Relapsed Multiple Myeloma: Second-Line Approaches

Robert A. Vescio, MD:Now that the patient’s progressing, the decision about what to do about the progression needs to be made. Clearly, something other than lenalidomide and dexamethasone has to be done. There are now a lot of options in multiple myeloma. The treatments can be relatively simple, like adding something to the lenalidomide and dexamethasone regimen. Choices for that may include Empliciti—elotuzumab. One could also add daratumumab. One could add back bortezomib, like she had used before, or ixazomib or carfilzomib. So, there are clearly many choices for adding a third drug to the regimen that she has already been taking.

I think it’s reasonable to add a drug to what she’s taking because she has tolerated the treatment well. It has worked for quite some time, and we know that one could get rid of lenalidomide at some point in the future—in the third- or fourth-line setting.

When patients relapse, the tradition is often to do a bone marrow aspirate and biopsy to confirm the disease status and, potentially, to further look at cytogenetic abnormalities within the malignant cells. Often, what mistakes genetically in the cancer cells that were present at the beginning differ. Things get added on as the cells continue to multiply. For this particular woman, I don’t feel it’s so necessary to do the bone marrow biopsy and genetic testing. At this particular time, I’m not sure that it’s going to change what I’m going to do. I already know she has high-risk disease. If it shows high-risk disease plus another mistake, she still has high-risk disease, so I don’t feel strongly that she needs a bone marrow aspirate and biopsy. I know traditionally, though, it’s done at many centers, and that’s certainly fine, as well.

Transcript edited for clarity.

A 55-year-old African-American Woman With Relapsed Multiple Myeloma

August 2015

• A 55-year-old African-American woman presented to her PCP complaining of worsening fatigue, back pain, and bone pain
• PMH: hypertension managed on a beta blocker, mild renal impairment
• Laboratory results:
  • Hb, 11.0 g/dL;
  • Ca²⁺, 10.1 mg/dL;
  • Creatinine, 1.2 mg/dL;
  • M-protein, 0.9 g/dL
  • Β2M, 5.0 mg/L
  • Albumin, 2.9 g/dL
• MRI showed multiple small lytic lesions in the T1/T2 vertebrae
• Bone marrow biopsy confirmed the diagnosis of multiple myeloma; R-ISS stage II; t(4;14)
• She was treated with lenalidomide/bortezomib/dexamethasone (RVd) for 6 months and achieved a VGPR
• The patient was recommended for autologous transplant, however, she instead opted to continue on a de-escalated treatment regimen of Rd after stating that she struggled to maintain her treatment schedule

May 2018

• M-protein, May 1.5 g/dL

June 2018

• M-protein, 1.7 g/dL

July 2018

• MRI, no new lytic skeletal lesions
• Laboratory results:
  • Hb, 11.5 g/dL;
  • Ca²⁺, 9.8 mg/dL;
  • Creatinine, 1.1 mg/dL;
  • M-protein, 1.9 g/dL
  • Β2M, 4.2 mg/L
• ECOG PS: 0