2. Sarah Newbury, the first reported patient with multiple
myeloma.
A) Bone destruction in the sternum. (B) The patient with fractured
femurs and right humerus. (C) Bone destruction involving the femur.
3. Timeline depicting the history and treatment of multiple myeloma from 1844 to the present.
Kyle R A , Rajkumar S V Blood 2008;111:2962-2972
4. Myeloma is a blood cancer
Incidence : 0.7M/0.5 F per 100,000
population (NCR, 2003)
Median age: 60 years
1/10 as common as leukaemias
5.
6. Is not known for sure
Decline in the immune system
Biological factors
Certain occupations
Exposure to certain chemicals
Exposure to radiation
Virus
7. 7
Cancer of plasma cells.
Plasma cells come from B lymphocytes, and produce
antibodies (immunoglobulins).
Myeloma cells produce abnormal immunoglobulins.
– Overproduce monoclonal protein or paraprotein.
– Ineffective immunoglobulins.
– Leads to decreased bone marrow function.
– Destruction of bone tissue.
30. International staging system (ISS)
Stage I — B2M <3.5 mg/L and serum
albumin ≥3.5 g/dL
Stage II — neither stage I nor stage III
Stage III — B2M ≥5.5 mg/L
Median overall survival for patients with ISS
stages I, II, and III are 62, 44, and 29
months
34. 34
• Currently incurable in most patients.
• Long-term complete responses are rare.
• Median survival with standard therapy about 3
years.
• Autologous stem cell transplant may prolong
progression free survival, but it’s not curative.
• Treatment of relapse:
– No standard therapy.
– Existing options inadequate.
New treatment options needed.
37. Indications for treatment
Risk stratification
- age
- co-morbidities
Eligibility for stem cell transplantation
38. Deferral of chemotherapy until progression to
symptomatic disease
Follow these patients closely, every 3 to 4 months, with
serum protein electrophoresis, complete blood count,
serum creatinine, and serum calcium
Metastatic bone survey should be considered annually
because asymptomatic bone lesions may develop
39. Anemia (hemoglobin <10 g/dL or 2 g/dL below
normal)
Hypercalcemia (serum calcium >11.5 mg/dL)
Renal insufficiency (serum creatinine>2 mg/dL)
Lytic bone lesions or severe osteopenia
Extramedullary plasmacytoma
40. Conventional chemotherapy
Survival ≤ 3 yrs
Transplantation
Prolongs survival 4-5 yrs
Novel agents targeting stromal interactions and
associated signaling pathways have superiority over
conventional chemotherapy
- increased % total responders
- increased depth of response
41. Era of Novel therapy as frontline > Conventional
chemotherapy
Autologous transplantation (high dose chemotherapy
and stem cell rescue) still an option for younger
patients
42. Examples of current Novel agent combinations:
Thalidomide based : TD, CTD, MPT
Bortezomib (Velcade) based:
Vdex, VMP, CVD, PAD, VRD
Lenalidomide (Revlimid) based: LenDex, Lendex
43. Younger patients
Timing
Upfront after initial therapy with novel
agents
Salvage for relapse
Single vs Tandem (Double)
Low TRM - <3%
44. Age >70 years
Significant comorbities (organ function)
Poor performance status
45. Generally not recommended (outside of
clinical trials)
High incidence of GVHD
High TRM (> 40%)
46. Radiotherapy
Surgery
Bone care – bisphosphonates
Transfusions
Growth factors
Treatment and prevention of infections
Monitoring, management and prevention of
s/e
47.
48.
49. Unexpected new long-term complications
Second cancers
Long-term maintenance for survivors:
quality of life
Family/social problems
Financial/insurance concerns
Other
50. 50
MM patients are expected to live longer
Proper health maintenance contributes toward
longer survival and quality of life
51. Biochemical
- significant increase in M-protein
Clinical
- CRAB criteria
Importance of monitoring and follow-up
52.
53.
54. New drugs on the horizon
Carfilzomib
Pomalidomide
Panobinostat
Vorinostat
Elotuzumab
Old drugs with new use
Bendamustine
55. Be informed
http://myeloma.org
Group support
meetings
support groups
http://malaysianmedicine.com
– Myeloma Support Group
56. Myeloma Info mobile application
mobile browser:
http://malaysianmedicine.com/myelomainfo