Case Presentation: Triple-Class Refractory Multiple Myeloma

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Adriana Rossi, MD: We have a case of a 75-year-old woman who was diagnosed with multiple myeloma 5 years ago, who is now coming back to clinic complaining of extreme fatigue, muscle weakness, and bony pain located in her hip and her forearm, as well as her low back. She mentions she’s taking antibiotics now for the third time in the past year for a recurring bacterial infection. Reviewing her chart, we see she initially received treatment with daratumumab, lenalidomide, and dexamethasone, and obtained a CR [complete response], which she maintained for 20 months. She was then switched to bortezomib, lenalidomide, and dexamethasone, and had stable disease this time for 16 months. And in her third line she started carfilzomib, pomalidomide and dexamethasone, achieving a partial response that lasted 12 months. Most recently, she was started on selinexor. She tolerated the treatment well for 9 months at which time her M protein was detected at 0.5 g/dL.

This was 3 months ago, so she has now been away from the clinic for 3 months, coming in with the above complaints, and on examination, indeed, she does have bony tenderness over the hip, the forearm and the low back, which are the areas that are hurting her. Clinical evaluations shows hemoglobin down to 6.2 g/dL, calcium of 8.4 mg/dL, LDH [lactate dehydrogenase] of 160 U/L. Her creatinine is 2.1 m/dL, albumin of 2.7 g/dL, and a beta-2 microglobulin of 4.9 μg/mL. Her M spike has risen to 4.2 g/dL, and her free light chains are up to 4.1 mg/dL. Skeletal survey and MRI show lytic lesions in the left hip, in the pelvis, L2 vertebrae, and a hairline fracture in the distal radius of the right arm. A bone marrow biopsy was completed and showed 62% plasma cells, which were kappa restricted. FISH [fluorescence in situ hybridization] showed the 11;14 translocation, which was present at the time of diagnosis, as well as a new deletion 17p. She’s been restaged as Revised-ISS [Revised International Staging System] stage II, and has an ECOG of 1. At that time, the decision was made to start treatment with belantamab.

Transcript edited for clarity.

Case: A 75-Year-Old Woman with Triple-Class Refractory Multiple Myeloma

Initial Presentation

• A 75-year-old woman diagnosed with multiple myeloma 5 years ago returns to the clinic with complaints of extreme fatigue, increased muscle weakness and new bone pain in her right hip, right forearm and low back. She reports that she is currently taking antibiotics for a bacterial infection, her third in the last 12 months.
• Treatment history:
  • Initially treated with DRd; CR lasting 20 months
  • Switched to VRd, stable disease lasting 16 months
  • Subsequently switched to KPd, achieved a PR lasting 12 months
  • Started selinexor; follow up at 9 months showed M protein increase by 0.5 g/dl; patient continued to feel well 
• Currently, 3 months after her last visit, she returns to the clinic for follow-up
• PE: new bony tenderness appreciated on right hip, pelvis forearm and lumbar spine; bruising and mild bleeding of the gums

Clinical Workup

• Labs: Hb 6.2 g/dL, calcium 8.4 mg/dL, LDH 160 U/L, creatinine 2.1 mg/dL, albumin 2.7 g/dL, b2 microgloblulin 4.9 mcg/mL, serum M-protein 4.2 g/dL, lambda free light chains 4.1 mg/dL
• HBV negative
• Skeletal survey and MRI revealed lytic bone lesions in the left hip, pelvis and L2 vertebrae and lytic lesions as well as a hairline fracture in the distal radius of the right arm
• Bone marrow shows 62% plasma cells IgG k
• FISH: t(11;14) at diagnosis; new del(17p)
• Diagnosis: R-ISS stage II MM
• ECOG 1

Treatment

• Initiated treatment with belantamab mafodotin