Preliminary Case Evaluation: An
Interactive Assessment of Audience
Treatment Options
Morie A. Gertz, MD
Case 1 N.B.
· 59-year-old right-sided rib pain
· X-ray clavicular fracture
· Needle biopsy plasma cells clonal
kappa
· Aspirate 22%; biopsy aggregates;
Labeling Index (LI) 1%
Case 1 N.B.
· Hb 12.6, Ca++9.3, Cr 0.8
· Serum 1.0 g/dL
· Immunofixation neg
· Urine 0.043 g immunofixation
· Quantitative immunoglobulins normal
Conventional Cytogenetics
· 45,X,X,+1,add(6)(q23),i(8)(q10),del(13)
(q12q22),-14,add(14)(q32),-15, +16,
der(16)t(1;16)(q21;q12.1),+17, -20,
+mar[1]/46,XX[29]
· -2 microglobulin 2.37
Question 1
Would you include FISH as part of your
initial work up for this patient?
1 = Yes
2 = No
Question 2
Would you include an MRI as part of your
initial work up for this patient?
1 = Yes
2 = No
Question 3
Would you include a PET scan as part of
your initial work up for this patient?
1 = Yes
2 = No
Clavicular
Plasmacytoma
Myeloma
demonstrating
classic lytic
bone disease
Question 4
What is appropriate induction therapy for
this patient with myeloma?
1. VAD
2. DEX
3. THAL/DEX
4. DT-PACE
5. Bortezomib +/- DEX-based therapies
6. Other
Initial Therapy Case 1
· Dexamethasone, bisphosphonates
· Declined use of liposomal
doxorubicin
· After 8 months of dexamethasone
­Stem cells collected mobilized
with Cyclophosphamide &
Filgrastim
­Yield 10x106 in 3 collections
Question 5
For patients who are candidates for
autotransplants, how many
autotransplants does one prepare for?
1. One transplant
2. Two transplants
3. Three transplants
4. More than 3 transplants
Next Therapy
· Pretransplant marrow 26%, labeling
index 0.6%
· Defers autotransplant
· Observed 20 months after diagnosis
· Urine 137 mg, 65 mg ;
FreeLite Chain 49.1 mg/dL
· Transplant discussed
Next Therapy
· Elects MP but after 7 months FreeLite
Chain up to 72 mg/dL
· Hemoglobin 6.7
· EPO level 1022, Marrow 42%, LI 2.2%
· 45,X,-X,
+add(1)(p13),t(6;15)(p12;p12),+9, -13,
-14,add(14)(q32),+19, -20[8]/46,XX[12]
· MEL 200 autotransplant
Case 1 Posttransplant
· Near-CR
· FreeLite Chain 9 mg/dL (4 X normal)
· Urine immunofixation+, no peak
visible
Question 6
What is appropriate maintenance
therapy in patients with initial CR,
near CR, or Very Good PR?
1. THAL
2. THAL + steroid
3. Steroid alone
4. No maintenance therapy
5. IFN
6. Other
Case 1
· Relapse 5 months later FreeLite
Chain 182 mg/dL
· Urine 4471 mg/Day
Question 7
When patient relapses after transplant, what
is appropriate therapy?
1. THAL-based therapy
2. Bortezomib-based therapy
3. Standard melphalan-based therapy
4. Steroid-based therapy
5. Transplant-based therapy
Case 2 R.K.
· 60-year-old localized adenocarcinoma
breast right-modified-radical-mastectomy
· Urine grade 1 protein
· 3 years later urine protein grade 3
· Hb 12.4, Ca++9.7, Cr. 0.9, 0.94
immunofixation , urine 811 mg spike
745 mg (92%)
· Marrow 12% PC's labeling index 0%
2-Micro 2.3
· Bone radiographs negative
Question 8
For patients who are NOT candidates for
autotransplant (or decline), what is appropriate
initial therapy?
1. Standard melphalan + prednisone (MP)
2. MP + THAL
3. THAL/DEX
4. VAD
5. All patients are candidates for melphalan-
dose-adjusted transplant
Question 9
What do you think is the minimal indication
for treatment of MM?
1. Rising levels of urinary light chain
2. Bone lesions by MRI
3. Elevated 2-microglobulins
4. Hb of 11 or higher
5. None of the above
Case 3 B.S.
· 66-year-old slips on stairs,
lancinating back pain, grade 8/10
· Hb 10.2, 4.6, Ig G 7140 aspirate 8%
PC's, biopsy small aggregates >20%
· 2-microglobulin 3.08
Multiple
Compression
Fractures
Question 10
What is the most appropriate intervention
for this patient with 6 weeks of persistent
pain and no neural deficit?
1. Bed rest
2. Bracing
3. Pain medications
4. Vertebral augmentation
5. Bisphosphonates
Case 4 J.R.
· 35-year-old, nausea and vomiting to ER
­ Hb 8.6, Ca++13.3, Cr 2.0
· Urine 6080 2.7 IgG, Fanconi's syndrome
· Marrow 80% PC, labeling index 4.5%
· 45-50,X,-X, add(1)(q21), del(1)(p13p32), +7,+11,
del(13) (q12q22), +15, der(16)t(1;16)(q23;q13),
+19,der(19;21)(p10;q10), +21[cp10]/46,XX[10]
· Dex for 4 months
­ Autotransplant MEL 200
­ Achieved CR
Question 11
What do you think is the most appropriate
type of transplant today?
1. Single auto
2. Scheduled tandem auto
3. Scheduled tandem "auto/mini-allo"
4. Single auto / late auto at relapse
5. Scheduled tandem auto / late auto at
relapse
6. New agents eliminate need for transplant
Case Evaluation Revisited
Morie A. Gertz, MD
Question 1
Would you include FISH as part of your
initial work up for this patient?
1 = Yes
2 = No
Question 2
Would you include an MRI as part of your
initial work up for this patient?
1 = Yes
2 = No
Question 3
Would you include a PET scan as part of
your initial work up for this patient?
1 = Yes
2 = No
Posttransplant Case 1
RELAPSE 6
MONTHS POST-
AUTOTX
Bilateral Ureteral
Obstruction Anuria
Biopsy:
Plasmacytoma
Stents placed
Question 4
When patient relapses after transplant, what
is appropriate therapy?
1. THAL-based therapy
2. Bortezomib-based therapy
3. Melphalan-based therapy
4. Steroid-based therapy
5. Transplant-based therapy
Salvage Therapy Case 1
· B-LTD salvage
­FreeLite Chain falls from
182 to 36.9 mg/dL
­Urine 4471 to 1641
­Zoster R C5
· Relapse after 5 months
­FreeLite Chain 498 mg/dL,
Urine 4859, LDH 571
Case 1
· Treated with single-agent Bortezomib
­No response
· Progressive cachexia, dies
41 months postdiagnosis, 11 months
post-salvage autotransplant
Question 5
What do you think is the minimal indication
for treatment of MM?
1. High levels of urinary light chain
2. Bone lesions by MRI
3. Elevated 2-microglobulins
4. Hb of 11 or higher
5. Other
Question 6
For patients who are NOT candidates for
autotransplant (or decline), what is appropriate
initial therapy?
1. Melphalan + prednisone (MP)
2. MP + THAL
3. THAL/DEX
4. VAD
5. All pts are candidates for autotransplant
Question 7
What is appropriate maintenance
therapy in patients with initial CR,
near CR, or very good PR?
1. THAL
2. THAL + steroid
3. Steroid alone
4. No maintenance therapy
5. IFN
6. Other
Case 2
· Observation for 10 years + 4 months.
Urine protein rose steadily over the
10 years.
· May 1999: urine 4288, 97%
· Offered participation in clinical trial of
Thal for asymptomatic myeloma
· Marrow 52% PCs
· Thalidomide 4 months @ 600 mg/Day
Question 8
What is appropriate induction therapy for this
patient with myeloma?
1. VAD
2. DEX
3. THAL/DEX
4. DT-PACE
5. Bortezomib +/- DEX-based therapies
6. Other
Case 2
· Urine 4096 off-study therapy failure
· Back to observation for 20 months
· June 2001: Hb 9.6, urine 6708 weight-
bearing pain, bone x-rays negative
Case 2
Case 2
· MP June 2001 to October 2001: urine
2449
· Resumed MP July 2002 to March 2004:
urine 3488 to 403
· September 2004: urine 774 observed @
16 years postdiagnosis
Question 9
What is the most appropriate intervention
for this patient with 6 weeks of persistent
pain and no neural deficit
1. Bed rest
2. Bracing
3. Pain medications
4. Vertebral augmentation
5. Bisphosphonates
Case 3
Case 3
Case 3
Case 3
Case 3
Question 10
For patients who are candidates for
autotransplant, how many autotransplants
does one prepare for?
1. One transplant
2. Two transplants
3. Three transplants
4. More than 3 transplants
Question 11
What do you think is the most appropriate
type of transplant today?
1. Single auto
2. Scheduled tandem auto
3. Scheduled tandem "auto/mini-allo"
4. Single auto / late auto at relapse
5. Scheduled tandem auto / late auto at
relapse
6. New agents eliminate need for transplant
Case 3
· Dexamethasone for 4 months @
40 mg for 4 days out of every 14 days
· Cyclophosphamide filgrastim
­ Mobilization 43x106, 1 collection
­ Autotransplant with MEL 200
­ 1/3 of cells infused
Case 4
· Nonmyeloablative transplant using
stem cells from father
­HLA A, B & DR match
· 2-CDA, ATG, ThioTepa
· Full donor chimerism d+50, no GVH
· Molecular CR
· d+290 monoclonal protein reappears
Case 4
· Donor lymphocyte infusion from
father
· Progression
· In succession had VBMCP,
thalidomide, BLT-D, bortezomib, IV
melphalan, methyl prednisolone,
lenalidomide, AsO3
· Oral cyclophosphamide, radiotherapy
to calvarial plasmacytomas,
dies 42 months after diagnosis

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