Recent Advances in Multiple Myeloma: Insights from Experts at University of Pennsylvania - Episode 8

Patient Case 3: Transplant-Ineligible Newly Diagnosed Multiple Myeloma

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Expert oncologists focus on a final patient case of transplant-ineligible newly diagnosed multiple myeloma and reflect on the treatment armamentarium in this setting.


Alfred Garfall, MD:I’ll describe our third case. This is a 72-year-old woman with a history of diabetes, hypertension, coronary artery disease, diastolic heart failure, and chronic obstructive pulmonary disease who developed new-onset renal failure with a creatinine of 1.8 mg/dL and anemia with a hemoglobin level of 8 g/dL. The initial evaluation showed a white blood cell count of 10 per mm3. Her platelet count was 296 per mm3, creatinine was 1.8 mg/dL, with normal albumin, slightly elevated calcium, and a beta-2 microglobulin level of 6.5 µg/mL. Serum protein electrophoresis was negative, but the serum-free kappa light chain was markedly elevated at 1359 mg/L ... The UPEP [urine protein electrophoresis] was positive for free monoclonal light chain. A bone marrow biopsy showed 60% infiltration by kappa-restricted plasma cells, and a PET [positron emission tomography]–CT scan showed no FDG [fluorodeoxyglucose], avid, or osteolytic lesions.

The patient started induction therapy with VRd [bortezomib, lenalidomide, dexamethasone] light, which is a de-intensified version of the classical VRd [bortezomib, lenalidomide, dexamethasone] regimen. [She received] bortezomib 1.3 mg/m2 weekly, lenalidomide 10 mg on days 1 to 21, and then weekly dexamethasone 20 mg. She was referred to our center for stem cell transplant evaluation.

The patient had achieved a partial response at the time of evaluation after 1 cycle of this regimen with the improvement in the kappa-free light chain of 337 mg/L. It was felt that she would not be a good candidate for high-dose melphalan based on her poor performance status and medical comorbidities. She still had a New York Heart Association Class IIIstatus at the time of evaluation. In a relatively short time on VRd [bortezomib, lenalidomide, dexamethasone]–light, she had developed a painful peripheral neuropathy. The treatments were switched to daratumumab, lenalidomide, and dexamethasone with subsequent further improvement in the response to a kappa-free light chain level of 70 mg/L at the last evaluation. Sandra, could you tell us a little about how this patient was treated and why you chose what you did for this patient?

Sandra Susanibar-Adaniya, MD: When the patient initially came to our center after the first cycle of VRd [bortezomib, lenalidomide, dexamethasone], she was having trouble tolerating the medication. As you show in the numbers, she was having a good response—more than 50% of her free kappa light chain went down—but she was having severe shortness of breath. The pain was keeping her up. The decision was to change to a regimen that can be equally successful but can improve her quality of life.

Fortunately, she did really well after the change. Neuropathy improved—she’s back to her baseline, so she’s able to enjoy life. We haven’t needed to reduce her Revlimid or anything like that. We continue her daratumumab. She’s receiving it monthly. She continues to be on Revlimid adjusted for her renal dose, so she’s getting 10 mg for 3 weeks on, 1 week off. The only thing different from the MAIA study is that I decreased the steroids when her response started to deepen because she has diabetes and because our patients suffered with the adverse effects of prolonged steroid use. That’s something that needs to be discussed more, because we have also have data from a small phase 3 randomized trial in Italy that showed that after 9 cycles of Revlimid-dexamethasone, a patient can safely go to just Revlimid.

Transcript edited for clarity.