Case Review: MM with High-Risk Cytogenetics

Robert A. Vescio, MD:The patient we’re talking about today is a 55-year-old African American woman. She presented to her physician feeling a bit tired and complained of some bone and back pain. She was evaluated and was noted to be a little bit anemic. Her kidney function was fine. Her calcium was normal. When they looked at her MRI, they found some lesions that were suggestive of a malignancy.

In order to confirm a diagnosis of multiple myeloma, she underwent a bone marrow biopsy. The bone marrow biopsy showed plasma cells consistent with cancer, and these cells contained the t(4;14) translocation. Given that her beta-2 microglobulin was 5.0, she was felt to have stage 2 disease, based on the revised ISS. Based on that, she was started on treatment with bortezomib, lenalidomide, and dexamethasone—the so-called VRd therapy. She received the regimen for 6 months and tolerated it well, achieving a very good partial response, not quite in remission.

At the time, she did speak with her physician about potentially doing a stem cell transplant. She decided not to go ahead with the high-dose chemotherapy. Instead, lenalidomide and dexamethasone was maintained for as long as her disease was controlled.

When thinking about her case, she’s young. She is 55 years old. I would certainly consider that young. And so, she has some high-risk features. The t(4;14) translocation tends to predict a more aggressive form of the disease with more rapid relapses.

I think she was appropriately treated, initially, with the bortezomib, lenalidomide, dexamethasone regimen. She seemed to tolerate it well and got to a very good partial response. However, I probably would have tried hard to convince her to undergo high-dose chemotherapy with a stem cell transplant because it has been shown to improve survival. At 55 years old, her main risk of dying is going to be from the multiple myeloma, not from some complication or something like that.

Transcript edited for clarity.

A 55-year-old African-American Woman With Relapsed Multiple Myeloma

August 2015

• A 55-year-old African-American woman presented to her PCP complaining of worsening fatigue, back pain, and bone pain
• PMH: hypertension managed on a beta blocker, mild renal impairment
• Laboratory results:
  • Hb, 11.0 g/dL;
  • Ca²⁺, 10.1 mg/dL;
  • Creatinine, 1.2 mg/dL;
  • M-protein, 0.9 g/dL
  • Β2M, 5.0 mg/L
  • Albumin, 2.9 g/dL
• MRI showed multiple small lytic lesions in the T1/T2 vertebrae
• Bone marrow biopsy confirmed the diagnosis of multiple myeloma; R-ISS stage II; t(4;14)
• She was treated with lenalidomide/bortezomib/dexamethasone (RVd) for 6 months and achieved a VGPR
• The patient was recommended for autologous transplant, however, she instead opted to continue on a de-escalated treatment regimen of Rd after stating that she struggled to maintain her treatment schedule

May 2018

• M-protein, May 1.5 g/dL

June 2018

• M-protein, 1.7 g/dL

July 2018

• MRI, no new lytic skeletal lesions
• Laboratory results:
  • Hb, 11.5 g/dL;
  • Ca²⁺, 9.8 mg/dL;
  • Creatinine, 1.1 mg/dL;
  • M-protein, 1.9 g/dL
  • Β2M, 4.2 mg/L
• ECOG PS: 0