Presentation Outline ICHP Annual Meeting September 13-15
Presentation Outline ICHP Annual Meeting September 13-15
Presentation Outline ICHP Annual Meeting September 13-15
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Standard Risk<br />
• Hyperdiploidy<br />
• t(11;14)<br />
• t(6;14)<br />
Kapoor et al. Int J Hematol. 2011;94:310‐320.<br />
Rajkumar. Am J Hematol. 2012;87:79‐88.<br />
Risk Stratification<br />
Intermediate<br />
Risk<br />
• t(4;14)<br />
•Deletion <strong>13</strong> or<br />
hhypodiploidy di l id bby<br />
conventional<br />
karyotyping<br />
High Risk<br />
• 17p deletion<br />
• t(14;16)<br />
• t(14;20)<br />
•High‐risk gene<br />
expression<br />
profiling (GEP)<br />
signature<br />
•Plasma cell<br />
leukemia<br />
Newly Diagnosed Myeloma Eligible for<br />
Transplantation<br />
High High‐Risk Risk Intermediate<br />
Intermediate‐Risk Risk Standard Standard‐Risk Risk<br />
VRD x 4 cycles VCD x 4 cycles<br />
Rd x 4 cycles<br />
ASCT<br />
Bortezomib‐based<br />
maintenance<br />
Rajkumar SV. Am J Hematol. 2012;87:79‐88.<br />
ASCT; 2 nd ASCT if<br />
not in CR or VGPR<br />
Bortezomib<br />
maintenance for<br />
2 years<br />
Early<br />
ASCT<br />
Delayed<br />
ASCT<br />
Lenalidomide<br />
maintenance if not<br />
in CR or VGPR<br />
following ASCT<br />
Newly Diagnosed Myeloma Not Eligible<br />
for Transplantation<br />
High High‐Risk Risk Intermediate<br />
Intermediate‐Risk Risk Standard Standard‐Risk Risk<br />
VRD x one year VCD x one year<br />
Rd*<br />
Bortezomib‐based<br />
maintenance<br />
Rajkumar SV. Am J Hematol. 2012;87:78‐88.<br />
Bortezomib<br />
maintenance for<br />
2 years if possible<br />
*Dexamethasone usually discontinued after 12 months; continued long‐term bortezomib or lenalidomide is an<br />
option for patients who are tolerating treatment well.<br />
Induction Therapy for<br />
Transplant Candidates<br />
Regimen NCCN Category<br />
Bortezomib/dexamethasone<br />
1<br />
Bortezomib/doxorubicin/dexamethasone<br />
1<br />
Bortezomib/thalidomide/dexamethasone<br />
1<br />
Lenalidomide*/dexamethasone<br />
1<br />
BBortezomib/cyclophosphamide/dexamethasone BBortezomib/cyclophosphamide/dexamethasone t ib/ l h h id /d th<br />
2A<br />
Bortezomib/lenalidomide*/dexamethasone<br />
2A<br />
Thalidomide/dexamethasone 2B<br />
Dexamethasone 2B<br />
Liposomal doxorubicin/vincristine/dexamethasone 2B<br />
*Consider harvesting peripheral blood stem cells prior to prolonged exposure to lenalidomide.<br />
Category 1 –The recommendation is based on high‐level evidence and there is uniform NCCN consensus<br />
Category 2A –The recommendation is based on lower‐level evidence and there is uniform NCCN consensus<br />
Category 2B –The recommendation is based on lower‐level evidence and there is nonuniform NCCN consensus<br />
The NCCN Clinical Practice Guidelines in Oncology Multiple Myeloma (Version 1.2012). © 2011 National Comprehensive Cancer<br />
Network, Inc. Available at: NCCN.org. Accessed [March <strong>13</strong>, 2012]. To view the most recent and complete version of the NCCN<br />
Guidelines, go online to NCCN.org.<br />
Induction Therapy for<br />
Nontransplant Candidates<br />
Regimen NCCN Category<br />
Melphalan/prednisone/bortezomib<br />
1<br />
Melphalan/prednisone/thalidomide Melphalan/prednisone/thalidomide<br />
1<br />
Melphalan/prednisone/lenalidomide<br />
1<br />
Lenalidomide/low‐dose dexamethasone<br />
1<br />
Bortezomib/dexamethasone Bortezomib/dexamethasone<br />
2A<br />
Melphalan/prednisone 2A<br />
Dexamethasone 2B<br />
Vincristine/doxorubicin/dexamethasone 2B<br />
Thalidomide/dexamethasone 2B<br />
Liposomal doxorubicin/vincristine/dexamethasone 2B<br />
Category 1 –The recommendation is based on high‐level evidence and there is uniform NCCN consensus<br />
Category 2A –The recommendation is based on lower‐level evidence and there is uniform NCCN consensus<br />
Category 2B –The recommendation is based on lower‐level evidence and there is nonuniform NCCN consensus<br />
The NCCN Clinical Practice Guidelines in Oncology Multiple Myeloma (Version 1.2012). © 2011 National Comprehensive Cancer<br />
Network, Inc. Available at: NCCN.org. Accessed [March <strong>13</strong>, 2012]. To view the most recent and complete version of the NCCN<br />
Guidelines, go online to NCCN.org.<br />
Maintenance Therapy<br />
Regimen NCCN Category<br />
Thalidomide<br />
1<br />
Bortezomib<br />
2A<br />
Lenalidomide*<br />
2A<br />
Interferon f<br />
2B<br />
Steroids 2B<br />
Thalidomide/prednisone 2B<br />
*There appears to be an increased risk for secondary cancers, especially with lenalidomide<br />
maintenance following transplant. The benefits and risk of maintenance therapy vs secondary cancers<br />
should be discussed with patients.<br />
Category 1 –The recommendation is based on high‐level evidence and there is uniform NCCN consensus<br />
Category 2A –The recommendation is based on lower‐level evidence and there is uniform NCCN consensus<br />
Category 2B –The recommendation is based on lower‐level evidence and there is nonuniform NCCN consensus<br />
The NCCN Clinical Practice Guidelines in Oncology Multiple Myeloma (Version 1.2012). © 2011 National Comprehensive Cancer<br />
Network, Inc. Available at: NCCN.org. Accessed [March <strong>13</strong>, 2012]. To view the most recent and complete version of the NCCN<br />
Guidelines, go online to NCCN.org.
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