Patient Case 2: Transplant-Ineligible Newly Diagnosed Multiple Myeloma


Panelists move on to review a patient case of transplant-ineligible newly diagnosed multiple myeloma and highlight clinical workup strategies.


Beth Faiman, PhD, MSN, APN-BC: Welcome to this focus discussion. We’re going to be highlighting a case of a patient with transplant-ineligible myeloma. I know you can’t wait, and I can’t wait to hear what you have to say about this case. This is a 72-year-old man. He has a past medical history of COPD [chronic obstructive pulmonary disease] that’s secondary to smoking; he was a miner. He has had hypertension and diabetes for 20 or 30 years, and he has acute chronic back pain. His wife told him to go to the chiropractor, but the pain got worse—surprise. To treat the back pain, he took NSAIDs [nonsteroidal anti-inflammatory drugs]—surprise.

Jack Khouri, MD: Surprise.

Beth Faiman, PhD, MSN, APN-BC: Because Tylenol didn’t work, he went to see a primary care provider. About 2 days later, he had new symptoms of shortness of breath, lower extremity swelling, lethargy, and confusion. His wife took him to the emergency department. At that time, blood work showed an elevated serum creatinine, about 2.6 g/dL. His baseline is about 1.7, 1.8 g/dL, so he had a history of mild renal insufficiency. He had mild elevated serum calcium with a normal albumin. Is this an acute hypercalcemia, with a calcium of 10.5 mg/dL? Or is it secondary to dehydration? Is this acute tubular necrosis, or something related to NSAIDs? The nephrology work-up showed a kidney ultrasound that had no hydronephrosis, but on urinalysis he had 3+ proteinuria. Kappa free light chains were identified as well.

He was admitted to the hospital, because that’s the appropriate place for him to be worked up. At that time, his calcium bumped up to 11.4 mg/dL. Albumin was low at 3.3 g/dL. LDH [lactate dehydrogenase] was surprisingly normal at 150 U/L. That’s odd, because I often see these patients have higher LDH, sometimes even 220. Serum creatinine was 2.6 g/dL, and hemoglobin was 10.8 g/dL. He has a history of CKD [chronic kidney disease]. Is this anemia related to that? The kappa free serum was measured at 18.32 mg/L; normal in our institution is 19.4 g/dL. He had a free light chain ratio of 122, so it was over 100. Who wants to talk about the criteria for diagnosis of myeloma and the SLiM-CRAB? Dr Mazzoni, you’re my go-to.

Sandra Mazzoni, DO: We’ve all heard of CRAB. That’s old school: the [elevated] calcium, the renal insufficiency, the anemia [and the bone lesions]. SLiM-CRAB is looking more specifically at light chain ratios, where the ratio is over 100. One big thing that has evolved over time is better imaging recommendations. We’re no longer relying on a skeletal survey, which is basically a whole-body x-ray. We want something more sensitive, a CT. We’re lucky we have a CT myeloma protocol, which is nice. There’s less radiation exposure in low-dose CT than in a full-body MRI. Not many of us use that because it takes hours to get that done or a PET [positron emission tomography]. If you have a measurement on an MRI that is over 1 mm—is that correct?

Beth Faiman, PhD, MSN, APN-BC: Five milliliters. More than 1 lesion.

Sandra Mazzoni, DO: More than 1 lesion, over 5 mm or 0.5 cm. Those are the new criteria. The big debate is if they meet none of the criteria except the light chain ratio, what do you do with these patients?

Beth Faiman, PhD, MSN, APN-BC: Exactly, and especially if you hydrate them. In our case study, you’d hydrate him. The creatinine then comes down to 1.7 g/dL again, and the anemia might be from iron deficiency; you’re optimizing that. What’s your work-up of somebody with anemia and elevated creatinine? Dr Williams, put on your consult hat. What would you do to make sure this patient doesn’t have myeloma?

Louis Williams, MD: For an anemia work-up, outside the world of multiple myeloma, you should have a peripheral smear, iron studies, and a micronutrient study, and look for hemolysis and the other standard causes of anemia. In the acute setting, if you don’t know what his baseline renal function is, it’s difficult to assess whether this is anemia of chronic renal disease. Spot erythropoietin levels aren’t that useful, but it’s a useful thing to think about if somebody comes in with baseline kidney disease. He didn’t have too much, but with this clinical picture, an SPEP [serum protein electrophoresis], a UPEP [urine protein electrophoresis], a paraprotein work-up, and a bone marrow biopsy would have been part of my initial work-up. Another part of the SLiM-CRAB is greater than 60% marrow plasmacytosis. You have a diagnosis right there.

Beth Faiman, PhD, MSN, APN-BC: You only need 1 for SLiM-CRAB criteria.

Louis Williams, MD: Yeah, you only need 1, and he’s already got 1.

Beth Faiman, PhD, MSN, APN-BC: He’s got an M-spike [monoclonal protein] of 2.72 g/dL, and he’s dumping this protein. This might be where we’d look for a monoclonal gammopathy of renal significance, do a kidney biopsy, and look at 1 of the nephropathies, assuming that’s not what happened in this case. An alternative scenario would be that you hydrated him, and the calcium came down, and he was dry, and the creatinine normalized. Hemoglobin came up with some ESA [erythropoiesis-stimulating agent] and iron infusion. Let’s say his TSAT [transferrin saturation] was 11%, and you do a colonoscopy. Let’s say we fix this guy and then screen him for clinical trial. I don’t know. We all have interest in disparities in clinical trials. That’s a big gap, and that’s a passion of mine. There’s a clinician bias to say, “They don’t want to drive so far. They don’t want to go through the testing to go on clinical trials.” But it’s up to us to offer the trials.

Jack Khouri, MD: Right.

Beth Faiman, PhD, MSN, APN-BC: What’s your take on clinical trials, Dr Khouri?

Jack Khouri, MD: I agree, especially in the setting of smoldering myeloma. We should always offer clinical trials, and we should never assume that they’re not interested, or that they have certain factors that are limiting for them to be eligible. We should inform the patient of studies and make a decision together.

Beth Faiman, PhD, MSN, APN-BC: We have high-risk smoldering [myeloma] trials at our institution. I always share the story about the patient who lived down the street, but we thought he didn’t want to drive down the street. We were talking about the whole-body MRI. We waited to change his insurance until the whole-body MRI and the PET scan were approved, and he successfully enrolled in the study for [patients with] high-risk smoldering [myeloma]. That’s a success story I like to share. What about your experience, Dr Williams? You had a great experience in the New York area dealing with some of these populations, and you just had a paper at ASH [American Society of Hematology Annual Meeting] on disparities.

Louis Williams, MD: Yes. The paper we talked about at ASH has to do with reducing disparities by disaggregating data from minority patient populations. That means thinking about minority patients as individuals, not just parts of a minority. We did this by looking at their admixture. When you label somebody in a particular ethnic group—like Hispanic, for example—that doesn’t have a lot of biological meaning. That may mean someone is from Europe, or native to South America, or some combination. Most individuals are some combination; they may even have African ancestry. In addition to the many initiatives around the social determinants of health, we’ve been looking on a genetic basis to differentiate patients. The hope is that this might guide clinical trial enrollment and structure trials in the future.

Beth Faiman, PhD, MSN, APN-BC: There’s a heterogeneity with the biological differences in all these groups, and they’re not clearly captured. Thank you so much for sharing that.

Transcript edited for clarity.

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