Case Overview: Multiple Myeloma

Now Viewing

EP: 1.Case Overview: Multiple Myeloma

EP: 2.Initial Impressions: Goals and Challenges

EP: 3.Considerations for Selecting First-Line Therapy in Newly Diagnosed Multiple Myeloma

EP: 4.Role of Monoclonal Antibodies in Up-front Therapy for Multiple Myeloma

EP: 5.Phase 3 MAIA Trial Review

Rafael Fonseca, MD: Thank you for joining us. My name is Rafael Fonseca. I’m a hematologist and oncologist at the Mayo Clinic in Arizona. I’m the interim executive director for the Mayo Clinic Cancer Center and most important, a myeloma doctor. Today I’d like to share with you the case of a 77-year-old woman with newly diagnosed multiple myeloma. We’ll walk ourselves through some of the implications regarding comorbidities, features at presentation, and through the process of treatment selection. For background, let’s present her case.

She’s age 77 and presents systemic symptoms with decreased appetite, fatigue, and back pain with a pretty much unremarkable medical history. During physical examination, she has pain during ambulation and point tenderness on palpation in her midback. She’s reported as having an ECOG performance status of 1. A clinical work-up is conducted, and what we find is that the patient has pretty significant anemia. Her hemoglobin is 9.2 g/dL; her corrected calcium is slightly elevated, 11.8 mg/dL; LDH [lactate dehydrogenase] was 285 U/L; and the creatinine is elevated at 2.1 mg/dL. Her albumin is normal, but in the low range, 3.8 g/dL, and she has a calculated clearance of creatinine of 45 cc/min. As the pathologist reviews the peripheral smear, they find rouleaux formation. We get back the results for the beta-2 microglobulin, which shows 4.2 mg/L. An M-protein is measured in serum protein electrophoresis as 2.5 g/dL. The light chains come back. We have a lambda light chain of 0.7 mg/dL, which is in the normal range. The kappa is elevated, although not dramatically, at 13.3 mg/dL.

Quick reminder: We know that some institutions report free light chains per liter, and some institutions report per deciliter, as we have in our case. An analysis of the bone marrow is done, and the patient has a 60% plasmacytosis. Not surprisingly, the patient is kappa restricted, and the cells are IgG kappa. Her M spike was also found to be IgG kappa by immunofixation. The same bone marrow shows that the FISH [fluorescence in situ hybridization] markers failed to detect high-risk markers, because she’s only shown to be hyperdiploid multiple myeloma. A 24-hour collection of urine is completed, and the patient has an M spike of 410 mg of lambda light chain over 24 hours. This is a little higher than what you would have predicted just looking at the serum level of her free light chains.

The patient goes through imaging studies: a PET [positron emission tomography]; a CT, which shows lytic lesions throughout with particular emphasis in the lumbar region at level of L2 and L3 vertebrae. In short, the patient is diagnosed as having revised ISS [International Staging System] multiple myeloma stage II. We’ll talk about some of the implications of comorbidities, as well as the various treatment options available to her. Because of the patient’s age primarily, despite her comorbidities and fitness status at the time of presentation, she is deemed not eligible for stem cell transplantation. In this case, the patient was initiated on treatment with four drugs. So the patient received the backbone combination of bortezomib, lenalidomide, and dexamethasone, because this is done with RVd. The patient also had daratumumab [Darzalex] added to this regimen, so what we are referring to is a GRIFFIN combination. We’ll talk more about that in detail. For summary, we have a 77-year-old woman with newly diagnosed multiple myeloma with clear evidence of end-organ damage and a necessary treatment. Fortunately, the patient has no high-risk genetic markers, but the indications that the patient will need to start on therapy are there.

Transcript edited for clarity.

Case: A 77-Year-Old Woman with Multiple Myeloma

Initial Presentation

• A 77-year-old woman presents with decreased appetites, fatigue, and back pain
• PMH: unremarkable
• PE: pain during ambulation, point tenderness on palpation of the mid-back
• ECOG 1

Clinical Workup

• Hb 9.2 g/dL, corrected calcium 11.8 mg/dL, LDH 285 U/L, creatinine 2.1 mg/dL, albumin 3.8 g/dL, CrCl 45 mL/min
• Peripheral blood smear showed rouleaux formation
• Beta-2 microgloblulin 4.2 mcg/mL, M-protein 2.5 g/dL
• Lambda free light chains: 0.7 mg/dL, kappa free light chains: 13.3 mg/dL
• FISH: hyperdiploid
• UPEP: M-spike of 410 mg of lambda light chains in 24 hours
• PET/CT revealed lytic bone lesions in at L2/L3
• Bone marrow biopsy shows 60% plasma cells IgG k
• Diagnosis: R-ISS stage II MM

Treatment

• Patient is ineligible for ASCT due to comorbidities
• Initiated treatment with daratumumab + bortezomib + lenalidomide + dexamethasone