Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.
A 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.
- Autologous stem cell transplantation following high-dose chemotherapy can improve overall and disease-free survival in patients with multiple myeloma.
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