Case Review of a 75-Year-Old Woman with Multiple Myeloma

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Saad Usmani, MD: My name is Saad Usmani. I’m the division chief of plasma cell disorders and the director of chemical research and hematologic malignancies at the Levine Cancer Institute in Charlotte, North Carolina.

Today we are going to talk about a case of a 75-year-old woman with newly diagnosed multiple myeloma. On initial presentation she had a 10-month history of new-onset back pain and fatigue, and her prior medical history includes hypercholesterolemia, diabetes with mild sensitive neuropathy, and weight control atrial fibrillation.

On physical exam she had boney tenderness appreciated in the hips and her lower back. Upon further work-up on labs she was found to have mild anemia with a hemoglobin of 10.2 g/dL. Calcium was mildly elevated at 11.1 mg/dL but still within normal limits. LDH [lactate dehydrogenase] was normal. Serum creatinine was 1.2 mg/dL; abdomen 2.7 g/dL.

Beta-2-microglobulin [B2M] was 2.6 μg/mL. Normal chemistries and electrolytes. On themmunofixation she had an M14 of 2.6 g/dL with IgG land type. And the lambda free light chains were elevated at 4.1 mg/dL with a ratio of 0.03.

Her hepatitis B and hepatitis C and initial vital panels were negative. Her skeletal survey revealed an L4 vertebral compression fracture, which was indeterminate, and multiple lytic lesions were present.

She gets a bone marrow biopsy, which shows 14% clonal plasma pills with kappa lights and restriction, and the FISH [fluorescent in situ hybridization] panel showed hyperdiploidy. She was diagnosed with revised ISS [insulin sliding scale] phase 2 disease based on the B2M, serum albumin, as well as the hyperdiploidy. She has an ECOG performance status of 1.

We must come up with a treatment plan for this patient in light of her comorbidities as well as presentation. Let’s go through the case with the following questions.

Based on what we’ve discussed about this 75-year-old woman, she has several comorbidities. Her ECOG performance status is 1, which is reasonable, but she does have comorbidities and sensitive neuropathy. For someone this age, you must consider several factors as you’re determining treatment. I would deem her a transplant-ineligible patient based on the features that have been presented. She biologically does not have high-risk disease. Hyperdiploidy tends to be a standard-risk feature for a majority of patients. Based on the guidelines, we would expect someone like her to have an intermediate prognosis with an overall survival of 7 to 8 years if not more. This survival is based on the published data right now, but for US patients, especially those being seen at myeloma centers, patients do have access to newer therapies and clinical trials. Overall survival [OS] is always getting better. That would be my initial impression for this patient.

Transcript edited for clarity.

Case: A 75-Year-Old Woman With Multiple Myeloma

Initial Presentation

• An active 75-year-old woman presented with new onset back pain and a 10-month history of fatigue, mild sensory neuropathy
• PMH: hypercholesterolemia, diabetes, and atrial fibrillation; all medically controlled
• PE: bony tenderness appreciated on the hips and lower back

Clinical Workup

• Labs: Hb 10.2 g/dL, calcium 11.1 mg/dL, LDH 186 U/L, creatinine 1.3 mg/dL, albumin 3.7 g/dL, beta-2 microgloblulin 3.6 mcg/mL, potassium 1100 g/dL, M-protein 2.6 g/dL, lambda free light chains 4.1 mg/dL
• Hepatitis B and C negative
• X-ray showed L4 vertebral compression fracture
• Skeletal survey showed multiple lytic lesions in femur
• Bone marrow shows 40% clonal plasma cells IgG k with hyperdiploidy FISH
• Diagnosis: R-ISS stage II MM
• ECOG 1

Treatment

• Patient is ineligible for ASCT due to comorbidities
• Initiated treatment with daratumumab + lenalidomide + dexamethasone