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Multiple Myeloma: Defining the High-Risk Patient and Determining the Optimal Treatment Strategy

  • Multiple Myeloma (R Niesvizky, Section Editor)
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Abstract

Multiple Myeloma (MM) is the second most common hematologic malignancy, with approximately 21,000 new diagnoses each year. The prognosis for MM is variable and depends on several factors. This chapter highlights the clinical and pathological features of multiple myeloma to help define the “high-risk” patient. The authors also review clinical trial data in an effort to delineate the optimal treatment strategy for this group of patients. While more research in this field is needed, the available evidence supports the use of bortezomib as induction therapy and maintenance for high-risk patients with multiple myeloma.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. • McCarthy PL, Owzar K, Hofmeister CC, et al. Lenalidomide after stem-cell transplantation for multiple myeloma. N Engl J Med. 2012;366(19):1770–81. This important trial (along with the IFM study published in the same issue of NEJM) established the role of lenalidomide maintenance after autologous stem cell transplant.

    Article  PubMed  CAS  Google Scholar 

  2. Kapoor P, Kumar S, Fonseca R, et al. Impact of risk stratification on outcome among patients with multiple myeloma receiving initial therapy with lenalidomide and dexamethasone. Blood. 2009;114(3):518–21.

    Article  PubMed  CAS  Google Scholar 

  3. Depil S, Leleu X, Micol JB, et al. Abnormal cytogenetics and significant bone marrow plasmacytosis are predictive of early progression and short survival in patients with low tumor mass asymptomatic multiple myeloma. Leuk Lymphoma. 2004;45(12):2481–4.

    Article  PubMed  Google Scholar 

  4. Fritz E, Ludwig H, Kundi M. Prognostic relevance of cellular morphology in multiple myeloma. Blood. 1984;63(5):1072–9.

    PubMed  CAS  Google Scholar 

  5. Greipp PR, Katzmann JA, O’Fallon WM, et al. Value of beta 2-microglobulin level and plasma cell labeling indices as prognostic factors in patients with newly diagnosed myeloma. Blood. 1988;72(1):219–23.

    PubMed  CAS  Google Scholar 

  6. Greipp PR, San Miguel JS, Durie BGM, et al. International staging system for multiple myeloma. J Clin Oncol. 2005;23(15):3412–20.

    Article  PubMed  Google Scholar 

  7. Durie BGM, Salmon SE. A clinical staging system for multiple myeloma. Cancer. 1975;36(3):842–54.

    Article  PubMed  CAS  Google Scholar 

  8. Kyle RA, Gertz MA, Witzig TE, et al. Review of 1027 patients with newly diagnosed multiple myeloma. Mayo Clin Proc. 2003;78(1):21–33.

    Article  PubMed  Google Scholar 

  9. Drayson M, Begum G, Basu S, et al. Effects of paraprotein heavy and light chain types and free light chain load on survival in myeloma: an analysis of patients receiving conventional-dose chemotherapy in Medical Research Council UK multiple myeloma trials. Blood. 2006;108(6):2013–9.

    Article  PubMed  CAS  Google Scholar 

  10. Avet-Loiseau H, Attal M, Moreau P. Genetic abnormalities and survival in multiple myeloma: the experience of the Intergroupe Francophone du Myélome. Blood. 2007;109(8):3489–95.

    Article  PubMed  CAS  Google Scholar 

  11. Avet-Loiseau H, Attal M, Campion L, et al. Long-term analysis of the IFM 99 trials for Myeloma: cytogenetic abnormalities [t(4;14), del(17p), 1q gains] play a major role in defining long-term survival. J Clin Oncol. 2012;30(16):1949–52.

    Article  PubMed  Google Scholar 

  12. Desikan R, Barlogie B, Sawyer J. Results of high-dose therapy for 1000 patients with multiple myeloma: durable complete remissions and superior survival in the absence of chromosome 13 abnormalities. Blood. 2000;95(12):4008–10.

    PubMed  CAS  Google Scholar 

  13. Dispenzieri A, Rajkumar SV, Gertz MA, et al. Treatment of newly diagnosed multiple myeloma patients based on Mayo stratification of Myeloma and Risk-adapted Therapy (mSMART): consensus statement. Mayo Clin Proc. 2007;82(3):323–41.

    PubMed  CAS  Google Scholar 

  14. Kumar SK, Mikhael JR, Buadi FK, et al. Management of newly diagnosed symptomatic multiple myeloma: updated Mayo Stratification of Myeloma and Risk-adapted Therapy (mSMART) consensus guidelines. Mayo Clin Proc. 2009;84(12):1095–110.

    Article  PubMed  CAS  Google Scholar 

  15. Zhan F, Huang Y, Colla S, et al. The molecular classification of multiple myeloma. Blood. 2006;108(6):2020–8.

    Article  PubMed  CAS  Google Scholar 

  16. Kumar SK, Rajkumar SV, Dispenzieri A. Improved survival in multiple myeloma and the impact of novel therapies. Blood. 2008;111(5):2516–20.

    Article  PubMed  CAS  Google Scholar 

  17. •• Bergsagel PL, Mateos MV, Gutierrez NC, et al. Improving overall survival and overcoming adverse prognosis in the treatment of cytogenetically high-risk multiple myeloma. Blood. 2013;121(6):884–92. Very important article which examined the role of novel therapies on the outcome of mm patients with high-risk karyotype/fish lesions.

    Article  PubMed  CAS  Google Scholar 

  18. •• Sonneveld P, Schmidt-Wolf IG, van der Holt B, et al. Bortezomib induction and maintenance treatment in patients with newly diagnosed multiple myeloma: results of the randomized phase III HOVON-65/GMMG-HD4 trial. J Clin Oncol. 2012;30(24):2946–55. Very important paper which helped define the efficacy and toxicity of maintance bortezomib after autologous stem cell transplant.

    Article  PubMed  CAS  Google Scholar 

  19. • Neben K, Lokhorst HM, Jauch A, et al. Administration of bortezomib before and after autologous stem cell transplantation improves outcome in multiple myeloma patients with deletion 17p. Blood. 2012;119(4):940–8. Important paper which examined the role of bortezomib in consolidation and maintenance for patients with a very high-risk 17p deletion.

    Article  PubMed  CAS  Google Scholar 

  20. San Miguel JF, Schlag R, Khuageva NK, et al. Bortezomib plus melphalan and prednisone for initial treatment of multiple myeloma. N Engl J Med. 2008;359(9):906–17.

    Article  PubMed  CAS  Google Scholar 

  21. • Avet-Loiseau H, Leleu X, Roussel M, et al. Bortezomib plus dexamethasone induction improves outcome of patients with t(4;14) myeloma but not outcome of patients with del (17p). J Clin Oncol. 2010;28(30):4630–4. Important paper which examined the role of bortezomib as part of induction therapy for patients with various cytogentic lesions in newly diagnosed mm.

    Article  PubMed  CAS  Google Scholar 

  22. Mateos MV, Gutiérrez NC, Martín-Ramos ML, et al. Outcome according to cytogenetic abnormalities and DNA ploidy in myeloma patients receiving short induction with weekly bortezomib followed by maintenance. Blood. 2011;118(17):4547–53.

    Article  PubMed  CAS  Google Scholar 

  23. • Rosiñol L, Oriol A, Teruel AI, et al. Superiority of bortezomib, thalidomide, and dexamethasone (VTD) as induction pretransplantation therapy in multiple myeloma: a randomized phase 3 PETHEMA/GEM study. Blood. 2012;120(8):1589–96. Important phase III trial which helped to establish the benefit of a triple-drug regimen for newly diagnosed mm.

    Article  PubMed  Google Scholar 

  24. Barlogie B, Pineda-Roman M, van Rhee F, et al. Thalidomide arm of total therapy 2 improves complete remission duration and survival in myeloma patients with metaphase cytogenetic abnormalities. Blood. 2008;120(8):1589–3121.

    Google Scholar 

  25. Barlogie B, Anaissie E, van Rhee F, et al. Incorporating bortezomib into upfront treatment for multiple myeloma: early results of total therapy 3. Br J Haematol. 2007;138(2):176–85.

    Article  PubMed  CAS  Google Scholar 

  26. Barlogie B, Tricot G, Anaissie E. Thalidomide and hematopoietic-cell transplantation for multiple myeloma. N Engl J Med. 2006;354:1021–30.

    Article  PubMed  CAS  Google Scholar 

  27. Shaughnessy JD, Zhou Y, Haessler J, et al. TP53 deletion is not an adverse feature in multiple myeloma treated with total therapy 3. Br J Haematol. 2009;354(10):1021–351.

    Google Scholar 

  28. • Dispenzieri A, Jacobus S, Vesole DH, et al. Primary therapy with single agent bortezomib as induction, maintenance and re-induction in patients with high-risk myeloma: results of the ECOG E2A02 trial. Leukemia. 2010;24(8):1406–11. One of the only prospective trials which enrolled high-risk mm patients.

    Article  PubMed  CAS  Google Scholar 

  29. Richardson PG, Weller E, Lonial S, et al. Lenalidomide, bortezomib, and dexamethasone combination therapy in patients with newly diagnosed multiple myeloma. Blood. 2010;116(5):679–86.

    Article  PubMed  CAS  Google Scholar 

  30. Richardson PG, Jagannath S, Jakubowiak AJ, et al. Phase II trial of lenalidomide, bortezomib, and dexamethasone in Patients (pts) with relapsed and relapsed/refractory Multiple Myeloma (MM): updated efficacy and safety data after >2 years of follow-up. Blood 2010 [abstract] Blood (ASH Annual Meeting Abstracts) 2010;116(21):3049.

    Google Scholar 

  31. Reece D, Song KW, Fu T, et al. Influence of cytogenetics in patients with relapsed or refractory multiple myeloma treated with lenalidomide plus dexamethasone: adverse effect of deletion 17p13. Blood. 2009;114(3):522–5.

    Article  PubMed  CAS  Google Scholar 

  32. • Avet-Loiseau H, Soulier J, Fermand JP, et al. Impact of high-risk cytogenetics and prior therapy on outcomes in patients with advanced relapsed or refractory multiple myeloma treated with lenalidomide plus dexamethasone. Leukemia. 2010;24(3):623–8. Important paper which helped to define the role of lenalidomide for high-risk patients.

    Article  PubMed  CAS  Google Scholar 

  33. Siegel DS, Martin T, Wang M, et al. A phase 2 study of single-agent carfilzomib (PX-171-003-A1) in patients with relapsed and refractory multiple myeloma. Blood. 2012;120(14):2817–25.

    Article  PubMed  CAS  Google Scholar 

  34. Jakubowiak AJ, Siegel DS, Martin T, et al. Treatment outcomes in patients with relapsed and refractory multiple myeloma and high-risk cytogenetics receiving single-agent carfilzomib in the PX-171-003-A1 study. Leukemia. 2013;114:1–6.

    Google Scholar 

  35. Egan JB, Shi CX, Tembe W, et al. Whole-genome sequencing of multiple myeloma from diagnosis to plasma cell leukemia reveals genomic initiating events, evolution, and clonal tides. Blood. 2012;120(5):1060–6.

    Article  PubMed  CAS  Google Scholar 

  36. Lloveras E, Solé F, Florensa L, et al. Contribution of cytogenetics and in situ hybridization to the study of monoclonal gammopathies of undetermined significance. Cancer Genet Cytogenet. 2002;132(1):25–9.

    Article  PubMed  CAS  Google Scholar 

  37. Moreau P, Pylypenko H, Grosicki S, et al. Subcutaneous versus intravenous administration of bortezomib in patients with relapsed multiple myeloma: a randomised, phase 3, non-inferiority study. Lancet Oncol. 2011;12(5):431–40.

    Article  PubMed  Google Scholar 

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Conflict of Interest

Jordan Schecter has received research support from and served as a consultant for Celgene.

Suzanne Lentzsch has received research support from and served as a consultant for Celgene.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

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Correspondence to Jordan Schecter.

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Schecter, J., Lentzsch, S. Multiple Myeloma: Defining the High-Risk Patient and Determining the Optimal Treatment Strategy. Curr Hematol Malig Rep 8, 277–283 (2013). https://doi.org/10.1007/s11899-013-0183-0

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  • DOI: https://doi.org/10.1007/s11899-013-0183-0

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