heavy chains.

The presence of asymptomatic lytic lesions implies a poor prognosis with the median time to progression for smoldering myeloma of less than one year, that explains why these lesions are excluded from patients with this diagnosis.

At the time of diagnosis two thirds of patients have bone pain, and are likely to subsequently sustain pathological fractures, particularly of the skull, spine and ribs.

70-80% of patients will have bone involvement, with risk for skeletal related events.

Extended survival associated with increased risk of skilled related events.

Multiple myeloma bone lesions usually do not heal, and fractures can result in permanent disability and may require surgery or joint replacement.

In patients with MM untreated for osteolytic lesions the median time to first skeletal related event is approximately 9 months (Berenson JR).

The risk of fracture is higher than for cancer of the breast, prostate, or lung.

Pathologic fractures associated with 20-44% increased risk for death..

Time to progressive disease for a low risk group with smoldering myeloma is 3-8 years while for high risk patients they will evolve into symptomatic disease within one to 2 years after diagnosis.

Treatment for smoldering myeloma is observation.

Majory of patients with high risk smoldering myeloma patients evolve into myeloma that requires treatment.

Active and symptomatic disease requires one or more of the following: calcium elevation of greater than 11.5 g per deciliter, renal insufficiency with creatinine of 2 mg per deciliter or greater, anemia with hemoglobin of less than 10 g, and lytic or osteopenia bone disease.

Renal impairment occurs in 20 to 40% of newly diagnosed patients.

The presence of renal impairment is associated with shorter overall survival and increased early death rates compared to patients with normal kidney function.

The median survival of patients with renal involvement is less than two years.

The presence of renal impairment with a creatinine of 2 mg per deciliter or greater is defined as having substage B for stages, I,II, and III Durie-Salmon multiple myeloma staging system.

Patients with creatinine of 2 mg per deciliter or greater are categorized as stage III in ISS staging system, as 82% of such patients have a Beta2-microglobulin value of greater than 5.5 mg per liter.

Patients with hyperdiploid karyotypes have good prognosis with chemotherapy induction and high dose chemotherapy with bone marrow transplantation.

Patients with the (4:14) or 17p gene deletion have poor prognosis with most conventional therapy.

Chromosome 13 abnormalities associated with unfavorable outcomes after conventional and stem cell transplant treatments.

Aneuploidy occurs frequently with monosomies including chromosomes 13, 14, 16 and 22 more frequent than trisomies of 3, 5, 7, 9, 11, 15, 19 and 21.

Hyperdiploid changes are associated with multiple trisomies and a low incidence of IgH translocations.

Nonhyperdiploid lesions have a high prevalence of IgH translocations.

In IgH translocations associated with 5 recurrent chromosomal partners including 11q13 (cyclin D1), 6p21 (cyclin D3), 4p16 (fibroblast growth factor receptor 3), 16q23 and 20q11.

CD138 immunostains utilized for quantification of myeloma.

Cross talk of myeloma cells with osteoblasts, osteoclasts, stromal cells, and T cells occur through cell to cell contact, or by chemokine, of cytokine adhesion molecule and metalloprotease over production. But

Most common symptoms on presentation are fatigue, bone pain and recurrent infections.

Cortical bone and medullary compartments are linked anatomically, but are functionally distinct.

Bone findings result of either inhibition of osteoblastic activity and or activation of osteoclast activity.

Cortical involvement results in endosteal scalloping, with invasion of the periosteum and at times extra osseous extension.

Bone lesions most commonly involve the vertebra, ribs, skull, pelvic bones and femur in descending order.

Distal bone involvement is less common than proximal bone involvement.

Diffuse osteopenia without focal bone lesions and sclerotic bone lesions may occur, uncommonly.

Plasmacytomas mostly arise as direct extension from skeletal tumors when they disrupt cortical bone.

Susceptibility to infection is due in part to a decreases in the production of normal immunoglobulins, defects in the complement system and other processes that occur with myeloma.

Predisposition to infection with encapsulated bacteria, such as Streptococcus pneumoniae, and Haemophilus influenzae.

Increased susceptibility to infection also related to immunosuppressive agents utilized to treat the disease.

Cumulative immunosuppression of the disease and its treatments result in emergence of infections, such as cytomegalovirus, varicella zoster, Aspergillus spp. and Fusarium spp.

In recent ears changes in the spectrum of infections, with an increased risk of fungal infections, such as aspergillosis and fusariosis.

Probable change of infections related to progressively aggressive treatments.

Invasive aspergillosis after hematopoietic stem cell transplant (HSCT) increasingly common and the risk is 4.5 times higher than patients with chronic myelogenous leukemia in chronic phase (Marr KA).

Anemia present in about 70% of patients at the time of diagnosis.

Serum creatinine is elevated in almost half of patients.

Conventional x-ray studies reveal skeletal abnormalities in approximately 80% of patients and include fractures, lytic lesions and osteoporosis.

Bone scans and serum alkaline phosphatase levels are normal due to the absence of osteoblast activity.

The presence and extent of bone marrow and extramedullary involvement are important factors influencing prognosis and clinical management.

Radiographs are usually obtained for staging purposes, but are limited for evaluating early disease.

MRI is more sensitive than radiographs in detecting bone marrow involvement however, such studies limited to the spine and pelvis would cause understaging in 10% of patients and will be normal in up to 20% of patients with stage I disease with only bone marrow involvement.

MRI can identify up to 30% of patients with bone lesions not seem on metastatic bone survey, and is a recommended test in symptomatic patients with normal bone x-rays. A

FDG PET is able to detect bone marrow involvement in patients with multiple myeloma, and is helpful in monitoring response to therapy as changes in metabolic activity of myelomatous lesions predict for clinical outcome.

Skeletal complications cause pain, disability, decreased mobility and impaired quality of life which can be improved with treatment.

Surgery radiation therapy are used to treat pathological fractures and the use of bisphosphosphonates is the standard of care for preventing and reducing the rate of skeletal related events in patients with bone metastases or osteolytic lesions.

Imbalance between osteoclast activation and osteoblast suppression with suppression of bone formation leading to purely lytic lesions.

Diagnostic criteria require the presence of at least 10% plasma cells on bone marrow examination, monoclonal protein in serum or urine and evidence of end-organ damage.

Urinary NTX (amino-terminal cross-linked telopeptide of type I collagen), serum CTX (carboxylate-terminal cross- linked telopeptide of type I collagen) and ICTP (CTX generated by matrix metalloproteinases) reflect severity of bone destruction and efficacy of treatment to bisphosphonates, and predict an increase of skeleton related events, disease progression, and overall survival (Terpos E et al).

Rarely involves extramedullary tissues, consisting of soft tissue masses of plasma cells with the aerodigestive tract the most commonly involved.

Soft tissue involvement reported in the orbits, ear canal, liver, spleen, kidneys and rectum.

Symptomatic disease characterized by end organ damage caused by plasma cell infiltration and proliferation and defined as CRAB with hypercalcemia, renal failure, anemia, bone disease.

Symptomatic disease is treated immediately, whereas asymptomatic disease requires clinical observation because early treatment does not show benefit.

Any chromosomal abnormality is associated with worse prognosis.

Neuropathy present in 3-13% at the time of diagnosis and prior to the initiation of therapy, and in 37-83% and previously treated individuals.

Neuro-physiologic abnormalities may be present in 11-52% of untreated patients and 39-46% of previously treated patients.

Risk factors for peripheral neuropathy include drug therapy, duration and intensity of drug therapy, cumulative dose of treatment, age and cold morbidities such as diabetes and alcohol, and presence of pre-existing neuropathy.

Thalidomide neuropathy causes a small and large fire sensory peripheral neuropathy with symmetrical loss of all modalities, in the lower extremities were affected most.

No cure exists presently.

Allogeneic BMT achieves long-term disease-free survival of 15%-20% of patients.

Two transplantations with high dose melphalan associated with a seven-year event-free and overall survival rates of 20 and 40%, respectively.

The event-free and overall survival rates for two high-dose transplantations are double over single transplantations.

The use of thalidomide in intensive melphalan chemotherapy with stem cell transplantation increases the rate of complete remission and event-free survival in previously untreated patients but does not increase overall survival.

Stem cell transplant most common indication.

Response rates are not valid surrogates for determining survival in myeloma studies.

Complete response rate requires: absence of original monoclonal protein in serum and urine that is maintained for a minimum of six weeks, less than 5% plasma cells in the bone marrow, no increase in size and number of lytic lesions, and disappearance of the soft tissue plasmacytomas.

Partial response requires: 50% or greater reduction in the level of the serum monoclonal protein, maintain for a minimum of six weeks, reduction in 24 hour urinary light chain excretion by 90% or greater to 200 mg, maintain for a minimum of six weeks, for patients with non-secretory disease. 50% or greater reduction in plasma cells in the bone marrow, maintain for a minimum of six weeks, a 50% or greater reduction in the size of soft tissue plasmacytomas, and no increase in the size of a number of lytic bone lesions.

Compared to the rapid reduction in levels of plasma proteins when patients undergo treatment, focal bone lesions take 1-2 year to regress and are often the first sites of relapse.

When patients evolve to myeloma from monoclonal gammopathy of uncertain significance or from a smoldering phase treatment rarely results in a complete remission and when that occurs it does effect the likelihood of survival reflecting the reestablishment of a stable condition.

Candidates for auto-transplantation should not receive induction therapy with stem cell damaging agents, such as melphalan, which can preclude stem cell harvest.

The administration of high dose melphalan for transplant patients is 200 mg per meter squared as the standard dose.

ASCT after high dose chemotherapy associated with a median survival of more than 5 years.

ASCT associated with a 3-5% mortality.

Autologous stem cell transplantation (ASCT) can be performed either early in the disease or at the time of first relapse with both strategies being useful.

A short course of induction therapy, 3-6 months, followed by autologous stem cell transplantation (ASCT) without maintenance therapy results in very good partial responses of 50-60% and complete response rates of 25-50% and a median time to progressive disease around 2 years.

Tandem ASCT or maintenance following ASCT improves progression free survival and overall survival, but the benefits appear to be primarily among those patients obtaining less than a (VGPR) very good partial response.

In phase II trials of lenalinomide and dexamethasone in previously untreated patients yielded a VGPR in 67% after a median of 19 cycles of treatment (Lacy MQ).

Bortezomib given subcutaneously on a weekly basis has the same efficacy as standard intravenous dosing twice a week with significantly less neurotoxicity.

Regimens containing bortezomib with thalidomide or lenalidomide led to 100% overall response rates and VGPR rates of more than 60% comparing favorably with ASCT.

These high response rates with the above new agents can be increased when they receive ASCT, suggesting ASCT still is a vital treatment.

VAD treatment generally preferred induction therapy for patients under the age of 70 years who are candidates for stem cell transplant.

Initial chemotherapy provides a response rate of 40-60% with a median duration of remission of 18 months and median survival duration of 30-60 months.

Standard chemotherapy has a complete response rate of <10%.

Conventional salvage chemotherapy results in responses of 20-40% with a median survival of 3-12 months.

Melphalan plus prednisone produces response rates, defined as greater than 50% reduction in monoclonal proteins, in 50-60% of patients.

Intergroupe Franocphone du Myelome randomized 488 patients 65-75 years of age to melphalan/prednisone, melphalan/dexamethasone, dexamethasone alone or dexamethasone and interferon alfa: none of the regimens had a significant number of complete responses and melphalan/dexamethasone has a significantly higher overall response rate at 70%, with increased incidence of infections and no significant improvement in median time to progression or median overall survival.

Combination chemotherapy with vincristine, BCNU, melphalan, cyclophosphamide and dexamethasone have response rates and survival times similar to melphalan and prednisone.

Overall results of allogeneic BMT complete remission rate of 22%-50% with treatment related toxicity 25%-56% primarily related to GVHD, infection and disease relapse.

Patients with lytic lesions or osteopenia should receive bisphosphonates indefinitely.

Up to 80% of patients at diagnosis present with osteolytic lesions, often with pain, bone fractures and hypercalcemia.

Malignant plasma cells stimulate bone resorption by osteoclasts and inhibit bone producing cells, the osteoblasts with an unbalanced bone destruction leading to bone lysis.

The number and function of osteoblasts are decreased with osteolytic lesions.

Activin A is a stromally derived osteoblast inhibitor induced by myeloma cells and is implicated in the patogenesis of bone disease (Vallet S et al).

Activin-A serum levels are elevated in newly diagnsed and relapsed patients with myeloma.

Activin a levels correlate with advanced disease and high bone resorption.

Dickkopf-1 (Dkk-1 and sclerosin inhibit Wingless type and integrase 1 (Wnt) signaling and are implicated in myeloma bone disease by inhibitinh osteoblast formation.

Dkk-1 serum levels are elevated with active myeloma and sclerosin levels are elevated in the plateau phase of disease.

Myeloma lesions and osteoporosis result from increased osteoclast activity probably mediated by increased levels of macrophage inflammatory protein 1alpha and receptor activator of nuclear factor-kappaB ligand (RANKL) and decreased levels of decoy receptors of RANKL (osteoprotegerin).

Plasma cells express RANKL on their surface and promote the availability of RANKL within the bone marrow microenvironment inducing stromal cell expression by a cell to cell contact.

To stem overproduction and activation of osteoclasts, osteoblasts secrete osteoprotegerin, which binds and sequesters RANKL, but myeloma cells reduce the availability of osteoprotegerin in the bone marrow microenvironment.

In a phase 3 study of multiple myeloma, randomization to zoledronic acid or not: disease progression in the control was associated with skeletal related events in 78.35 of cases vs. 55.5% in zoledronic acid group (Musto P).

Osteoclasts accumulate at bone resorbing surfaces adjacent to myeloma cells, but are not increased in areas uninvolved with malignancy.

Malignant plasma cells localize in the bone marrow through the interaction of adhesion receptors with their ligands on bone marrow stromal cells and extracellular matrix proteins.

Adhesion of myeloma cells in the bone marrow microenvironment is mediated by plasma cell membrane receptors.

Hypercalcemia occurs in 15% of patients at diagnosis.

Approximately 20% of patients with myeloma have a creatinine of 2.0 mg/dl at diagnosis.

Patients should receive influenza and Pneumococcal vaccinations.

Angiogenesis is increased in myeloma.

New definition for relapsed/recurrent patients include those who show disease progression within 60 days of discontinuing therapy.

Prognosis with relapsed MM is poor with median overall survival of less than 1 year among patients who have received 2 or more line of therapy (Kumar SK et al).

Response rate to VAD (vincristine, adriamycin and dexamethasone) approximately 55-65%.

In newly diagnosed patients response rate to pegylated liposomal doxorubicin, vincristine and dexamethasone (DVd) 88% with 12% complete remissions.

DVd regimen decreases angiogenic activity in myelomatous bone marrows.

Bortezomib therapy in patients with 13q deletion can produce durable responses indicating this drug can overcome the adverse affects of 13q del abnormalities.

APEX study (Assessment of Proteasome Inhibition of Extending Remissions), a phase III trial comparing high dose dexamethasone to single gent bortezomib in patients with relapsed disease: overall response rate of 38% for bortezomib and 18% for high dose dexamethasone.

SUMMIT (Study of Uncontrolled Multiple Myeloma managed with proteasome Inhibition Therapy) 27% response rate to bortezomib, complete remission and partial response, was 27% among 202 relapsed or refractory myeloma patients with a median of 6 prior therapies.

CREST trial out of 27 patients refractory myeloma patients treated with 1.0 mg/m2 30% achieved a complete or partial remission and 38% of patients receiving 1.3 mg/m2 obtained a complete or partial remission.

In the CREST trial the addition of dexamethasone to bortezomib increased response rates to 37% in the 1.0 mg/m2 group and to 50% in the 1.3 mg/m2 patients.

Response rate of bortezomib, melphalan, prednisone and thalidomide (VMPT) overall response rate of 67%, with 43% achieving a very good or better partial response (Palumbo).

Bortezomib plus doxorubicin results in 72% response rate with 36% achieving a complete or near complete remission, and bortezomib plus pegylated liposome doxorubicin has a response rate of 48% (Orlowski)

EVOLUTION trial of bortezomib, dexamethasone, cyclophosphamide and lenalidomide (VDCR) in patients who were previously untreated and with a Karnofsky score of 50% or higher-bortezomib 1.3 mg/m2 I.V. days 1,4,8, and 11, dexamethasone orally 40 mg on days 1,8, and 15, lenalidomide 15 mg days 1-14 and cyclophosphamide 100-5000 mg/m2 orally days 1 an 8: overall response rate 100%, 20% with a stringent complete remission, 36% complete remission or better, and 69% a very good partial response.

Carfilozomib when combined with lenalidomide, and dexamethasone (CRd) in myeloma has a response rate of 100% in newly diagnosed patients, and a complete or near complete response rate of 61%.

RVD-lenalidomide, bortezomib, dexamethasone trial of 66 newly diagnosed patients as initial therapy followed by autologous stem cell transplant or maintenance therapy: 100% of patients achieved a partial response or better, with high rates of complete response, or near complete response and had a median follow-up of 21 months, the estimated 18 month progression free survival and overall viable rates were 75% and 97% with or without autologous stem cell transplant, respectively- indicating RVD is equally effective with or without autologous stem cell transplant (Anderson KC et al).

Phase III study of 460 patients with newly diagnosed disease who were to undergo autologous stem cell transplant were randomized to receive induction therapy with 3 cycles bortezomib, with dexamethasone plus thalidomide or dexamethasone plus thalidomide alone-following double stem cell transplantation the randomization was continued with two consolidation cycles and then dexamethasone maintenance: bortezomib containing regimens associated with superior results-complete remission rates with induction of 32% vs. 12%, higher very good response rates, 4.7% of patients without bortezomib had progressive disease and not patient with bortezomib had progressive disease.

In a phase 3 trial evaluating more than 600 patients assigned to receive maintenance lenalidomide or placebo following high-dose therapy and autologous stem cell transplantation, followed by two months of lenalidomide treatment after achieving complete remission:Lenalidomide maintenance therapy almost doubled three-year progression free survival at 68% versus 35% for placebo (Attal M et al).

Maintenance therapy of lenalidomide in patients who have a a remission after autologus stem cell transplanation results in slowing of disease progression by 54% (Attal M et al).

In a phase III Intergroup Study of Lenalidomide maintenance therapy of 10 mg a day following ASCT resulted in a 60% reduction in the risk of disease progression, with significant fewer patients experiencing an event compared with placebo, 19.9% versus 41.5%, median time to disease progression for lenalidomide compared to placebo was 42.3 months versus 21.8 months (McCarthy PL).

The survival of patients with MM after they become refractory to bortezomib and one of the immune mediated inflammatory disease drugs is about 9 months (International Myeloma Working Group).

Up to 10-20% of patients with newly diagnosed myeloma develop deep vein thrombophlebitis in the first 6 months of therapy.

As compared to a single stem-cell transplantation a double transplantation with high dose chemotherapy improves overall survival.

Stem-cell transplantation is recommended for young patients as part of the initial treatment or at the time of disease progression.

The median duration of remission in patients treated with stem-cell transplantation does not exceed three years and almost all patients relapse.

The complete remission rate after high-dose chemotherapy and stem-cell transplant is the most important prognostic factor for survival.

Maintenance therapy after stem cell transplantation with thalidomide in the Intergroupe Francophone du Myelome 99-02 showed at a median 29 month follow-up that 52% of patients had improvement in event free survival compared with 36% and 37% with observation and palidronate, only arms, respectively.

Thalidomide inhibits multiple myeloma cell growth and survival, decreases the adhesion of myeloma cell and bone marrow stroma, alters secretion of cytokines such as IL-6, sensitizes myeloma cells to chemotherapy, and has antiangiogenic effects.

Response rates to thalidomide in newly diagnosed patients around 30% and in combination with steroids up to 60%.

Phase III trials MM-009 and MM-010 revealed response time and progression improved with lenalidomide plus dexamethasone compared with dexamethasone alone.

Response rate in recurrent or refractory disease with dexamethasone and lenalidomide is about 50%.

Lenalidomide, cyclophosphamide and dexamethasone in relapsed myeloma has an overall response rate of 65%, complete response rate of 5%, and the rate of very good partial response or better was 15% (Schey SA et al).

A combination of lenalidomide, infusional adriamycin and dexamethasone (RAD) in patients with relapsed disease had and overall response rate of 73% with 15%complete remissions and 45% very good partial responses, with a median time to progression of 45 weeks, and the median progression free survival of 40 weeks (Knop S).

In the combination study of lenalidomide, infusional adriamycin and dexamethasone (RAD) there was no difference in time to progression among patients who achieved a complete remission compared to those with a very good partial response, and the presence of a deletion 17p13 was associated with a lower response and shorter time to progression (Knop S).

Relapsed patients that are naive to an agent are generally treated with a new regimen incorporating such an agent.

In a phase 2 trial Carfilzomib had an overall response rate in heavily pretreated patients of 24% and an additional 13% had a minor response with an overall clinical benefit of 37%.

Relapsed patients are considered for ASCT with high dose chemotherapy, and long term survivors of ASCT are considered for retreatment with such therapy.

Efficacy in relapsed patients with thalidomide: 32% response rate and 2 year event free and overall survival 20% and 48%, respectively.

Combination of dexamethasone, thalidomide,, cisplatin, doxorubicin, cyclophosphamide and etoposide in relapsed and refractory myeloma resulted in a 32% partial response and a complete response rate of 16% (LeeCK et al).

Adding thalidomide to pegylated liposomal doxorubicin , vincristine and dexamethasone have relatively high complete or nearly complete remission rates of 46% in newly diagnosed and refractory myeloma patients.

In patients with refractory or relapsed disease combination of bortezomib and low dose melphalan induce near complete remission and partial remissions in 9% and 32%, respectively in phase I/II trials.

Near complete remission rate of 12% and partial remission rate of 41% reported in a study of refractory/ relapsed patients treated with thalidomide plus low dose melphalan.

High-dose chemotherapy with autologous stem cell support improves remission rates, progression free survival, and overall survival and is the standard of care for younger patients.

Autologous transplantation is not curative.

Optimal time for induction therapy prior to autologous stem cell transplant is not known., although most studies suggest a pretransplant induction period of 4-6 months.

Free light chain assay is useful to monitor many patients with oligosecretory and nonsecretory myeloma.

Adverse markers include increased plasma cell labeling index, increased beta 2 microglobulin, low levels of serum albumin, circulating plasma cells and bone marrow plasmablastic features.

Vascular endothelial growth factor and fibroblast growth factor stimulate angiogenesis, inhibit multiple myeloma cell migration and reduce dendritic cell formation.

Defects in immunological functions of dendritic function in myeloma, with lack of CD80 and CD86 molecules, defective antigen presentation, and accumulation of immature and inactivated dendritic cells.

Patients with smoldering myeloma do not require treatment, as they could be in that phase for 1-3 years.

Median time to progression to myeloma from smoldering myeloma in some series is 5-7 years, reflecting considerable heterogeneity of the biology of the disease.

Patients younger than 70 years of age and in good general health that are candidates for auto-transplantation should not receive stem cell damaging chemotherapy (melphalan) agents as induction.

No evidence exists to suggest that a good partial response before autologous stem cell transplant is inferior to a complete response with regard to overall survival.

For non-transplant candidates a number of regimens can be considered as appropriate regimens.

International Staging System incorporates reproducible parameters of albumin and ß2-microglobulin resulting in low, intermediate and high risk groups with median survival of 62, 45 and 19 months, respectively.

Efficacy of retreatment is approximately proportional to the depth and duration of the initial remission, that is, the better the response and a longer remission, the higher the predicted efficacy pretreatment.

Retreatment of multiple myeloma is associated with 60% response rate, in patients who had an initial partial response only (Wolf J et al).