International Myeloma
Myeloma Foundation
Multiple Myeloma 101
Washin
i gto
t n, D.C.
D.C.
August 8, 2009
Robert A. Kyle, MD
CP1123175-1
CP1123175-2
Multiple Myeloma
Epidemiology
· 1% of all malignancies
· 10% of hematologic malignancies
· Incidence
4/100 000
,
in Caucasians
C
8/100 000
,
in African-Americans
CP1123175-1
Multiple Myeloma
Mayo
M
Cli
C
Cli i
n c 1985-1998
Hemoglobin at Diagnosis (g/dL)
n=1 025
,
8
7%
7
8.1-10
10.1-12
28%
38%
>12
27%
Median 10.9
Range 2.7-17
CP1123175-3
Multiple Myeloma
Mayo Clinic 1985
1985--1998
1998
Serum Calcium at Diagnosis (mg/dL)
n=1 018
,
11.
11 0
10.2-10.9
13%
14%
10.1
73%
Median 9.6
Range 7.2-17.2
CP1123175-4
Multiple Myeloma
Mayo
M
Cli
C
Cli i
n c 1985-1998
Serum Creatinine at Diagnosis (mg/dL)
n=1 020
,
1.3-1.9
29%
2.0
19%
1.2
52%
Median 1.2
Range 0.5-18.2
CP1123175-5
Serum Protein Electrophoresis
Alb 1
2
CP1123175-6
Multiple Myeloma
Mayo Cli
C
Cli i
n c 1985-1998
Serum + Urine at Diagnosis
n=1,027
S ­ U ­
3%
S +/or U +
97%
CP1123175-7
Nonsecretory Myeloma 1985
1985--1998
1998
Si
Surv
S
i
urv
l
va
100
Nonsecretory
80
Secretory
60
%
40
20
0
0
5
10
15
Years
Y
CP1123175-8
Light
Light--Chain
Chain Myeloma 1985
1985--1998
1998
Survival
100
Heavy chain
80
Light chain
60
%
40
20
0
0
5
10
15
Years
Y
CP1123175-9
Multiple Myeloma
Mayo Cli
C
Cli i
n c 1985-1998
Skeletal Survey at Diagnosis
n=1,005
Osteoporosis only
Normal
3%
21%
Lytic/Fx
76%
CP1123175-11
Multiple Myeloma
Criteria for Diagnosis
Bone marrow with >10%
>
plasma cells or
plasmac
p
ytoma
y
py
+ 1 of the following
followin
· M-protein in serum (usually > 3.0 g/dL)
· M
ti
-prot
-pro ei
e n in urine
· Ly
L tic
y
bone lesions
End-organ damage: CRAB (hypercalcemia,
(hyperc
r
l
ena i
ffi
nsu
i
c ency,
ency a
i
nem a, bone
b
li
lesi
es
)
ons
CP1123175-12
Brit J Haem 121:749, 2003
Smoldering Multiple Myeloma (SMM)
M-protein in serum
>3
> g/dL
and/or
Plasma cells in marrow
>10%
Anemia
None
Calcium
Normal
Creatinine
Normal
Ly
L tic
y
Lyt
Ly i
t c
i lesions
llesions
None
Plasma cell labeling index
Low
No end organ damage
CP1123175-13
Multiple Myeloma
Indications for Therapy
M-protein in serum
M
ti
-prot
-pro ei
e n in urine
hemoglobin
calcium or creatinine
Ly
L tic
y
bone lesions
Extramedullary plasmacytoma
CP1123175-15
Epitaph
I felt well, but wanted to feel
bt
be t
bttter
tt
­ therefore,
f
I am here
J. Waldenström
W
CP1123175-16
CP1123175-17
Survival from Onset of Treatment of
Multiple Myeloma
100
80
60
Placebo
Surviving
(%)
40
Urethane
20
0
0
10
20
30
40
50
Months
Holland, et al., 1966, Blood 27(3):335
CP1123175-18
Multiple Myeloma 1971
1971--2006
2006
n=2,
n=2 981
,
1.0
0.8
rviving
P<0.001
r 0.6
su
Survival, med
44.8 mo
0.4
Survival, med
rtion
29.9 mo
Di
i
agnos s
i aft
fter 1996
0.2
Diagnosis during/
Propo
before 1996
0.0
0
20
40
60
80
100
120
140
Ti
T
Time
me
m from diagnosis (months)
((months)
Kumar et al: Blood 11
1 1
1 :2516, 2008
CP1315995-1
Relapse After Autologous Transplant
for Multiple Myeloma
y
py
1.0
n=161
Survival, med
n=387
0.8
30.9 mo
rviving
P<0.001
r 0.6
su
Exposed to new drugs
0.4
rtion
n=226
0.2
Survival, med
14.8 mo
Propo
No exposure to
to new
n
new drugs
0.0
0
20406080
100
Ti
T
Time
me
m from post-
post ASCT
-
relapse (months)
((months)
Kumar et al: Blood 11
1 1
1 :2516, 2008
CP1315995-3
Multip
Multi le My
pyeloma
Therapy of Hypercalcemia
· Hydration
· Prednisone
· Bi
h
sp
h
osp ona
h
tes
t
Multip
Multi le My
pyeloma
Spinal Cord Compression
· Back pain and leg weakness
· Incontinence
· Paraspinal mass
· MRI
· Radiation therapy
· Surgical decompression
Multip
Multi le My
pyeloma
Infections
· Pneumococcal vaccine
· Influenza vaccine
· Antibiotics ­ first
first 2 months
· Gamma globulin, IV