A 68-Year-Old Man with Multiple Myeloma - Episode 1

Case Presentation: A 68-Year-Old Man With Multiple Myeloma

Natalie Callander, MD, presents a case of a 68-year-old man with multiple myeloma and reviews first-line treatment options.

Natalie S. Callander, MD: I’d like to start by presenting for you a case that is very emblematic of patients we see in all of our practices. This is a 68-year-old man who had a 5-month history of fatigue and hip pain. He didn’t have a whole lot of other comorbidities, just a little bit of hypertension, and when he comes in to see you, he is having some bone pain, particularly on the hips and the lower back. The pain is affecting his functioning, so his performance status is 1. On work-up, he’s found to be anemic with hemoglobin of 10.3 g/dL and a calcium of 11.4 mg/dL. His LDH [lactate dehydrogenase] is normal, and his creatinine is slightly elevated at 1.2 mg/dL. His albumin is normal, and his beta-2 macroglobulin is slightly elevated at 3.9 μg/mL. He has a monoclonal protein of 2.7 g/dL, which in this case is IgG [immunoglobulin G] lambda. His creatinine clearance, as you might guess, is a little bit reduced at 45 mL/min. He’s tested for hepatitis B and C and he’s negative, and he gets a skeletal survey showing lesions in the left hip. Cytogenetics and FISH [fluorescent in situ hybridization] studies show a deletion of 17p, and by Revised-ISS [Revised International Staging System] staging, because of his normal albumin his only slightly elevated beta-2 macroglobulin and a normal LDH, he is Revised-ISS stage 2.

There are a couple of things to note about this case. One thing is that most people in this day and age would probably do more than a skeletal survey if it’s available because advanced imaging can show you lesions that you don’t appreciate by just a straight-up skeletal survey. In addition, sometimes these patients…come up with extramedullary disease, so it’s important to get a good idea of how advanced a patient is at the time they present. This patient does look like they have high-risk cytogenetics. We’re learning more and more about 17p deletion, and in this case we’re just given information that there is a deletion present. We know that patients who have not just a deletion but perhaps a mutation in the remaining allele can have even worse prognosis. It’s something we’ll continue to note, but this would give the patient high-risk cytogenetics.

We started on what most people would consider a standard regimen of lenalidomide, bortezomib, and dexamethasone, for 8 cycles, and then receives an autologous stem cell transplant and is given lenalidomide maintenance. But he relapses quickly. This dimension of the case underscores a couple of things. In a patient with standard-risk myeloma, we typically expect, based on some previous studies such as the STaMINA trial and the IFM 2009 trial, to see a progression-free survival with a package of induction, transplant, and lenalidomide maintenance of around 3 to 4 years, based on those 2 large trials. This patient is obviously having far less, and that underscores that high-risk cytogenetic patients can have a worse outcome. There are even patients among them who look like they start off with easily treated myeloma, who then end up showing an early relapse, as this patient is.

This transcript was edited for clarity.

A 68-Year-Old Man with Multiple Myeloma

Initial Presentation

  • An active 68-year-old man presented with a 5-month history of fatigue and new onset hip pain
  • PMH: HTN, medically controlled
  • PE: tenderness appreciated on palpation at the hips and lower back
  • ECOG PS 1


Clinical workup

  • Labs: Hb 10.3 g/dL, calcium 11.4 mg/dL, LDH 190 U/L, creatinine 1.2 mg/dL, albumin 3.9 g/dL, beta-2 microgloblulin 3.9 mcg/mL, M-protein 2.7 g/dL, lambda free light chains 4.1 mg/dL, CLCr 45mL/min 
  • Hepatitis B and C negative
  • Skeletal survey showed lytic lesions in the left hip 
  • Bone marrow shows 42% clonal plasma cells IgG k
  • FISH: del(17p)
  • Diagnosis: R-ISS stage II MM

Treatment

  • Initiated lenalidomide + bortezomib + dexamethasone for 8 cycles
  • He underwent ASCT 
  • He continued 15 months maintenance lenalidomide
  • Imaging at follow-up revealed progression of disease 
  • Selinexor + bortezomib + dexamethasone was initiated