2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

CURRENT STATUS OF MYELOMA THERAPY
KEY POINTS
Table 1. Diagnostic Criteria for Multiple Myeloma and Related Disorders
Disorder Disease Definition
Monoclonal gammopathy of undetermined
significance (MGUS)
● The diagnosis of multiple myeloma requires 10% or
more clonal plasma cells on bone marrow examination
or a biopsy-proven plasmacytoma plus evidence
of end-organ damage felt to be related to the underlying
plasma cell disorder.
● Patients with 17p deletion, t(14;16), t(14;20), or highrisk
gene expression profiling signature have highrisk
myeloma; patients with t(4;14) translocation
have intermediate-risk disease; all others are considered
to have standard-risk myeloma.
● A risk-adapted strategy to multiple myeloma is essential
because prognosis varies dramatically across
risk groups, the various modern regimens in use have
different safety and cost profiles, and there are no
clear survival or quality-of-life data from randomized
trials showing a clear superiority of one strategy over
the other.
● Risk-stratified therapy relies on both host factors as
well as prognostic markers of disease aggressiveness.
● Bortezomib-based regimens appear to be able to overcome
the poor prognostic effect of t4;14 translocation.
All three criteria must be met:
• Serum monoclonal protein �3gm/dL
• Clonal bone marrow plasma cells �10%, and
• Absence of end-organ damage such as hypercalcemia, renal insufficiency, anemia, and bone lesions (CRAB) that can be
attributed to the plasma cell proliferative disorder; or in the case of IgM MGUS, no evidence of anemia, constitutional
symptoms, hyperviscosity, lymphadenopathy, or hepatosplenomegaly that can be attributed to the underlying
lymphoproliferative disorder.
Light chain MGUS All criteria must be met:
• Abnormal FLC ratio (�0.26 or �1.65)
• Increased level of the appropriate involved light chain (increased kappa FLC in patients with ratio �1.65 and increased
lambda FLC in patients with ratio �0.26)
• Absence of end-organ damage such as hypercalcemia, renal insufficiency, anemia, and bone lesions (CRAB) that can be
attributed to the plasma cell proliferative disorder
• No immunoglobulin heavy chain expression on immunofixation
Smoldering multiple myeloma (also referred
to as asymptomatic multiple myeloma)
Both criteria must be met:
• Serum monoclonal protein (IgG or IgA) �3gm/dL and/or clonal bone marrow plasma cells �10%, and
• Absence of end-organ damage such as lytic bone lesions, anemia, hypercalcemia, or renal failure that can be attributed
to a plasma cell proliferative disorder
Solitary Plasmacytoma All four criteria must be met
• Biopsy-proven solitary lesion of bone or soft tissue with evidence of clonal plasma cells
• Normal bone marrow with no evidence of clonal plasma cells
• Normal skeletal survey and MRI of spine and pelvis (except for the primary solitary lesion)
• Absence of end-organ damage such as hypercalcemia, renal insufficiency, anemia, or other bone lesions (CRAB) that
can be attributed to a lympho-plasma cell proliferative disorder
Multiple myeloma All three criteria must be met except as noted:
• Clonal bone marrow plasma cells �10% and/or biopsy proven plasmacytoma
• Presence of serum and/or urinary monoclonal protein (except in patients with true non-secretory multiple myeloma), and
• Evidence of end organ damage that can be attributed to the underlying plasma cell proliferative disorder, specifically
o Hypercalcemia: Serum calcium �11.5 mg/dL or
o Renal insufficiency: Serum creatinine �1.73 mmol/L (or �2 mg/dL) or estimated creatinine clearance less than 40
mL/min
o Anemia: Normochromic, normocytic with a hemoglobin value of �2 g/dL below the lower limit of normal or a
hemoglobin value �10 g/dL
o Bone lesions: Lytic lesions, severe osteopenia or pathologic fractures
Modified from Kyle and Rajkumar. 1
(15% of myeloma) have a median OS of 2 to 3 years, despite
initial therapy containing bortezomib, tandem ASCT, and
routine use of maintenance therapy. 1
Risk-Adapted Therapy
With the number of regimens and combinations in myeloma
available, and the lack of phase III trials demonstrating
superiority in the only two endpoints that matter
(overall survival and/or quality of life), the choice of therapy
is often made based on physician discretion, bias, and
limited data from phase II studies. Further, the regimens
available have considerably different profiles in terms of
safety, convenience, and cost, thereby dictating the need for
Modified from Rajkumar. 2
Table 2. Risk-Stratification of Myeloma
A. Standard Risk
• Hyperdiploidy
• t (11;14)
• t (6;14)
B. Intermediate Risk
• t (4;14)
C. High Risk
• 17p deletion
• t (14;16)
• t (14;20)
• High-risk gene expression profiling signature
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