Numerous treatment options are available for patients with early relapsed multiple myeloma. Clinicians should consider using a monoclonal antibody for patients who have not yet received one, or changing either the immunomodulatory drug, the proteasome inhibitor, or both. Clinical trials are another option, or clinicians can refer transplant-naïve patients for autologous stem cell transplantation (ASCT). For patients with late relapse, a clinical trial is recommended, if possible, but many patients are ineligible due to poor blood cell counts or other factors. Additional treatment options include selinexor combinations, belantamab mafodotin-blmf, melflufen, or CAR T-cell therapy. Salvage ASCT should also be considered for this challenging population.
Presenter: Natalie S. Callander
Presenter: Natalie S. Callander
Smoldering multiple myeloma represents approximately 10% to 15% of all myeloma cases, but more thorough evaluation may decrease that number in the future. Risk stratification is important in this patient population to avoid overtreatment or undertreatment. Patients with low-risk disease can be observed without treatment, but those at higher-risk should be enrolled on clinical trials. If a clinical trial is not an option in these patients, a time-limited intervention with lenalidomide ± dexamethasone can be considered.
Timothy M. Schmidt and Natalie S. Callander
The presence of monoclonal proteins is common, with a prevalence in the United States around 5% that increases with age. Although most patients are asymptomatic, most cases are caused by a clonal plasma cell disorder. Monoclonal gammopathy of undetermined significance (MGUS) and smoldering multiple myeloma (SMM) are asymptomatic precursor conditions with variable risk of progression to multiple myeloma. In recent years, significant progress has been made to better understand the factors that lead to the development of symptoms and progression to myeloma. This review summarizes the current diagnosis treatment guidelines for MGUS and SMM and highlights recent advances that underscore a shifting paradigm in the evaluation and management of plasma cell precursor conditions.
Zhubin J. Gahvari, Michael Lasarev, Jens C. Eickhoff, Aric C. Hall, Peiman Hematti, Mark B. Juckett, Vaishalee P. Kenkre, and Natalie S. Callander
Background: Obesity, and in particular severe obesity, is increasingly prevalent in the United States. Epidemiological studies have shown an association in multiple myeloma (MM) between obesity and mortality (Teras et al, Br J Haematol 2014). Autologous peripheral blood stem cell transplantation (autoPBSCT) remains a crucial aspect of treating MM, and the NCCN Guidelines recommend all eligible patients be evaluated for transplant. There is limited data analyzing the relationship between severe obesity and transplant outcomes in MM patients in the era of modern therapy, routine post-transplant maintenance, and genetic-based risk stratification. Methods: We retrospectively reviewed consecutive patients undergoing autoPBSCT for MM at our institution from 2010–2017. Patients were categorized by body mass index (BMI) and Revised International Staging System (R-ISS) score. Patients were followed from time of first transplant until death. Surviving patients and those lost to follow-up were censored at last point of contact. Cox proportional hazard regression models and associated log-rank tests were used to assess whether age, BMI, lag time between diagnosis and transplant, and R-ISS score were associated with risk of death. Post-transplant hospital length of stay (LOS) was evaluated using generalized linear models with response following a gamma distribution. Results: 314 patients (59.2% male) were included. BMI was categorized as nonobese ([16, 30) kg/m2; n=178, 56.7%), obese ([30, 35) kg/m2; n=72, 22.9%) or severely obese ([35, 55) kg/m2; n=64, 20.4%) and was not found to be associated with risk of death following transplant, either independently (P=.17) or when adjusting for age, sex, lag, and R-ISS (P=.26). As expected, R-ISS score was associated (P=.006) with risk of death after transplant. No association was found between mean LOS and BMI (P=.875). Kaplan-Meier mortality estimates are shown in . Conclusions: Obesity and severe obesity were not associated with an increased risk of mortality for MM patients receiving autoPBSCT. Although severe obesity is a health hazard, this should not be used to exclude patients from transplant.
Muhamed Baljevic, Douglas W. Sborov, Ming Y. Lim, Jens Hillengass, Thomas Martin, Jorge J. Castillo, Michael B. Streiff, Shaji K. Kumar, and Natalie S. Callander
Venous thromboembolism (VTE) is a major complication in all patients with cancer. Compared with the general population, patients with multiple myeloma (MM) have a 9-fold increase in VTE risk, likely because of their malignancy, its treatments, and other additional patient-related factors. In MM, thromboembolism events tend to occur within 6 months of treatment initiation, regardless of treatment regimen; however, the use of immunomodulatory agents such as thalidomide or lenalidomide, especially in combination with dexamethasone or multiagent chemotherapy, is known to create a significant risk for VTE. Currently, official recommendations for VTE prophylaxis in MM outlined in various national guidelines or multidisciplinary society panels are based on expert opinion, because data from randomized controlled trials are scarce. Large studies which have mainly focused on the efficacy of thromboprophylaxis in patients with cancer at higher risk for VTE either had a very low representation of patients with MM, or excluded them all together, limiting our ability to draw evidence-based conclusions on how to effectively protect MM population from VTE. In this brief perspective, we highlight some of the greatest challenges that have hampered the field concerning the availability of high-quality clinical trial data for the formulation of best VTE prophylaxis strategies in patients with newly diagnosed MM, as well as the rationale for the latest updates in the NCCN Guidelines on this topic.
Shaji K. Kumar, Natalie S. Callander, Melissa Alsina, Djordje Atanackovic, J. Sybil Biermann, Jason C. Chandler, Caitlin Costello, Matthew Faiman, Henry C. Fung, Cristina Gasparetto, Kelly Godby, Craig Hofmeister, Leona Holmberg, Sarah Holstein, Carol Ann Huff, Adetola Kassim, Michaela Liedtke, Thomas Martin, James Omel, Noopur Raje, Frederic J. Reu, Seema Singhal, George Somlo, Keith Stockerl-Goldstein, Steven P. Treon, Donna Weber, Joachim Yahalom, Dorothy A. Shead, and Rashmi Kumar
Multiple myeloma (MM) is caused by the neoplastic proliferation of plasma cells. These neoplastic plasma cells proliferate and produce monoclonal immunoglobulin in the bone marrow causing skeletal damage, a hallmark of multiple myeloma. Other MM-related complications include hypercalcemia, renal insufficiency, anemia, and infections. The NCCN Multiple Myeloma Panel members have developed guidelines for the management of patients with various plasma cell dyscrasias, including solitary plasmacytoma, smoldering myeloma, multiple myeloma, systemic light chain amyloidosis, and Waldenström's macroglobulinemia. The recommendations specific to the diagnosis and treatment of patients with newly diagnosed MM are discussed in this article.
Featured Updates to the NCCN Guidelines
Natalie S. Callander, Muhamed Baljevic, Kehinde Adekola, Larry D. Anderson Jr, Erica Campagnaro, Jorge J. Castillo, Caitlin Costello, Srinivas Devarakonda, Noura Elsedawy, Matthew Faiman, Alfred Garfall, Kelly Godby, Jens Hillengass, Leona Holmberg, Myo Htut, Carol Ann Huff, Malin Hultcrantz, Yubin Kang, Sarah Larson, Michaela Liedtke, Thomas Martin, James Omel, Douglas Sborov, Kenneth Shain, Keith Stockerl-Goldstein, Donna Weber, Ryan A. Berardi, Rashmi Kumar, and Shaji K. Kumar
The NCCN Guidelines for Multiple Myeloma provide recommendations for diagnosis, initial workup, treatment, follow-up, and supportive care for patients with various plasma cell neoplasms, including multiple myeloma. These NCCN Guidelines Insights highlight some of the important updates/changes specific to the treatment of patients with multiple myeloma in the 2022 version of the guidelines.
Featured Updates to the NCCN Guidelines
Shaji K. Kumar, Natalie S. Callander, Jens Hillengass, Michaela Liedtke, Muhamed Baljevic, Erica Campagnaro, Jorge J. Castillo, Jason C. Chandler, Robert F. Cornell, Caitlin Costello, Yvonne Efebera, Matthew Faiman, Alfred Garfall, Kelly Godby, Leona Holmberg, Myo Htut, Carol Ann Huff, Yubin Kang, Ola Landgren, Ehsan Malek, Thomas Martin, James Omel, Noopur Raje, Douglas Sborov, Seema Singhal, Keith Stockerl-Goldstein, Carlyn Tan, Donna Weber, Alyse Johnson-Chilla, Jennifer Keller, and Rashmi Kumar
The NCCN Guidelines for Multiple Myeloma provide recommendations for diagnosis, workup, treatment, follow-up, and supportive care for patients with monoclonal gammopathy of renal significance, solitary plasmacytoma, smoldering myeloma, and multiple myeloma. These NCCN Guidelines Insights highlight some of the important updates and changes in the 1.2020 version of the NCCN Guidelines for Multiple Myeloma.
Shaji K. Kumar, Natalie S. Callander, Kehinde Adekola, Larry Anderson, Muhamed Baljevic, Erica Campagnaro, Jorge J. Castillo, Jason C. Chandler, Caitlin Costello, Yvonne Efebera, Matthew Faiman, Alfred Garfall, Kelly Godby, Jens Hillengass, Leona Holmberg, Myo Htut, Carol Ann Huff, Yubin Kang, Malin Hultcrantz, Sarah Larson, Michaela Liedtke, Thomas Martin, James Omel, Kenneth Shain, Douglas Sborov, Keith Stockerl-Goldstein, Donna Weber, Jennifer Keller, and Rashmi Kumar
Multiple myeloma is a malignant neoplasm of plasma cells that accumulate in bone marrow, leading to bone destruction and marrow failure. This manuscript discusses the management of patients with solitary plasmacytoma, smoldering multiple myeloma, and newly diagnosed multiple myeloma.
Shaji K. Kumar, Natalie S. Callander, Melissa Alsina, Djordje Atanackovic, J. Sybil Biermann, Jorge Castillo, Jason C. Chandler, Caitlin Costello, Matthew Faiman, Henry C. Fung, Kelly Godby, Craig Hofmeister, Leona Holmberg, Sarah Holstein, Carol Ann Huff, Yubin Kang, Adetola Kassim, Michaela Liedtke, Ehsan Malek, Thomas Martin, Vishala T. Neppalli, James Omel, Noopur Raje, Seema Singhal, George Somlo, Keith Stockerl-Goldstein, Donna Weber, Joachim Yahalom, Rashmi Kumar, and Dorothy A. Shead
The NCCN Guidelines for Multiple Myeloma provide recommendations for diagnosis, evaluation, treatment, including supportive-care, and follow-up for patients with myeloma. These NCCN Guidelines Insights highlight the important updates/changes specific to the myeloma therapy options in the 2018 version of the NCCN Guidelines.