MKSAP: 50-year-old woman with advanced multiple myeloma

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

MKSAP: 50 year old woman with advanced multiple myelomaA 50-year-old woman with advanced multiple myeloma diagnosed 6 months ago undergoes a follow-up visit. Treatment includes daily oral thalidomide and pulse dexamethasone. The patient now feels well.

Laboratory studies indicate a serum monoclonal protein concentration of 3.0 g/dL (30 g/L). Hemoglobin concentration, serum calcium level, and renal function studies are normal. A bone marrow aspirate shows reduction in plasma cells from 50% to 10%.

Which of the following is the most appropriate treatment to optimize this patient’s disease-free and overall survival?

A) Autologous stem cell transplantation
B) Continuation of oral thalidomide
C) Initiation of parenteral bisphosphonates
D) Initiation of oral melphalan

Answer and critique

The correct answer is A) Autologous stem cell transplantation.

Thalidomide plus dexamethasone is standard first-line chemotherapy for patients younger than 65 years who are candidates for autologous stem cell transplantation. The overall response rate to this chemotherapy is approximately 65% to 75%. In patients who do have a favorable hematologic response to initial therapy, several randomized clinical trials have shown improvement in both overall and disease-free survival if these patients are subsequently treated with autologous stem cell transplantation. Patients who have no contraindications to intensive therapy with thalidomide and dexamethasone and autologous stem cell transplantation should therefore be offered this treatment as the best option to improve overall and disease-free survival.

Continuation of thalidomide with or without dexamethasone cannot be recommended, although clinical trials are evaluating the effectiveness of this agent as maintenance therapy after stem cell transplantation. Thalidomide has not been studied in this setting and is not approved for this indication. Furthermore, it is unknown whether thalidomide confers a survival advantage compared with autologous stem cell transplantation for patients with advanced multiple myeloma who have responded to initial therapy. Although parenteral bisphosphonates may reduce or prevent skeletal complications in patients with multiple myeloma, they do not improve disease-free survival.

Oral melphalan should not be used in patients who are potential candidates for stem cell transplantation because this treatment can impair the future collection of peripheral stem cells necessary for stem cell transplantation.

Key Point

  • Autologous stem cell transplantation following high-dose chemotherapy can improve overall and disease-free survival in patients with multiple myeloma.

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  • Pat Killingsworth

    Really? Thal/dex, then SCT is the best you can come up with? What, did Velcade and Revlimid just disappear?

    At first I thought this was a European site, since Revlimid is not allowed to be used off-label in newly diagnosed patients “across the pond.” But no, this is referencing a patient in the U.S.

    Again, this isn’t the worst treatment available. But it is about five years behind the current “state of the art” treatment options.

    This is a prime example of why getting a second opinion at a recognized center which specializes in treating myeloma is so, so important!

    Hey, I’m just a patient (who happens to be a medical writer specializing in blood cancers). But here are some other treatment options:

    State of the art induction is Revlimid/Velcade/dexamethasone. Once tumor burden is low enough, stem cells are harvested. Patient then has the option of continuing on Revlimid or Velcade maintenance, or moving on to stem cell transplant.

    About 40% of patients are now waiting until first relapse to get their transplant.

    Not to include the two best available anti-myeloma drugs in this exercise seems crazy to me But I’m just a patient…

  • mdstudent

    Attendings have any thoughts about a “patient (who happens to be a medical writer specializing in blood cancers)” that states the boards are five years behind the correct treatment?

    Does that make the question obsolete already?

    • Patientadvocate

      No it doesn’t. The previous writer is correct. Revlimid/dex/velcade have all been shown in recent clinical trials to be the most effective and aggressive treatments available to date,as first line therapies, along with asct. I am very surprised, however, that this site would not do the necessary research to reach the same conclusion.

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