Quiz: Does Pamidronate Increase Survival in Myeloma With Bony Involvement?

Are you up to date on the National Comprehensive Cancer Center (NCCN) guidelines for multiple myeloma? And do you know the best way to treat a 66-year-old patient with a lytic rib mass that shows infiltration by kappa light chain restricted plasma cells on core needle biopsy? Test your knowledge in our latest quiz.

Question 1

Answer

C.Osteonecrosis of the jaw is more commonly seen in patients being treated with zoledronic acid as compared with pamidronate. Osteopenia and/or osteolytic lesions occur in more than 80% of patients with multiple myeloma and are associated with increased risk for skeletal fractures, decreased performance status, and impairment in quality of life. While a study demonstrated decreased risk for skeletal events in patients treated with pamidronate, there was not a statistically significant improvement in overall survival. Another study demonstrated an increased risk of osteonecrosis of the jaw in patients treated with zoledronic acid when compared to those treated with pamidronate. Zoledronic acid has not been shown to be superior to pamidronate in preventing skeletal events.

Question 2

A 66-year-old male with hypertension and hyperlipidemia presents to his primary care physician with 3 months of progressive left rib pain. Radiographs show a destructive lesion involving the left, posterior 11th rib. CT scans show a 3-cm lytic mass with destruction of the rib. Core needle biopsy shows infiltration by kappa light chain restricted plasma cells. Complete blood count (CBC) and comprehensive metabolic panel (CMP) are normal. Serum protein electrophoresis (SPEP) shows an M-spike of 1.2 g/dL. Serum immunofixation shows an IgG kappa monoclonal immunoglobulin. Beta-2 microglobulin is 2.5. Kappa light chains are minimally elevated with a preserved kappa/lambda ratio. Twenty-four-hour urine shows no proteinuria with negative urine protein electrophoresis (UPEP) and urine immunofixation. Serum albumin is 3.8. Bone marrow aspirate and biopsy are negative for involvement by plasma cell myeloma. Skeletal survey identifies the lytic lesion in the left 11th rib but is otherwise normal. PET/CT scan shows a 2.8-cm hypermetabolic mass involving the left 11th rib but is otherwise normal.

Answer

A.Referral to radiation oncology for radiotherapy to the 11th rib. The patient’s workup is consistent with a solitary osseous plasmacytoma. Per the NCCN guidelines the recommendation is referral to radiation oncology for 40–50 Gy to the involved site followed by routine follow-up every 3 to 6 months with CBC, CMP, SPEP, UPEP, serum free light chain (FLC) assay and skeletal survey as clinically indicated or annually. Initiation of systemic therapy is reserved for progression to overt multiple myeloma.

Question 3

A 63-year-old man with no major medical problems presents to his primary care physician for routine annual physical exam. Labs reveal an elevated total protein of 9.3. Hemoglobin, calcium, and creatinine are normal. SPEP reveals a monoclonal protein measuring 4.3 g/dL. Serum immunofixation shows a monoclonal IgG kappa paraprotein. Kappa FLCs are measured at 900 with a lambda FLC level of 6.1. Bone marrow biopsy shows infiltration by 65% kappa light chain restricted plasma cells. Skeletal survey and PET scan are both negative for osseous lesions.

Answer

C.Initiation of therapy with a combination of lenalidomide, bortezomib, and dexamethasone. Despite the absence of end organ damage, the patient meets criteria for active myeloma based on the myeloma defining events of a serum FLC ratio being > 100 and > 60% clonal bone marrow plasma cells, so initiation of therapy is indicated. In a 63-year-old, non-frail, healthy individual, a three-drug regimen would be preferred to a two-drug regimen.

Question 4

A 68-year-old female with IgA kappa multiple myeloma who attained a stringent complete response following autologous stem cell transplant is being treated with lenalidomide maintenance. She is followed every 3 months with CBC, CMP, SPEP, and kappa/lambda FLCs. At a follow-up visit her M-spike is noted to be positive, measuring 0.2 g/dL. Other labs are normal. Repeat SPEP 3 months later shows that the M-spike has risen to 0.4 g/dL. Other labs including UPEP are within normal limits. Bone marrow biopsy shows no increase in plasma cells.

Answer

C.Continue observation with close monitoring of labs. Despite the patient’s M-spike rising, according to NCCN guidelines, she does not yet meet the criteria for progressive disease and therapy should not be altered. Progressive disease is defined as an increase of 25% from the lowest confirmed response in serum monoclonal protein (absolute increase must be > 0.5 g/dL or > 1g/dL if lowest M-component was > 5 g/dL), or urine monoclonal protein (absolute increase must be > 200 mg/24 hours). In patients without measurable serum and urine M-protein levels, the difference between involved and uninvolved FLC levels must increase by at least 10 mg/dL. In patients without measurable serum and urine M-protein levels and without measurable involved FLC levels, bone marrow plasma cell percentage must increase by at least 10%.

Question 5

A 49-year-old female undergoes evaluation for an elevated total protein that is incidentally detected on routine health maintenance examination. Workup reveals an M-spike of 3.5 g/dL. Serum immunofixation is positive for an IgA kappa paraprotein. CBC, CMP, and beta-2 microglobulin are within normal limits. FLC ratio is normal at 1.0. Bone marrow biopsy reveals involvement by 25% monoclonal plasma cells. PET/CT scan shows no bone lesions. The patient is diagnosed with smoldering multiple myeloma.

Answer

C.50%. Patients with smoldering multiple myeloma can be risk-stratified using several different prognostic tools. The Mayo Clinic criteria considers risk factors for progression to be bone marrow plasma cells greater than 10%, M-protein greater than 3 mg/dL, and FLC ratio < 0.125 or > 8. Patients with one risk factor have a 25% risk of progression at 5 years; two risk factors, a 50% risk of progression at 5 years; and three risk factors, a 75% risk of progression at 5 years.