Practice Support Cases

65-year-old man Relapsed Multiple Myeloma
A patient relapses after achieving complete response for three years post induction and high-dose therapy/autologous stem cell transplantation (HDT-ASCT). What additional factors must be taken into account for further treatment and what are those treatment options? Follow the case of this 65-year-old man and decide if this is how you would treat this patient.

Renal Failure in Relapsed Patient
A common and serious side effect of the proteasome inhibitor bortezomib is renal impairment. Treating and reversing renal impairment requires reviewing many factors including duration and response to initial therapy, regimen, and preexisting toxicities. Follow the same 65-year-old man with relapsed multiple myeloma and see how he would be treated with this side effect.

48-year-old man Refractory Multiple Myeloma
The choice of an appropriate therapy for refractory multiple myeloma should take into consideration disease, regimen, and patient-related factors. Consider this patient case study of a 48-year-old male diagnosed and treated for multiple myeloma. He remained in the maintenance phase for over a year, then presented with a new lesion on his femur. Follow his case and decide how you would treat this patient.
76-year-old woman Maintenance Therapy in a Standard Risk, Non-transplant Eligible Patient
A 76-year-old female initially treated with melphalan, prednisone, and lenalidomide (MPR) achieves a very good partial response. Is she a good candidate for maintenance therapy? What agent or regimen would you use?
62-year-old man Should this patient receive maintenance therapy?
A 62-year-old male treated for multiple myeloma receives initial induction therapy of RVD for 4 cycles, G-CSF alone for SC mobilization and ASCT using melphalan 200 mg/m² resulting in the patient reaching complete response (CR).

Does this patient require maintenance therapy? If so, what therapies should he receive?
61-year-old man Relapsed Myeloma: Considerations and Treatment
A 61-year-old man was initially diagnosed with ISS stage III IgG lambda multiple myeloma with bone lesions. His FISH and cytogenetics were normal and received treatment. He had a very good partial response to the initial treatment but returned to the clinic two years later with complaints of back pain. Tests discovered lytic bone lesions and an elevated M-protein.

How would you treat this patient with relapsed multiple myeloma?
53-year-old man Diagnosing Smoldering Myeloma
A 53-year-old man presented for a routine exam. Standard blood work showed an elevated erythrocyte sedimentation rate with elevated serum proteins (90 g/L). There was no prior history of disease or family history of hematologic disorders or malignancies and he was in relatively good health.

How do you identify suspected smoldering myeloma, MGUS or active myeloma in this patient?
58-year-old woman Supportive Care of Multiple Myeloma Patients: What are the best options?
Mrs. S is a 58-year-old female presenting with fatigue and pain in the right leg and back. The initial laboratory analysis shows Mrs. S. to have anemia, hypercalcemia, and renal dysfunction. Additional testing of the bone marrow biopsy with 20% plasma cells was shown to be kappa restricted. Her cytogenetics are normal with a positive FISH test for del(13). Her skeletal survey has a compression fracture at T10 and a lytic lesion in the right femur. The CRAB analysis is positive for calcium elevation, renal insufficiency, anemia, and bone disease.

Based on her laboratory results, Mrs. S. requires treatment for hypercalcemia, renal dysfunction, and bone disease. What are the best options?

63-year-old man Initial Therapy for Patients with Multiple Myeloma Eligible for Transplant: What are the initial myeloma therapy options?
Mr. K is a 63-year-old Caucasian male with no past medical history except for well-controlled hypertension. The patient tripped and developed a vertebral compression fracture. He was evaluated for kyphoplasty and was found to have lytic bone lesions. Based upon his age, performance status, and comorbidities, Mr. K is a candidate for autologous stem cell transplant.

What are the initial myeloma therapy options for Mr. K?
77-year-old woman Initial Therapy for MM Patients Not Eligible for Transplant: What initial therapies should be considered?
A 77-year-old African American female with a past medical history of poorly controlled hypertension and chronic kidney insufficiency (CKI), has become more anemic, and requires assistance with many instrumental activities of daily living. A skeletal survey finds widespread osteoporosis and lytic lesions in the proximal left femur. Based upon her frailty and comorbidities, Mrs. T is not a candidate for autologous stem cell transplant.

What are the initial myeloma therapies that Mrs. T should consider?

62-year-old man Diagnosing Multiple Myeloma: What tests/criteria are required?
A 57-year-old Caucasian male with no past medical history except for well-controlled hypertension trips and develops a vertebral compression fracture. He was evaluated for kyphoplasty and was found to have lytic bone lesions.

Is this multiple myeloma?
78-year-old woman Elderly Patient with Relapsed Multiple Myeloma
A 78-year-old female diagnosed with multiple myeloma four years earlier presents with acute knee pain. She has received melphalan, prednisone, and bortezomib induction and had achieved complete response. Based on clinical, radiographic, and laboratory results she is diagnosed with relapsed multiple myeloma.

What treatment options and dose intensity would you use for this elderly patient?

62-year-old man Diagnosis, Staging, Risk Stratification, Prognosis and Response Assessment
A 62-year-old man, presents to the ER with increasing fatigue, bone aches and back pain. Over the past six months, he has lost 20 pounds and complains of nausea and general malaise. He has a 10-year history of hypertension and poorly controlled type II diabetes which includes mild diabetic peripheral neuropathy for the past three years. He has been referred to an oncologist due to lab test findings at this ER visit.

How would you stage this person? What diagnostic tests would you order? How would you treat this patient and what response could be expected?
61-year-old woman Newly Diagnosed, Transplant Eligible
A 61-year-old woman with a history of high blood pressure that is well controlled and otherwise in good health is diagnosed with Stage II multiple myeloma after falling and suffering a vertebral compression fracture.

How would you treat this patient? Would she be a good transplant candidate or would induction therapy with novel agents be preferable?
79-year-old male Newly Diagnosed, Elderly, Non-transplant Patient
A 79-year-old male with a history of well-controlled hypertension, hyperlipidemia, prostatic hypertrophy, and a 6-year-old coronary stent placement. He presents with five months of progressive fatigue, dyspnea, bony pains, anorexia and an ECOG performance status of 1. He is diagnosed with Stage III disease.

What treatment would you use for this elderly patient? What side effects and toxicities would be of most concern?
44-year-old woman Relapsed/Refractory Disease Management
A 44-year-old woman, diagnosed with ISS stage II multiple myeloma, was treated with four cycles of infusional vincristine and doxorubicin along with pulsed dexamethasone. After four cycles she had a stem cell transplant with high-dose melphalan and achieved complete remission. Her maintenance regimen included pamidronate and prednisone. Five years later, she is beginning to show signs of relapse.

What treatment plan would you follow for this patient?
61-year-old woman Maintenance Therapy for Multiple Myeloma
A 61-year-old woman is diagnosed with ISS stage II multiple myeloma after a vertebral compression fracture. She was treated with bortezomib, and after two cycles she achieved a partial response, but then the dose of bortezomib was decreased due to the occurrence of peripheral neuropathy, and after three cycles, the patient achieved an immunofixation-negative CR. Then she underwent stem cell collection for a possible autologous transplant.

Do we give this patient the maintenance therapy and, if so, which and for how long should we give this treatment?
45-year-old woman The Multidisciplinary Team Approach: Managing the Newly Diagnosed Patient
This is a 45-year-old who presents with kappa light chain myeloma. She has 5 grams of urine protein with Bence-Jones at around 3 grams. Her creatinine is 1.7, her beta-2 microglobulin is 4.7. She has no paraprotein peak in the blood, but her light chains are around 120,000, which gives her a very elevated kappa-lambda ratio.

How should we treat this patient? What are her risk factors? Is she a candidate for transplant? What special consideration should we take in the patient based on her comorbidities and her disease characteristics?