Natalie Callander, MD, presents the case of a 61-year-old woman with transplant-preferred newly diagnosed multiple myeloma (NDMM) and offers her initial impressions.
Case: A 61-Year-Old Woman with Transplant-Preferred Newly Diagnosed Multiple Myeloma (NDMM)
Clinical Workup and Diagnosis:
Natalie Callander, MD: Good morning. I’m here to lead a case discussion about transplant-eligible patients with multiple myeloma [MM] and basically looking at some of the new data from ASH [American Society of Hematology Annual Meeting] and about treatment choices. We’re going to start with a case here. This is a 61-year-old woman who otherwise is in good health, has a little bit of hypertension, and doesn’t smoke. Otherwise, she’s in pretty good shape, but has had a few months of bone pain and fatigue and comes in to see her physician. She has some labs done that show that she’s quite anemic with a hemoglobin of 7.
This leads to running a number of tests that lead to the discovery of a monoclonal protein of 5.1 g of monoclonal IgG [immunoglobulin G] kappa. Beta-2 microglobulin is elevated at 6 mg/L. The patient has a high LDH [lactate dehydrogenase] of 600 with the upper limits normal of 250 and is found to have by FISH [fluorescence in situ hybridization] analysis on a bone marrow biopsy showing 28% plasma cells. Most of the cells analyzed by FISH show a p53 deletion. The patient does have a PET [positron emission tomography] scan done, which shows that she’s got lytic bone disease in the shoulders, and she does not have any evidence of extramedullary disease. The creatinine is essentially normal, a little bit elevated and her calcium level is 13.2 mg/dL.
This patient has revised ISS [International Staging System] stage 3 disease by virtue of the fact that she has an elevated beta-2 microglobulin and 2 high-risk features. One is an elevated LDH and the other is a p53 deletion. If you look at patients in general with multiple myeloma, right now, we’re doing a whole lot better in terms of both the ability to get patients to remission, but also survival. For the average patient with standard-risk multiple myeloma, we’re looking at a median of about a 10-year survival. Patients such as the one listed here are probably not going to do as well as that based on the fact that in most of the older studies their median survival can be in the neighborhood of 3 to 5 years, so considerably less.
Regardless of the age of the patient, in the myeloma world, the median age of diagnosis is now around 70 years old. So this particular person would be considered quite on the young side. But regardless of that, for any patient who has high-risk multiple myeloma, I think most people who deal with myeloma would recommend that those kinds of patients go for a transplant if possible. And maybe only the frail is not considered for transplantation at all. Because we really feel like we have some data that supports the use of transplants, particularly in this group of patients with high-risk disease. Now, the definition of high risk is continuing to evolve. We’re going to talk about that a little bit later, but I think suffice it to say that for most high-risk patients that I see, I certainly am always thinking about a way to get them to transplant, even if they are in their 70s.
Transcript edited for clarity.