A 75-Year-Old Man With Multiple Myeloma - Episode 1

Case Overview: A 75-Year-Old Man with Multiple Myeloma

April 7, 2021
Jonathan L. Kaufman, MD

Jonathan L. Kaufman, MD reviews the case of a 75-year-old man with multiple myeloma by discussing the patient’s presentation, clinical workup, and initial prognosis.

Jonathan L. Kaufman, MD: Today I'll be presenting a patient with newly diagnosed [multiple] myeloma who is not a transplant candidate. He is a 75-year-old man who presented with worsening fatigue on exertion, pallor, and hip pain. He has a past medical history of osteoarthritis. When we saw him, he appeared to be tired, had poor hand grip strength, and mild tenderness to palpation of his left hip. His ECOG performance status was 2; he had to spend some part of the day resting because of these new symptoms.

Upon laboratory evaluation, he was found to be anemic with a hemoglobin of 9.8 g/dL. His calcium was elevated with a corrected calcium 11.9 mg/dL. LDH [lactate dehydrogenase] was elevated at 295 U/L. Creatinine was modestly elevated at 1.4 mg/dL. Albumin was preserved at 3.7 g/dL and creatinine clearance was measured at approximately 50 ml/minute. His peripheral smear showed Rouleaux formation. Beta 2 microglobulin was modestly elevated at 5.1 mcg/mL, and his M protein was 2.2 g/dL. His free lambda light chain was 0.6 mg/dL and his free Kappa light chain was 14.3 mg/dL, for an elevated kappa lambda ratio of 29. FISH [fluorescence in situ hybridization] testing revealed hyperdiploidy. Urine protein electrophoresis revealed 400 mg of a Kappa light chain in a 24-hour urine.

His PET [positron emission tomography] scan revealed lytic bone lesions, including FDG avidity in his left hip. Bone marrow biopsy revealed 50% to 60% plasma cells that were IgG Kappa; he [received a diagnosis of] myeloma. His ISS [International Staging System] stage was ISS stage 2, and his revised ISS stage was ISS stage 2. He'd be considered a standard risk myeloma. He was considered not a candidate for transplant; based on his age, which was the least important of the 3 comorbidities, which were moderate, but mostly performance status. This patient was initiated on therapy with the combination of daratumumab, lenalidomide and Dexamethasone.

The patient's prognosis at diagnosis is dependent on his stage and risk status as well as fitness. We likely put him based on his performance status and symptoms in the frail category. He doesn't have high-risk myeloma by revised ISS stage or by FISH, however he does have ISS and revised ISS stage 2 myeloma and an elevated LDH; he is frail. His prognosis is relatively poor, but not as bad as a biologically high-risk patient.

Transcript edited for clarity.


Case: A 75-Year-Old Man with Multiple Myeloma

Initial Presentation

  • A 75-year-old man presents with worsening fatigue on exertion, pallor, and hip pain
  • PMH: osteoarthritis
  • PE: tired appearing male, poor hand-grip strength, mild tenderness on palpation of the left hip
  • ECOG 2


Clinical workup

  • Hb 9.8 g/dL, corrected calcium 11.9mg/dL, LDH 295U/L, creatinine 1.4mg/dL, albumin 3.7g/dL, CrCl 50mL/min
  • Peripheral blood smear showed rouleaux formation
  • Beta-2 microgloblulin 5.1 mcg/mL, M-protein 2.2 g/dL
  • Lambda free light chains: 0.6 mg/dL, kappa free light chains: 14.3 mg/dL, ratio: 29 (k/l)
  • FISH: hyperdiploid
  • UPEP: M-spike of 400 mg of lambda light chains in 24 hours
  • PET/CT revealed lytic bone lesions in the left hip
  • Bone marrow biopsy shows 58% plasma cells IgG k
  • Diagnosis: ISS and R-ISS, standard risk, stage II MM

Treatment

  • Patient is ineligible for ASCT due to comorbidities
  • Initiated treatment with daratumumab + bortezomib + melphalan + prednisone