Myeloma + Plasma Cell Disorders: talking about MM, MGUS, WM, and AL

1. Myeloma and
Plasma Cell Disorders
4/12/2017
Larry Anderson, MD, PhD
Director, Myeloma, Waldenstrom’s,
and Amyloidosis Program

2. Plasma Cell Disorder Spectrum
 Monoclonal Gammopathy of Undetermined
Significance (MGUS)
 Smoldering/Asymptomatic Myeloma (SMM)
 Symptomatic Multiple Myeloma
 Solitary Plasmacytoma (Bone vs Extramedullary)
 Waldenström’s Macroglobulinemia (WM)
 Primary Light Chain Amyloidosis (AL)

3. MGUS
62% (803)
Myeloma
15% (193)
Amyloidosis
(AL) 8% (130)
Lymphoproliferative
2.5% (31)
SMM
3.5% (44)
Solitary or extramedullary,
1.5% (20)
WM, 3% (41)
Other, 2.5% (34)
n=1296
Distribution of Monoclonal Gammopathies
Kyle RA and Rajkumar SV. Cecil Textbook of Medicine, 22nd Edition, 2004

4. Initial Diagnostic Workup
 CBC
 Chem panel
 Calcium/albumin
 Quant Ig (IgG,A,M)
 Immunofixation
Electrophoresis (not
just SPEP which can
miss small spikes)
 Serum Light Chains
 Bone Marrow
Biopsy
 24-hour urine
UPEP/immunofix
 Beta2-microglobulin
 Skeletal survey
 If skel survey neg
but symptoms get
MRI and/or PET/CT

5. Dispenzieri A, Gertz MA, et al.
Mayo Clin Proc 2001;76:476-87
61% Liver disease
22% CTD
6% Chronic infxn

6. Immunofixation
(IFE)

7. Criteria for Diagnosis of Myeloma
MGUS
 <3 g/dL M spike
 <10% PC
AND
Smoldering MM
 3 g M spike
 OR 10% PC
Symptomatic
Myeloma
10% PC
+/- M-spike
AND
NO CRAB ≥ 1 CRAB:
Calcium elevation,
Renal dysfunction
Anemia (Hgb <10)
Bone lesions

8. Ultra High Risk SMM = Active Myeloma
Not CRAB but now SLiM CRAB
•S (60% PCs)
•Li (Light chains I/U Ratio >100)
•M (MRI >1 focal lesion)
•C (calcium elevation)
•R (renal insufficiency)
•A (anemia)
•B (bone disease) Lancet Oncology 11/2014

9. Risk Factors for Progression of MGUS to MM
• M-spike > 1.5 g/dL
• Non-IgG Subtype (IgA or IgM)
• Abnormal Serum Free Light Chain Ratio
Any of these 3 factors (or CRAB) warrants a BM Bx,
imaging, and closer follow-up
IgG 1% per year, IgM MGUS 1.5% per year
Rajkumar et al., Blood 2005 and Blood Reviews 2007.
Risk Factors for Progression of SM to MM
• M-spike > 3 g/dL
• PCs >10%
• Abnormal Serum Free Light Chain Ratio

10. Probability of Progression to Active/Symptomatic
MM in pts with Smoldering MM or MGUS
Kyle RA et al. N Engl J Med 2007;356:2582-2590
These patients DO NOT require treatment!!
(unless the progress to Symptomatic MM).
Many NEVER require treatment!

11. Management of MGUS and SMM
 MGUS:
– Avg 1% per year progression to MM
– If NO risk factors, repeat labs in 6 mo and
then q 1-2 years
– If any risk factor, repeat labs q 6 mo x 1 yr
and then yearly
 Smoldering MM (Stage I):
– Avg 10% per year prog to Sx MM
– Repeat labs q 3-4 months
– Skeletal survey yearly

12. Multiple Myeloma Classic Triad
M-Spike
>10% Malignant Clonal Plasma
Cells in Bone Marrow
Lytic Bone
Lesions

13. Durie-Salmon Staging System for Myeloma
Stage Criteria
I All of the following:
Hemoglobin >10 g/dL
Serum calcium level normal
Normal bones or solitary plasmacytoma on X-Ray
Low M component production rate:
IgG <5 g/dL; IgA <3 g/dL
Bence Jones protein <4 g/24 hr
(Smoldering Myeloma – does not need treatment)
II Not fitting stage I or III
III One or more of the following:
Hemoglobin <8.5 g/dL
Serum calcium level >12 mg/dL
Lytic bone lesions on x-ray
High M-component production rate:
IgG >7 g/dL; IgA >5 g/dL
Bence Jones protein >12 g/24 hr
Durie B, Salmon S. Cancer. 1975;36:842; Multiple Myeloma Research Foundation.
Subclassification Criteria
A Normal renal function (serum creatinine level <2.0 mg/dL)
B Abnormal renal function (serum creatinine level 2.0 mg/dL)

14. Greipp PR, et al. Blood 2005
INTERNATIONAL STAGING SYSTEM

15. REVISED INTERNATIONAL STAGING SYSTEM
R-ISS

16. Multiple Myeloma Facts
 2nd most common Hematologic Malignancy
 ~30,330 people Dx with MM in 2016 in US
 65,000 people in the US living with myeloma
 12,650 MM patients die each year in US
 Median age at Dx 65-68 years (only 4% <45)
 Incidence twice as high in African Americans

17.  More frequent in men (1.3:1)
 bone/back pain, fatigue/anemia or infections
 This disease remains incurable in most patients
 Median survival with older therapies 3yrs, with
transplant 5-7 years, and with novel therapies +
transplant probably 8-10 years (see graph)
 M protein seen in 99% of cases in serum and/or
urine, IgG > 50%, IgA 20-25%, IgE/IgD 1-3%,
light chain only 5-10%, 1% nonsecretory
Multiple Myeloma Facts

18. Management of
Active/Sympotomatic MM
 Those patients with CRAB (Stage II or III
Disease) need treatment
 Even Active MM outcomes can vary widely,
and there are many treatment options
– Need to stratify prognosis based on risk
factors and whether or not the pt is a stem
cell transplant candidate
– mSmart System

19. Mayo Stratification of Myeloma and
Risk-Adapted Therapy (mSMART):

20. Year Milestone Notes
1962
Melphalan-
prednisone (MP)
Introduction of melphalan in the 1960s associated with
improved survival. More intense chemotherapy
regimens increased response rates, but no
improvement in survival compared to MP
1996 Autologous SCT
Several randomized trials demonstrated a survival
advantage for ASCT compared to conventional
chemotherapy (CCT).
1999
Thalidomide
(Thalomid)
First IMID: Improved response rates and PFS compared
to dexamethasone alone. When added to MP, it
improves survival compared to MP alone
2003
Bortezomib
(Velcade)
First Proteasome Inhibitor (PI): improves survival
compared to high-dose Dex in relpased MM, and VMP
improves survival in newly Dx pts compared to MP
2006
Lenalidomide
(Revlimid)
2nd Gen IMID: Given with weekly dex, improved survival
compared with dex in relapsed myeloma
2012
Carfilzomib
(Kyprolis)
2nd Gen PI: 22% Response rate if refractory to both Vel
and Rev. Also KRd better than Rd, updated approval in
2015
2013
Pomalidomide
(Pomalyst)
3rd Gen IMID: 30% Response rate if refractory to both
Vel and Rev (Only works if given with weekly Dex)
MAJOR MILESTONES IN MYELOMA THERAPY

21. Year Milestone Notes
2015
Panobinostat
(Farydak)
Pan Histone Deacytylase Inhibitor. Approved in combination
with Velcade for Relapsed MM
2015 Ixazomib (Ninlaro)
First Oral Proteasome Inhibitor: Given once weekly days
1/8/15 along with Rev and Dex for relapse. Much less
neuropathy risk.
2015
Daratumumab
(Darzalex)
Anti-CD38 Monoclonal Antibody. 29% Response rate
alone. (Also can be combined with Rev or Pom per ASH
data and Vel per ASCO data). Initially Required 3 prior
Lines of Therapy
2015
Elotuzumab
(Empliciti)
Anti-SLAMF7 (CS1) Monoclonal Antibody. Must be given
along with IMID such as Revlimid for activity. Requires
only 1 prior line of therapy
2015
Carfilzomib
(Kyprolis) updates
Approved as triple therapy with KRd (superior outcomes in
Aspire vs Rd) and also as high dose 56 mg/m2 (superior
outcomes in Endeavor vs Vd)
2016
Daratumumab
updates
Approved as triple therapy with Len/dex and Vel/dex for 2nd
line therapy
2017
Lenalidmide
Maintenance
Approved
MAJOR MILESTONES IN MYELOMA THERAPY

22. Therapeutic algorithms for newly diagnosed
patients with plasma cell myeloma
Induction Consolidation
Front line treatment
Maintenance
Maintenance
Salvage
Relapsed
Rev/Dex, Vel/Dex
RVD, VCD
CTD, VTD, VDD,
MPT, MPV, MPR
Auto-SCT
None
Rev
Thalidomide
Prednisone
Velcade
Clinical Trial
Whatever worked
before or
haven’t tried

23. International Myeloma Working Group
Uniform Response Criteria
Durie BGM, et al. Leukemia. 2006;20:1467-1473.
PR: ≥ 50% reduction in serum M-protein
VGPR: > 90% reduction in M-protein
Near CR: Negative SPEP/UPEP but POSITIVE Immunofixation
(Faint monoclonal band but too small to quantitate)
CR: Negative SPEP AND Negative Immunofixation (serum and urine)
Stringent CR: CR + Normalization of free light chain ratio
(serum free light chain assay), <1% plasma cells (NOW
proposing new criteria for absence of aberrant cells on flow
cytometry due to better survival in these pts)
Anything VGPR or better considered a “Deep Remission”

24.  Autologous peripheral blood stem cells collected by
apheresis, frozen, later used as a “rescue” from marrow
ablative effect of high dose chemo
 Introduced in the 1980’s, several randomized trials in the
1990’s and early 2000’s using high dose melphalan and
ASCT showed improved PFS and Overall Survival
 Generally see 1-2 year survival increase compared to
conventional chemotherapy
 SOC since the 1990’s and remains today
Attal M, et al. N Engl J Med 1996;335:91-7. Child JA, et al. N Engl J Med 2003:1875-83.
High Dose Chemotherapy with
Autologous Stem Cell Transplantation (ASCT)

25. 54
42
Attal M, et al. N Engl J Med. 1996;335:91-97. Child JA, et al. N Engl J Med. 2003;348:1875-1883.
15 30 45 60
25
50
75
100
OS(%)
0
0
High dose (ASCT)
Conventional dose
Mos
20 40 60 80
25
50
75
100
Survival(%)
0
0
High Dose (Auto SCT)
Standard therapy
Mos
P = .03
ASCT vs Conventional
Chemotherapy

26.  At our transplant center we transplant Myeloma
patients up to age 75, depending on comorbidities
 Generally done after 3-6 cycles of induction therapy
but also possible to store stem cells and hold off on
transplant until later relapse
 Tandem ASCT subgroup analysis shows benefit only
in pts not achieving VGPR after first SCT
 Allogeneic SCT may “cure” small subset of patients
but very toxic due to GVHD and no clear benefit over
Auto
Attal M, et al. N Engl J Med 2003;349:2495-502
ASCT, cont’d

27. NOVEL THERAPIES
• Not traditional chemotherapy (which
kills both cancer and healthy cells by
attacking cell division)
• These drugs target the cancer cells by
attacking other pathways besides cell
division and are more cancer specific,
often less toxic

28. Thalidomide (Thalomid)
 First “Novel Agent” (non-chemo) routinely used for
therapy of myeloma (other than steroids) (ORAL!)
 Several Mechanisms:
 Stimulation of T-cells and natural killer cells
(Hence the term “Immunomodulatory” agent = IMiD)
 Anti-angiogenesis properties (decreased VEGF)
 Suppress Myeloma growth factors: IL-6, TNF-alpha
 Inhibits myeloma cell adhesion to stroma
 Side Effects:
 Teratogenic!!
 Peripheral Neuropathy!!!
 DVT/PE (requires full anticoag),
 Constipation, and Sedation

29. MECHANISM OF IMIDS
Teo SK.. AAPS Journal. 2005

30. Bortezomib (Velcade)
 First-in-class proteasome inhibitor, approved 2003 (IV)
 Potentiates sensitivity of myeloma to both
conventional and novel therapeutic agents (IV or SQ)
 Mechanism of action
– Reversible inhibitor of 26S proteasome
– Inhibition of proteasome prevents proteolysis of ubiquitinated
proteins
– disrupts homeostasis, leads to apoptosis
– Overcomes t(4;14) and del 13q (now intermediate) but not 17p
 Side Effects:
• Peripheral Neuropathy!
• Decreased by SQ or q week
Decreased Plt or WBC
Zoster due to IC

31. Armand J et al. The Oncologist 2007;12:281-29
PROTEASOME INHIBITION BY BORTEZOMIB.

32. Lenalidomide (Revlimid)
 FDA approved in 2005
 More “potent” immunomodulator than thalidomide
 Up to 50,000 times more potent inhibitor of TNF
 Fewer side effects compared to thalidomide:
 no neuropathy, less constipation, less VTE (ASA
prophylaxis), and sedation; more
myelosuppression/cytopenias
 May be teratogenic so same safety precautions
 Oral (d1-21, 1 wk off)
Schey SA et al. J Clin Oncol. 2004;22:16
Richardson P, Anderson K. J Clin Oncol. 2004;22:16

33. Novel Agents
+ ASCT
ASCT

35. VAD TD RD VTD CVD RVD CVRD

36. Combinations of Novel Agents
 3 Drug Regimens (especially those that have 2
novel agents) improves response rates and
chances of deep remission
 VRD and CyBorD (VCD) are very well tolerated and
97% response rates
 Adding a 4th drug (VRCD, VMPT) may slightly
increase response rate but increases toxicity and
not yet shown to have survival benefit
 All patients will eventually relapse

37. Lenalidomide Maintenance Effect on PFS

38. Lenalidomide Maintenance Effect on OS
Only gave 2 years and stopped,
while American study gave
Until PD

39. Relapse Therapy

40.  Tetrapeptide epoxyketone
 Novel proteasome inhibitor
– Binds irreversibly, given by IV infusion (2 d/wk)
 Active in 22% of MM pts refractory to Velcade and
Revlimid (and may be more powerful than velcade
in up-front therapy but studies ongoing)
 Mainly Hematologic toxicity, Peripheral Neuropathy
RARE (despite being similar to Velcade)
 FDA Approved July 2012 (only for those that are
relapsing after prior velcade and revlimid)
 2015 approved in combo with Rev/dex
Carfilzomib (Kyprolis)
1. Kuhn DJ, et al. Blood. 2007;110:3281-3290. 2. O’Connor OA, et al. Clin Cancer Res. 2009;15:7085-
7091. 3. Vij R, et al. Blood. 2012;[Epub ahead of print].
Carfilzomib
O O O O
O O
O
N N
H
N
H
H
N
H
N

42. New IMiDs (more potent, less toxic)
Pomalidomide - 30% Response in Rev and
Vel-Refractory pts (FDA approved 2/2013)

43. 3 Recently approved Therapies
New Proteosome Inhibitors (ORAL)
Ixazomib (Ninlaro) – weekly pill combined
with Rev/Dex in relapsed pts (Triple Oral
Therapy without neuropathy!!!)
Monoclonal Antibodies targeting PCs
Daratumumab (monoclonal antibody targeting
CD38), single agent responses 29%, combined
with Imid OR Velcade 83-93% (initially 4th line
but now 2nd line therapy!)
Elotuzumab (Anti-CS1/SLAMF7) ~ 80%
Response in Relapsed pts combined with
Rev/dex but not alone (activates NK cells)

44. Supportive Care
Don’t Forget:
 Bisphosphonates
 Monthly 1st year, then q 3 months 2nd year
– Dental eval before starting to avoid needing dental
extractions and risk of ONJ
 Surgery (repair impending hip fractures)
 Kyphoplasty/Vertebroplasty for compression Fx
 Acyclovir with Velcade
 Dialysis
 Collect stem cells before too much myelotoxic
therapy (Avoid Mel or >4 cycles of Rev)

45. Conclusions
 Between the 60’s and 90’s there was nothing better than
MP for Myeloma and survival was dismal
Survival improved with high dose chemo and ASCT
No new MM drugs approved for 4 decades from the 60’s
until 2003 but now we have 4 highly active Novel agents
approved over the past 9 years
Survival is Improving in Myeloma with combinations of
Novel Agents and Auto SCT over the past decade
Although we have effective therapies, all MM pts relapse
and become refractory to all therapies so we need more
Not known if combinations of these new drugs will make
myeloma curable vs a chronic disease

46. Topics if time allows:
Plasmacytoma
Amyloidosis
Waldenstrom’s and POEMS

47. PLASMACYTOMA
 Can be solitary or multifocal
 Can arise in bone or soft tissue (Extramedullary)
 Most common EM location is the upper resp tract
(80%), 10yr DFS 70-80%. (10-15% develop MM)
 Bone plasmacytomas higher risk of progression to
MM (10yr DFS 25-50%)(50-60% develop MM)
 Treatment of solitary is local radiation +/- surgery
(The only curable plasma cell disorder)
 Multifocal plasmacytomas treated like myeloma.

48. AL Amyloidosis
 Deposition of fibrillar light chains in tissues that is
detected by Congo red staining (green birefringence)
 Median age at presentation 65yrs, med survival 13mo
 Can be localized or systemic (primary systemic
amyloidosis)
 Range of presentation: nephrotic syndrome,
cardiomyopathy, macroglossia, neuropathy, skin lesions
 Dx based on biopsy and presence of M spike in serum or
urine and Mass Spec at Mayo for subtyping.
 No systemic treatment needed for localized deposits,
only symptom relief
 Systemic disease treated similar to myeloma (Auto
PBSCT or novel agents like Velcade).
 Worse prognosis if elevated BNP, troponin, septal
thickness >13mm, multiple organ dysfxn

49. Combined Bone Marrow and Fat Pad: 89%

51. - 94% response rate, 71% complete hematologic response,
24% partial response
- Time to Light Chain response was 2 months but organ
response 6 months.
- 3 pts originally not eligible for ASCT became eligible .
- 50% had a 50% decrease in proteinuria.
- Of the 7 pts monitored for cardiac biomarkers, 5 improved
(with 3 normalized)

53. Characteristic combination of :
Monoclonal IgM protein (Immunoglobulin) secretion
Infiltration of the bone marrow with clonal
lymphoplasmacytic Lymphoma (LPL) cells
90% have mutation in MyD88 gene in the LPL cells
1% are Non-IgM and called LPL but not WM
Cause Unknown but can run in families in 20%
Diagnosis of Waldenström’s Macroglobulinemia (WM)
aka Lymphoplasmacytic Lymphoma (LPL):

54. Signs/Symptoms of WM/LPL
 Low blood counts (Marrow replacement)
• Anemia (Hgb <10) or Low platelets (Plt <100)
 Hyperviscosity (Sludging due to very high IgM)
• Dizziness, blurry vision, nose bleeds (Medical
Emergency)
 Enlargement of spleen, liver or bulky lymph nodes (>5cm)
 4% with Neuropathy (anti-MAG, Sulfatide, GM1, etc)
 Cold Agglutinins or Cryoglobulins (monoclonal)
 Fevers/Night Sweats/Weight Loss
 Systemic Amyloidosis

55. Therapy for Symptomatic
Waldenström’s Macroglobulinemia
 No treatment for Smoldering WM (Risk of progression
similar to SMM 4-10% per year)
 Plasmapheresis for temporary control of hyperviscosity
 First-line treatment options in WM
– Alkylating agents, rituximab, proteasome inhibitor, steroids
 Best response w/ combination Bendamustine/Rituximab,
Cytoxan/Rituxaimab, Bortezomib/Rituximab/Dex
 Single agent Rituxan VERY effective and minimally toxic
 Avoid single agent Rituxan if IgM >5000 due to >50%
risk of IgM “Flare”
 Ibrutinib (btk inhiitor) approved 2012 (oral tki) and the
ONLY FDA approved therapy for WM

56. POEMS SYNDROME
(aka: Osteosclerotic Myeloma)
Polyneuropathy
Organomegaly
Endocrinopathy
Monoclonal protein (usually IgA)
Skin changes

57. Criteria for the diagnosis of POEMS syndrome
Mandatory major criteria (both required)
Polyneuropathy
Monoclonal plasma cell proliferative disorder (95% are lambda)
Other major criteria (one required)
Sclerotic bone lesions
Castleman's disease
Elevated levels of vascular endothelial growth factor (VEGF)*
Minor criteria (one required)
Organomegaly (splenomegaly, hepatomegaly, or lymphadenopathy)
Extravascular volume overload (edema, pleural effusion, or ascites)
Endocrinopathy (adrenal, thyroid, pituitary, gonadal, parathyroid,
pancreatic, DM)•
Skin changes (hyperpigmentation, hypertrichosis, hemangiomata,
plethora, acrocyanosis, flushing, white nails)
Papilledema
Thrombocytosis/polycythemia
The diagnosis of POEMS syndrome is confirmed when both of the mandatory major criteria,
one of the three other major criteria, and one of the six minor criteria are present.
• In order to consider endocrinopathy as a minor criterion, an endocrine disorder other than diabetes or
hypothyroidism is required since these two disorders are common in the general population.

58. • VEGF mediated in part (not the paraprotein)
• Both sensory and motor symptoms are
distal, symmetric, progressive
• Severe weakness in >50%, chronic
inflammatory demyelinating
polyneuropathy.
• Sural nerve Bx usually shows both axonal
degeneration and demyelination
• Response to therapy based on (IFE, light
chains, VEGF level), imaging studies (if PET
avid mass), and later symptom
improvement.
• Neuropathy takes ~3 months to stabilize, 6
mo to begin to improve, 2-3 yrs for max
improvement after SCT
POEMS syndrome

59. Case #1
 55 y/o WF with h/o early Breast Cancer 2001
(lumpectomy/radiation, aromatase), early
Uterine Cancer 1999 (TAH/BSO), hypothyroid,
on routine f/u late 2008 noted to have elevated
total protein 8.9, globulin 4.9 (actually stable)
 Further workup showed M-spike 2.4 IgM Kappa,
Total IgM 3630, Free Kappa 93.1mg/L, K/L 50.9,
Viscosity 1.9, Beta 2 Micro 2.6, Hgb 12.4, Plt 339
 Bone Marrow Bx done 1/2/09: LPL involving
50% of cellularity, aspirate diff shows 31%
Lymphs + 8% PCs, Flow shows clonal Kappa
Restricted LPL
 What Treatment would you start??

60. Case #1, cont’d
 No Splenomegaly, bulky adenopathy,
Cytopenias, B-Symptoms, hyperviscosity,
Neuropathy, skeletal survey neg, CT C/A/P
neg
 Therefore “Smoldering WM” and NO need
for treatment
 Watch and wait with repeat labs and
checkup every 3 months the 1st year, q4
months the 2nd year, then at least every 6
months if stable with no progression
 Graph of IgM and M-spike …….

61. Case Scenario #1, cont’d
IgM Over Past 7 Years (Observation Only)

62. Case #2
 80 y/o WF with increasing back pain,
osteoporosis, compression fractures but no
lytic lesions. Workup showed anemia w/
Hgb 9.5, elevated total protein, M-spike >
3 g/dL
 Referred for Treatment of “Multiple
Myeloma”

63. Case #2
 Don’t forget to do the immunofixation and
quantitative immunogloblins:
 IgM 6380, M-spike 3.6 g/dL IgM Lambda, Hgb
9.1, viscosity 2.3, Beta 2 Micro 4.74, Lambda 60
 BMBx showed similar findings to the previous
case with 54% Lymphoplasmacytic Infiltrate.
Imaging confirmed several compression fractures
and osteoporosis but NO lytic lesions

64. Case #2, cont’d
 IgM >5000 but elderly, no hyperviscosity,
tried the oral cytoxan in combination with
Rituxan (DRC) but had terrible nausea with
one dose of oral cytoxan so changed to
single agent Rituxan and did well without
flare
 4 weekly doses followed by another 4
weekly doses 3 months later (weeks 12-
15)
 Graph of IgM …….

65. Case #2
IgM Over Past 6 Years
Rituximab 4 wkly doses repeated at 3 months apart
(2/09, 5/09 followed by 3 year remission, then 2/12, 5/12
now 1 dose q 3 mo Maintenance)
IgM Continued to Improve
on Maintenance
Q 3 month dosing, off
maintenance 3 years and
IgM 120 now (normal 230)

66. Case #3
 62 y/o WF (Daughter of Case #2)
 Was seeing PCP at UTSW for back pain and URI, found to
have elevated total protein
 1/6/14: Returned to PCP for results of SPEP: M-spike 2.27
g/dL. She called me and I saw her for new pt consult same
day expecting to see WM!
 Kappa FLC 174, IgM 5686, BMBx showed 30-40% PCs,
Kappa restricted, IgM+, Cyclin D1+, FISH showed t(11;14)
 Xrays: subcortical lucency of the left hip greater trochanter,
1.5cm lytic lesion of L1 on PET/CT so Stage IIA IgM
Myeloma
 Failed Rev/dex, 92% VGPR to VRD, stable VGPR s/p SCT for
2 years, then failed Ninlaro, Pom, now responding to
Dara/Pom/Dex combo

67. Questions ?