We are international
Donate

Part II of IMF's 'Master Class' Brings Myeloma Doctors Together to Share Expertise

| 7 Comments | No TrackBacks
durieblog_app.jpg



Ist International Myeloma Working Group (IMWG)
Myeloma Training Course: Master Class
Day by Day Summary of Key Points



August 8, 2012
Dr. Robert Vescio 
STEP 4: Supportive Care: And How To Get It

  • The underlying biology of myeloma bone disease was presented
  • Dr. Vescio discussed the anti-osteoclast and potential anti-myeloma effects of bisphosphonates such as AREDIA�, ZOMETA� and Clodronate�
  • The Risk Factors for, and management of, ONJ were discussed. The current frequency of occurrence is approximately 3-5 % having been 5-10% only 5-10 years ago when there was much less awareness RE: Prevention and management strategies. A key aspect of prevention is to avoid tooth extraction for patients receiving bisphosphonate therapy. Expert dental consultation may be required to assess alternate management options. It appears that ONJ is rare in China (or rarely observed).
  • The benefits of vertebroplasty and kyphoplasty were discussed
  • A Range of other supportive care measures were discussed including:
    • Hypercalcemia management
    • Renal insufficiency or failure
    • Spinal cord compression
    • Infection complications
    • Hyperviscosity
  • As the Director of the Amyloid Center @ Cedars-Sinai Comprehensive Cancer Center, Dr. Vescio also discussed the biology, types , clinical features and management of amyloidosis both systemic and localized.
  • Cardiac amyloidosis was identified as the key high risk feature
  • It was emphasized to avoid simple oral MP (melphalan/prednisone) in treatment of amyloidosis
  • Conversely the value of VELCADE, REVLIMID and ASCT in selected patients was reviewed.
  • Review was provided by Dr. Yanchen Li from Chaoyang Hospital in Beijing

August 14, 2012
Bill Bensinger
STEP 5: Transplant: Do You Need One?

  • The Role of Transplant in 2012 was presented and discussed by Dr. Bill Bensinger
  • Options for Frontline induction pre-ASCT were again discussed. Regimens identified were:
    • VCD (Velcade/Cytoxan/Dex)
    • PAD (Velcade/Adriamycin/Dex)
    • VTD (VRD if available) (Velcade/Thalidomide or Revlimid/Dex)
    • Rd (Revlimid/low dose Dex)
  • The time of transplant was reviewed at length considering "early" versus "late" discussing the various PFS and OS outcomes
  • In general 4 cycles of induction were recommended before transplant, with a plan for transplant irrespective of Response in the absence of progressive disease. It was not recommended to continue or change induction with a view to achieving better response prior to proceeding to transplant.
  • It was emphasized that it is important to focus on quality of life (QOL) in considering alternative treatment strategies.
  • The standard preparative regimen for autotransplant is Melphalan 200 mg/m2.
  • A second transplant should rarely be considered as a planned tandem transplant. However, a second transplant can be considered if:
    • There is < VGPR with a first transplant and there was significant evidence of cytoreduction (response) with the first transplant.
    • If there is a > 2 year remission with a first transplant, especially if unmaintained
    • At relapse if there are limited alternative options
    • Earlier in the disease course if limited options exist
  • There was an extended discussion re: the pros and cons of post-transplant maintenance primarily in reference to the REVLIMID data in the IFM and CALBG trials. The doubling of PFS was noted as was the improved OS in the CALGB trial. Also noted was the increased occurrence of second primary malignancies (SPMs) - overall at about a 5-7% level in these settings.
  • Distinction was made between the rare 20 AML which is unfortunately usually rapidly fatal and the more common second solid malignancies which are typically well managed or curable and do not impact overall survival. Overall, the net benefit is therefore in favor of maintenance for a majority of patients.
  • In China, Thalidomide is available and is used for maintenance. VELCADE is also available, but too expensive for use in China. Revlimid is not yet available.
  • Potential novel transplant preparative regimens were discussed:
      • "VEL/MEL": VELCADE given prior to high-dose melphalan
      • Melphalan @ 280 mg/m2 using Amifostine as a protective agent
  • Protocols for stem cell mobilization were discussed including: G-CSF, G-CSF + Cytoxan and G-CSF + Prelixafor (MOZOBILTM) Mozobil is not available in China. Risk factors for "Mobilization Failure" were discussed.
  • Pre-transplant, it is important to identify and exclude patients with pre-existing MDS (can use Cytogenetics/FISH/FLOW analyses). Second harvesting can be carried out later in the disease course if necessary.
  • The very poor outcome with full allotransplant was noted. Although, rarely performed in the U.S.: it is still an option in China.
  • Overall guidelines for transplant were summarized:
    • Autotransplant: Still a standard of care if feasible
    • Allo transplant: Rarely indicated
    • Mini-Allotransplant Recommended for use in clinical trials for "High Risk" patients

August 9, 2012
Dr. Vincent Rajkumar
STEP 6: Response Assessment: Is Treatment Working?

  • Dr. Rajkumar first reviewed the basics of Response Criteria as outlined in the Uniform Response IMWG Manuscript of 2006.
  • Potential pitfalls were emphasized including
    • Relapse from CR or a very low level of M-component which requires both at >25% increase AND > 500 mg/dl increase on SPEP.
  • At higher levels of response the M-component increase be at least > 1.0 GMS/dl if lowest level of serum M-component is 5 Gm/dl
  • Dr. Rajkumar provided great caution about evaluating "responders" as a group, because many time dependent and other biases can account for improved outcomes
  • In addition the fact that improved progression free survival (PFS) may not lead to improved overall survival (OS) was reviewed in detail with examples from numerous trials
  • It was also emphasized that "High-Risk" and "Good Risk" patients must be identified and evaluated separately.
  • Surrogate markers were discussed. An M-Component is a surrogate marker which is usually quite reliable, but ultimately is only as indirect indicator of myeloma disease status. There can, for example, be light chain or Bence Jones escape when the Serum M-component can be misleading.
  • Cytogenetics and FISH, as well as, Gene Expression Profiling (GEP) are key prognostic factors which the Mayo Team has organized as part of the mSMART program available on the web.
  • A simple recommendation for 2012 is:
    • High-Risk: if feasible consider use of VRD (Velcade/Revlimid/Dex) induction
    • Standard (including Low) Risk recommended
      • VCD (Velcade/Cytoxan/Dex)
        Or
      • Rd (Revlimid/low dose Dex)

As Key Choices

  • In other situations consider:
    • DT-PACE for plasma cell leukemia or extramedually disease
    • VCD/VRD/VTD/PAD all to be considered for Relapsing Patients also
    • The current diagnostic criteria for Amyloidosis were reviewed
    • The current "Clinical Trials Program" at the Mayo Clinic was presented and felt to be an excellent and quite impressive impressive model for China.

7 Comments

My husband was diagnosed with multiple myeloma at Mass General Hospital in 'arch of 2011. Besides the few lesion on his skull, he was deemed in very good condition. After the standard first round of treatment, he was rushed to MGH and was soon diagnosed with amyloidosis of the GI tract. He remained at MGH until his death 35 days later.

My questions: I have two adult children. Are they at a higher risk for developing either MM or amyloidosis because their father had it? Can you explain what causes amyloidosis?

Than you,

Katy Bousquet

Is this information available in any type of webcast/teleconference that we can listen to?

Dr Durie, I want to Thank You for keeping us informed on Everything Myeloma in the world. I have learned so much from your articles and talks over the psat 1 1/2 years. I am starting a Support Group in Florida and I will be using all the information I have recieved from you to help others. And finally I want to thank you for choosing and staying in the Multiple Myeloma field of medicine and education. You are a God Send!!


Before 15 years I was involve with cars severe accident
Cause multiples fractures in bones.
Before 8 moths I was diagnosed as multiple myeloma disease.
Do we can find a connection between them?

My husband was diagnosed with multiple myeloma in 2008. He was diagnosed in the early stages of the disease and underwent chemo for 6 months. To this date the cancer is at a "controllable" level and he still has no known lesions on his bones.
My husband was employed at a naval shipyard and was exposed to various environmental elements. We know of others he worked with having similar cancers. Has any study been conducted to show how many patients were employed at a government facility who contracted multiple myeloma or similar cancers

Gladys C,
I was diagnosied in 12/06 at the young age of 43 . I grew up next to an army base in NNY where agent Orange was tested back in the 60s. I have researched that particular chemical and the US Govt has acknowledged a correlation between contact with that chemical and cases of MM. Unfortunately there us nothing we can do at this point as it ws taken to the highest courts we have and a judgment was made then and Govt employess are covered but as civlians we are left to fight on our own. :) I am convinced that poor dispossal was the cause of mine and the many many others in this area, cancer cell, who are fighting or have lost their lives. Thats all behind me now and I just go on fighting and enjoying thetime I have with those that I love.faith is strong treatment,
Good luck to you and you husband

Interesting update on maintenance therapy, but I am curious to know if the experts discussed consolidation therapy?

Leave a comment

To subscribe to this blog, enter your email address below: