Plasma Cell Neoplasms

Chapter 38 Plasma Cell Neoplasms

Treatment of Relapsed Multiple Myeloma

Ensure that the patient has a relapse requiring intervention. The conversion from a negative immune-fixation analysis to a positive study result is not an indication to initiate salvage therapy. A clear clinical relapse with new or increased evidence of end-organ damage or a substantial or aggressive biochemical relapse as defined by criteria for progressive disease are indications for the initiation of treatment.

Selection of treatment depends on prior therapy received.

Special considerations

Entry in clinical trials

CNS, Central nervous system; CSF, cerebrospinal fluid; LDH, lactate dehydrogenase; SCT, stem cell transplantation.

Treatment of Newly Diagnosed Multiple Myeloma

Confirm that the patient has symptomatic myeloma. Patients with MGUS or SMM should not be treated outside of a clinical trial.

Perform risk stratification using ISS staging, FISH, or cytogenetics, and assessment of renal function and measurement of LDH level to develop long-term plan based on estimate of prognosis. Although initial treatment is not affected by risk category, later consideration of more aggressive consolidation or use of allogeneic SCT in eligible patients can be considered in high-risk younger patients.

Induction: Both transplant-eligible and ineligible patients can be treated with a triple-drug regimen (bortezomib and dexamethasone with lenalidomide, with thalidomide or cyclophosphamide, or cyclophosphamide, thalidomide, dexamethasone) for 3 to 6 cycles before transplant or 9 to 12 months for transplant-ineligible patients. For transplant-ineligible patients, additional options include a two-drug regimen (dexamethasone with lenalidomide, with bortezomib, or with thalidomide) or melphalan containing regimen such as melphalan with prednisone in combination with any of the newer agents, MPT, MPV, or MPR.

Drug Selection should be influenced depending on patient characteristics.

Transplant-eligible patients can undergo a single autologous transplant with melphalan with a second autologous transplant being optional depending on the overall response or on the protocol in which the patient is participating.

Maintenance: After transplant or optimal induction therapy (to best response), patients can receive maintenance with thalidomide, lenalidomide, or bortezomib. For high-risk patients, both bortezomib and lenalidomide or thalidomide combination can be used. Selection can be influenced based on their induction regimen.

Improving complete response rates is a key goal of current trials, but patients can live a long time with residual paraprotein.

FISH, Fluorescent in situ hybridization; ISS, International Staging System; LDH, lactate dehydrogenase; MGUS, monoclonal gammopathy of unknown significance; MPR, melphalan, prednisone, lenalidomide; MPT, melphalan, prednisone, thalidomide; MPV, melphalan, prednisone, bortezomib; SCT, stem cell transplantation; VCD, bortezomib, cyclophosphamide, dexamethasone; VTD, bortezomib, thalidomide, dexamethasone.

Table 38-4 Phenotypic Characterization of Plasma Cells

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Jun 12, 2016 | Posted by in HEMATOLOGY | Comments Off on Plasma Cell Neoplasms

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Adhesion Molecule Normal Plasma Cells Multiple Myeloma Cells
CD138 + +
CD19 +
CD38 + +
CD40 + +
CD45 + *
CD27 +