A 68-Year-Old Man with Multiple Myeloma - Episode 4

The Evolving Treatment Landscape in MM

April 14, 2021
Natalie S. Callander, MD

Dr. Natalie Callander describes promising new treatment approaches for patients with multiple myeloma.

Natalie S. Callander, MD: The future of treatment in myeloma is going to consist of the introduction of a lot of cellular therapeutic options, and we’re all looking forward to the introduction of CAR [chimeric antigen receptor] T-cell transplants. Both the KarMMa and CARTITUDE-1 trials were updated at this year’s ASH [American Society of Hematology annual meeting], and both of these particular CAR T systems showed great response rates, upward of 85% to 90%, almost 100% in the CARTITUDE trial. They are showing great activity in patients who are refractory to therapy, and the progression-free survival is around 10 to 12 months. We’re going to be seeing that kind of intervention with CAR T moved into an earlier point in myeloma treatment. Of course, there are several studies underway looking at that principle, but we’re waiting for our first CAR T approval, which we think will happen very soon. 

Also, to be introduced are going to be the bispecific antibodies. These are molecules that in some cases target BCMA [B-cell maturation antigen], but there are also other targets emerging, and they do bring together the myeloma cells with a T cell, with the CD3 [receptor] end of this package. There are a few drugs; teclistamab has probably the most advanced data, which were updated at ASH, and showed very exciting data in the use of this drug subcutaneously. There’s also talquetamab and cevostamab; these are 2 other bispecifics targeting different antigens on myeloma cells.

All of these kinds of agents are going to be introduced, perhaps earlier and earlier. What we’re also going to see as we go forth is combinations that we’re familiar with but are being tweaked. For example, some of the drugs such as belantamab might be moved up into the front line to see whether that will improve responses. We are anticipating that we will see some use of selinexor potentially in the upfront area as well. This is going to be an exciting time in myeloma.

This transcript is 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