Patient Case Introduction: A 65-year-old Female Diagnosed with Transplant-eligible NDMM
Moderator Sagar Lonial, MD, FACP, and colleagues engage with the first patient case: a 65-year-old female diagnosed with transplant-eligible NDMM.
Dr. Sagar Lonial: Welcome to this Cancer Network Around the Practice program titled Treatment of Multiple Myeloma: Insights from Experts at Emory University. I'm your host, Dr. Sagar Lonial. I'm the chief medical officer at the Winship Cancer Institute, and professor and chair in the Department of Hematology and Medical Oncology at the Emory University School of Medicine. I have a great panel consisting of experts in the treatment of hematologic malignancies that has joined me today, and I'd like for them to introduce themselves to you as we speak. So, let's start off with Dr. Nooka.
Dr. Ajay Nooka: I'm Ajay Nooka. I'm a professor in the Department of Hematology and Oncology. I'm honored to be here with my privileged colleagues here today.
Dr. Sagar Lonial: Dr. Kaufman.
Dr. Jonathan L. Kaufman: Hi, Jonathan Kaufman. I'm a professor of hematology and medical oncology at Emory University.
Dr. Sagar Lonial: And Dr. Joseph.
Dr. Nisha Joseph: Hi, I'm Nisha Joseph. I'm an assistant professor of the Department of Hematology and Medical Oncology at Emory University.
Dr. Sagar Lonial: Thank you all for joining me today. Today we're going to be discussing some key updates that were presented at recent meetings regarding the treatment of patients with multiple myeloma. We will discuss these updates in the context of the treatment landscape and how they might affect clinical practice. So, let's begin. Dr. Joseph, I think you've got a case to start us off.
Dr. Nisha Joseph: That's right. So, we're going to start with the first case talking about transplant-eligible newly diagnosed myeloma patient. So, this is a 65-year-old female who initially presented for hematologic evaluation. After routine labs, showed a macrocytic anemia, or hemoglobin was 10.3. She did note some generalized aches and pains, but otherwise, has been in her usual state of health and her past medical history and social history, family history is unremarkable. Next slide. So, further laboratory studies to further investigate the anemia, including immunologic panel, showed a repeat hemoglobin is now nine and a half. Her calcium was 10.1, creatinine is normal at 0.75, albumin is 3.9, and her beta-2 microglobulin is 2.51. LDH is not elevated at 133. Her SPEP and immunofixation showed 2.9 gram IgG lambda paraprotein, she has an elevated lambda light chain of 129 with an abnormal ratio of 0.07, and her IgG is elevated at 37;16. Her UPEP and immunofixation are negative. Next slide. A marrow is done, which shows 30% clonal lambda restricted plasma cells with a normal female karyotype, and FISH showing hyperdiploidy, the gain of 11q and TRiSM use of three, seven, and nine. PET-scan is subsequently done to evaluate for bone disease and shows FTG autolytic lesions throughout the axial and apendicular skeleton. Next slide. So, she's diagnosed with ISS-1, revised ISS stage 1 standard-risk myeloma, presenting with anemia lytic bone disease. So, I started her on induction therapy with the quadruple, with daratumumab in addition to RVd. She did develop some GERD and gastritis symptoms with cycle-2 likely related to the dexamethasone, and that resolved with the PPI. She was also continued on standard supportive care, which we give with induction therapy. She completed four cycles, achieved a VGPR, and subsequently underwent an autologous stem cell transplant with day-100 restaging also showing a VGPR. She was then started on maintenance lenalidomide, which she continues to this day, and continues to have good response.
Dr. Sagar Lonial: I think that's a really good way to begin our discussion, and before we go through some of the sort of pertinent issues here from Jonathan and Ajay, any sort of quick-brief pearls of wisdom about managing a case similar to this that would be relevant for our audience to hear from you?
Dr. Jonathan L. Kaufman: This is a really typical case. The patient has clearly symptomatic myeloma with anemia and lytic bone disease, standard-risk disease, and our approach has been, for standard-risk patients, to give the quadruple of Dara-RVd and offer early autologous transplant followed by lenalidomide maintenance.
Dr. Ajay Nooka: Agree, this has been our practice for the last five years, and using the quadruplet agents, we're able to get those depths of responses that we have not been seeing with the three drug treatments. However, the post-transplant setting, we've resorted to going onto a single-agent maintenance, which differs slightly from the existing literature.
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