Sarah Newbury, the first reported patient with multiple
A) Bone destruction in the sternum. (B) The patient with fractured
femurs and right humerus. (C) Bone destruction involving the femur.
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
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
Is not known for sure
Decline in the immune system
Exposure to certain chemicals
Exposure to radiation
Cancer of plasma cells.
Plasma cells come from B lymphocytes, and produce
Myeloma cells produce abnormal immunoglobulins.
– Overproduce monoclonal protein or paraprotein.
– Ineffective immunoglobulins.
– Leads to decreased bone marrow function.
– Destruction of bone tissue.
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
• Currently incurable in most patients.
• Long-term complete responses are rare.
• Median survival with standard therapy about 3
• 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.
Indications for treatment
Eligibility for stem cell transplantation
Deferral of chemotherapy until progression to
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
Anemia (hemoglobin <10 g/dL or 2 g/dL below
Hypercalcemia (serum calcium >11.5 mg/dL)
Renal insufficiency (serum creatinine>2 mg/dL)
Lytic bone lesions or severe osteopenia
Survival ≤ 3 yrs
Prolongs survival 4-5 yrs
Novel agents targeting stromal interactions and
associated signaling pathways have superiority over
- increased % total responders
- increased depth of response
Era of Novel therapy as frontline > Conventional
Autologous transplantation (high dose chemotherapy
and stem cell rescue) still an option for younger
Examples of current Novel agent combinations:
Thalidomide based : TD, CTD, MPT
Bortezomib (Velcade) based:
Vdex, VMP, CVD, PAD, VRD
Lenalidomide (Revlimid) based: LenDex, Lendex
Upfront after initial therapy with novel
Salvage for relapse
Single vs Tandem (Double)
Low TRM - <3%
Age >70 years
Significant comorbities (organ function)
Poor performance status
Generally not recommended (outside of
High incidence of GVHD
High TRM (> 40%)
Bone care – bisphosphonates
Treatment and prevention of infections
Monitoring, management and prevention of
Unexpected new long-term complications
Long-term maintenance for survivors:
quality of life
MM patients are expected to live longer
Proper health maintenance contributes toward
longer survival and quality of life
- significant increase in M-protein
- CRAB criteria
Importance of monitoring and follow-up
New drugs on the horizon
Old drugs with new use
– Myeloma Support Group
Myeloma Info mobile application