- General Information About Plasma Cell Neoplasms
- Stage Information
- Treatment Option Overview for Plasma Cell Neoplasms
- Treatment for Amyloidosis Associated With Plasma Cell Disorders
- Treatment for Monoclonal Gammopathy of Undetermined Significance
- Treatment for Waldenström Macroglobulinemia (Lymphoplasmacytic Lymphoma)
- Treatment for Isolated Plasmacytoma of Bone
- Treatment for Extramedullary Plasmacytoma
- Treatment for Multiple Myeloma
- Refractory Multiple Myeloma
- Get More Information From NCI
- Changes to This Summary (01 / 28 / 2011)
- More Information
- About This PDQ Summary
Plasma Cell Neoplasms (Including Multiple Myeloma) Treatment (PDQ®): Treatment - Health Professional Information [NCI]
This information is produced and provided by the National Cancer Institute (NCI). The information in this topic may have changed since it was written. For the most current information, contact the National Cancer Institute via the Internet web site at http://cancer.gov or call 1-800-4-CANCER.
Plasma Cell Neoplasms (Including Multiple Myeloma) Treatment
General Information About Plasma Cell Neoplasms
There are several types of plasma cell neoplasms. These diseases are all associated with a monoclonal (or myeloma) protein (M protein). They include monoclonal gammopathy of undetermined significance (MGUS), isolated plasmacytoma of the bone, extramedullary plasmacytoma, and multiple myeloma.
Incidence and Mortality
Estimated new cases and deaths from multiple myeloma in the United States in 2010:
- New cases: 20,580.
- Deaths: 10,580.
Clinical Presentation and Evaluation
Table 1. Clinical Presentation of Plasma Cell Neoplasms
|Plasma Cell Neoplasm||M Protein Type||Pathology||Clinical Presentation|
|MGUS||IgG kappa or lambda; or IgA kappa or lambda||<10% plasma cells in bone marrow||Asymptomatic, with minimal evidence of disease (aside from the presence of an M protein)|
|Isolated plasmacytoma of bone||IgG kappa or lambda; or IgA kappa or gamma||Solitary lesion of bone; <10% plasma cells in marrow of uninvolved site||Symptomatic|
|Extramedullary plasmacytoma||IgG kappa or lambda; or IgA kappa or gamma||Solitary lesion of soft tissue; most commonly occurs in the nasopharynx, tonsils, or paranasal sinuses||Symptomatic|
|Multiple myeloma||IgG kappa or lambda; or IgA kappa or gamma||Often, multiple lesions of bone||Symptomatic|
Evaluation of patients with monoclonal (or myeloma) protein (M protein)
Idiotypic myeloma cells can be found in the blood of myeloma patients in all stages of the disease.[4,5] For this reason, when treatment is indicated, systemic treatment must be considered for all patients with symptomatic plasma cell neoplasms. Patients with MGUS or asymptomatic, smoldering myeloma do not require immediate treatment but must be followed carefully for signs of disease progression.
Patients with a monoclonal (or myeloma) protein (M protein) in the serum and/or urine are evaluated by some of the following criteria:
- Measure and follow the serum M protein by serum electrophoresis or by specific immunoglobulin assays; however, specific immunoglobulin quantification always overestimates the M protein because normal immunoglobulins are included in the result. For this reason, baseline and follow-up measurements of the M protein should be done by the same method. Quantitative serum-free light chains may be helpful to follow response if an M protein is not apparent.
- Measure and follow the amount of M protein light chains excreted in the urine over 24 hours. Measure the total amount of protein excreted over 24 hours and multiply this value by the percentage of urine protein that is M protein, as determined by electrophoresis of concentrated urine protein. An easier, but less accurate, method uses a spot-urine protein electrophoresis.
- Identify the heavy and light chain of the M protein by immunofixation electrophoresis.
- Measure the hemoglobin, leukocyte, platelet, and differential counts.
- Sometimes, determine the percentage of marrow plasma cells. Be aware that marrow plasma cell distribution may vary in different sites.
- Measure serum-free kappa and lambda light chain. This is especially useful in cases of oligosecretory plasma cell dyscrasia or for following cases of light chain amyloidosis.
- Take needle aspirates of a solitary lytic bone lesion, extramedullary tumor(s), or enlarged lymph node(s) to determine whether these are plasmacytomas.
- Evaluate renal function with serum creatinine and a creatinine clearance.
- Electrophoresis of concentrated urine protein is very helpful in differentiating glomerular lesions from tubular lesions. Glomerular lesions, such as those resulting from glomerular deposits of amyloid or light chain deposition disease, result in the nonselective leakage of all serum proteins into the urine; the electrophoresis pattern of this urine resembles the serum pattern with a preponderance of albumin.
In most myeloma patients, the glomeruli function normally allows only the small molecular weight proteins, such as light chains, to filter into the urine. The concentration of protein in the tubules increases as water is reabsorbed. This leads to precipitation of proteins and the formation of tubular casts, which may injure the tubular cells. With tubular lesions, the typical electrophoresis pattern shows a small albumin peak and a larger light chain peak in the globulin region; this tubular pattern is the usual pattern found in myeloma patients.
- Measure serum levels of calcium, alkaline phosphatase, lactic dehydrogenase, and, when indicated by clinical symptoms, cryoglobulins and serum viscosity.
- Obtain radiographs of the skull, ribs, vertebrae, pelvis, shoulder girdle, and long bones. Whole-body, low-dose, nonenhanced multidetector computed tomography and magnetic resonance imaging (MRI) are being evaluated as measures for therapy response monitoring.[10,11] MRI of the spine or long bones is more sensitive in detecting lytic lesions, but any prognostic or therapeutic value for this information remains to be determined.
- Perform MRI if a paraspinal mass is detected or if symptoms suggest spinal cord or nerve root compression.
- If amyloidosis is suspected, perform a needle aspiration of subcutaneous abdominal fat and stain the bone marrow biopsy for amyloid as the easiest and safest way to confirm the diagnosis.
- Measure serum albumin and beta-2-microglobulin as independent prognostic factors.[13,14]
- A high plasma cell labeling index (≥3%) or the presence of circulating myeloma cells are considered poor prognostic factors.
These initial studies should be compared with subsequent values at a later time, when it is necessary to decide whether the disease is stable or progressive, responding to treatment, or getting worse.
As mentioned before, the major challenge is to separate the stable, asymptomatic group of patients who do not require treatment from patients with progressive, symptomatic myeloma who should be treated immediately.[6,7]
Monoclonal Gammopathy of Undetermined Significance (MGUS)
Patients with MGUS have an M protein in the serum without findings of multiple myeloma, macroglobulinemia, amyloidosis, or lymphoma and have fewer than 10% of plasma cells in the bone marrow.[2,16,17] Patients with smoldering myeloma have similar characteristics but may have more than 10% of marrow plasma cells.
These types of patients are asymptomatic and should not be treated. They must, however, be followed carefully since about 1% to 2% of MGUS patients per year will progress to develop myeloma (most commonly), amyloidosis, lymphoma, or chronic lymphocytic leukemia and may then require therapy.[18,19]
Risk factors that predict disease progression include the following:
- An abnormal serum-free light chain ratio.
- Non-IgG class MGUS.
- A high serum M protein level (≥15 g/L).
Isolated Plasmacytoma of Bone
The patient has an isolated plasmacytoma of the bone if the following are found:
- A solitary lytic lesion of plasma cells is found on skeletal survey in an otherwise asymptomatic patient.
- A bone marrow examination from an uninvolved site contains less than 10% plasma cells.[24,25,26]
When clinically indicated, MRI may reveal unsuspected bony lesions that were undetected on standard radiographs. MRI scans of the total spine may identify other bony lesions.
A patient has extramedullary plasmacytoma if the following are found:
- Isolated plasma cell tumors of soft tissues, most commonly occurring in the tonsils, nasopharynx, or paranasal sinuses.
- Negative findings on skeletal x-rays and bone marrow biopsy.[28,29,30]
Multiple myeloma is a systemic malignancy of plasma cells that typically involves multiple sites within the bone marrow and secretes all or part of a monoclonal antibody.
Multiple myeloma is highly treatable but rarely curable. The median survival in the prechemotherapy era was about 7 months. After the introduction of chemotherapy, prognosis improved significantly with a median survival of 24 to 30 months and a 10-year survival of 3%. Even further improvements in prognosis have occurred because of the introduction of newer therapies such as pulse corticosteroids, thalidomide, bortezomib, and autologous and allogeneic stem cell transplantation, with median survivals of 45 to 60 months.[31,32,33]
Multiple myeloma is potentially curable when it presents as a solitary plasmacytoma of bone or as an extramedullary plasmacytoma. (Refer to the Isolated Plasmacytoma of Bone and Extramedullary Plasmacytoma sections of this summary for more information.)
Amyloidosis Associated With Plasma Cell Neoplasms
Multiple myeloma and other plasma cell neoplasms may cause a condition called amyloidosis. Primary amyloidosis can result in severe organ dysfunction especially in the kidney, heart, or peripheral nerves. Elevated serum levels of cardiac troponins and brain natriuretic peptide are poor prognostic factors. A proposed staging system for primary systemic amyloidosis based on these serum levels requires independent and prospective confirmation.
No generally accepted staging system exists for monoclonal gammopathy of undetermined significance (MGUS), isolated plasmacytoma of bone, or extramedullary plasmacytoma. Of the plasma cell neoplasms, a staging system exists only for multiple myeloma.
Multiple myeloma is staged by estimating the myeloma tumor cell mass on the basis of the amount of monoclonal (or myeloma) protein (M protein) in the serum and/or urine, along with various clinical parameters, such as hemoglobin and serum calcium concentrations, the number of lytic bone lesions, and the presence or absence of renal failure. Impaired renal function worsens prognosis regardless of stage.
The stage of the disease at presentation is a strong determinant of survival, but it has little influence on the choice of therapy since almost all patients, except for rare patients with solitary bone tumors or extramedullary plasmacytomas, have generalized disease.
International staging system
The International Myeloma Working Group studied 11,171 patients, of whom 2,901 received high-dose therapy and 8,270 received only standard-dose therapy.
An International Staging System was derived and is shown below in Table 2.
Table 2. The International Staging System for Multiple Myeloma
|Stage||Criteria||Median Survival (mo)|
|I||Beta-2-microglobulin <3.5 mg/L and albumin ≥3.5 g/dL||62|
|II||Beta-2-microglobulin <3.5 mg/L and albumin <3.5 g/dL or beta-2-microglobulin 3.5 mg/L to <5.5 mg/L||44|
|III||Beta-2-microglobulin ≥5.5 mg/L||29|
Genetic factors and risk groups
Genetic aberrations detected by interphase fluorescence in situ hybridization (FISH) may define prognostic groups in retrospective and prospective analyses.[2,3] Short survival and shorter duration of response to therapy have been reported with t(4;14)(p16;q32), t(14;16)(q32;q23), cytogenetic deletion of 13q-14, and deletion of 17p13 (p53 locus).[2,3,4,5,6] The question of whether the choice of therapy based on FISH analysis can influence outcome must await further study in prospective trials.
Newer clinical investigations are stratifying patients with multiple myeloma into a so-called standard-risk group, which accounts for 75% of patients and has a median survival of 3 to 6 years, and a high-risk group, which has a median survival of less than 3 years.[2,3,4,5,6,7] (See Table 3 below.) This stratification, based on cytogenetic findings, has been derived from retrospective analyses and requires prospective validation. Bone marrow samples are sent for cytogenetic and FISH analysis.
Table 3. Risk Groups for Multiple Myeloma
|Risk Group||Cytogenetic Findings||Disease Characteristics|
|Standard risk||Has any of the following cytogenetic findings: (1) no adverse FISH or cytogenetics, (2) hyperdiploidy, (3) t(11;14) by FISH, or (4) t(6;14) by FISH.||These patients most often have (1) disease that expresses IgG kappa monoclonal gammopathies and (2) lytic bone lesions.|
|High risk||Has any of the following cytogenetic findings: (1) del 17p by FISH, (2) t(4;14) by FISH, (3) t(14;16) by FISH, (4) cytogenetic del 13, or (5) hypodiploidy.||These patients have (1) disease that expresses IgA lambda monoclonal gammopathies (often) and (2) skeletal-related complications (less often).|
Treatment Option Overview for Plasma Cell Neoplasms
The major challenge in treating plasma cell neoplasms is to separate the stable, asymptomatic group of patients who do not require immediate treatment from patients with progressive, symptomatic myeloma who should be treated immediately.[1,2] Monoclonal gammopathy of undetermined significance or smoldering myeloma must be distinguished from progressive myeloma.
Asymptomatic Plasma Cell Disorders
Symptomatic Plasma Cell Disorders
Treatment should be given to patients with symptomatic advanced disease.
Treatment should be directed at reducing the tumor cell burden and reversing any complications of disease, such as renal failure, infection, hyperviscosity, or hypercalcemia, with appropriate medical management. (Refer to the PDQ summary on Hypercalcemia for more information.)
Response criteria have been developed for patients on clinical trials.
Current therapy for patients with symptomatic myeloma can be divided into the following categories:
- Induction therapies.
- Consolidation therapies, which are less applicable for the very elderly.
- Maintenance therapies.
- Supportive care, such as bisphosphonates. (For more information on supportive care therapies, such as bisphosphonates, refer to the PDQ summary on Pain.)
Treatment for Amyloidosis Associated With Plasma Cell Disorders
Standard Treatment Options for Amyloidosis Associated With Plasma Cell Disorders
Standard treatment options for amyloidosis associated with plasma cell disorders include the following:
|2.||Stem cell rescue.|
As is true for all plasma cell dyscrasias, anecdotal responses for amyloidosis have been reported, as in the Southwest Oncology Group's trial (SWOG-9628), for dexamethasone alone and in combination with thalidomide and cyclophosphamide or lenalidomide.[3,4,5,6]
Stem cell rescue
A randomized prospective study of 100 patients with immunoglobulin amyloidosis light chain compared melphalan plus high-dose dexamethasone with high-dose melphalan plus autologous stem cell rescue.
After a median follow-up of 3 years, median OS favored the nontransplant arm (56.9 mo vs. 22.2 mo; P = .04).[Level of evidence: 1iiA] The 24% transplant-related mortality in this series and others reflects the difficulties involved with high-dose chemotherapy in older patients with organ dysfunction.[7,8,9,10] A randomized trial confirming the benefit of autologous transplantation is not anticipated.
An anecdotal series describes full-intensity and reduced-intensity allogeneic stem cell transplantation.
Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with primary systemic amyloidosis. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
Treatment for Monoclonal Gammopathy of Undetermined Significance
Standard Treatment Options for Monoclonal Gammopathy of Undetermined Significance (MGUS)
Standard treatment options for MGUS include the following:
Multiple myeloma, other plasma cell dyscrasia, or lymphoma will develop in 12% of patients by 10 years, 25% by 20 years, and 30% by 25 years.
All patients with MGUS should be kept under observation to detect increases in M protein levels and development of a plasma cell dyscrasia. Higher levels of initial M protein levels may correlate with increased risk of progression to multiple myeloma. In a large retrospective report, the risk of progression at 20 years was 14% for an initial monoclonal protein level of 0.5 g/dL or less, 25% for a level of 1.5 g/dL, 41% for a level of 2.0 g/dL, 49% for a level of 2.5 g/dL, and 64% for a level of 3.0 g/dL.
Treatment is delayed until the disease progresses to the stage that symptoms or signs appear.
Patients with MGUS or smoldering myeloma do not respond more frequently, achieve longer remissions, or have improved survival if chemotherapy is started early while they are still asymptomatic as opposed to waiting for progression before treatment is initiated.[2,3,4,5]
Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with monoclonal gammopathy of undetermined significance. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
Treatment for Waldenström Macroglobulinemia (Lymphoplasmacytic Lymphoma)
Refer to the Waldenström macroglobulinemia section in the PDQ summary on Adult Non-Hodgkin Lymphoma Treatment for more information.
Treatment for Isolated Plasmacytoma of Bone
Standard Treatment Options for Isolated Plasmacytoma of Bone
Standard treatment options for isolated plasmacytoma of bone include the following:
|1.||Radiation therapy to the lesion.|
|2.||Chemotherapy (if the monoclonal [or myeloma] protein [M protein] increases and other evidence of symptomatic multiple myeloma occurs).|
About 25% of patients have a serum and/or urine M protein; this should disappear following adequate radiation therapy to the lytic lesion.
The survival rate of patients with isolated plasmacytoma of bone treated with radiation therapy to the lesion is greater than 50% at 10 years, which is much better than the survival rate of patients with disseminated multiple myeloma.
Most patients will eventually develop disseminated disease and require chemotherapy; almost 50% of them will do so within 2 years of diagnosis.[2,3] However, patients with serum paraprotein or Bence Jones protein, who have complete disappearance of these proteins after radiation therapy, may be expected to remain free of disease for prolonged periods.[2,4] Patients who progress to multiple myeloma tend to have good responses to chemotherapy with a median survival of 63 months after progression.[2,4]
Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with isolated plasmacytoma of bone. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
Treatment for Extramedullary Plasmacytoma
Standard Treatment Options for Extramedullary Plasmacytoma
Standard treatment options for extramedullary plasmacytoma include the following:
|1.||Radiation therapy to the isolated lesion with fields that cover the regional lymph nodes, if possible.[1,2]|
|2.||In some cases, surgical resection may be considered, but it is usually followed by radiation therapy.|
|3.||If the monoclonal (or myeloma) protein (M protein) persists or reappears, the patient may need further radiation therapy. In some patients, the plasmacytoma may shrink, but not disappear, and the M protein persists. These types of patients should be followed closely. Surgery should be performed if the plasmacytoma is in a site where it can be removed easily (e.g., in the tonsil); the M protein may disappear from the blood or urine. In other cases, persistence or an increasing M protein may herald progression to multiple myeloma.|
|4.||Chemotherapy is required if the disease progresses and causes symptoms.|
Patients with isolated plasma cell tumors of soft tissues, most commonly occurring in the tonsils, nasopharynx, or paranasal sinuses, should have skeletal x-rays and bone marrow biopsy (both of which should be negative) and evaluation for M protein in serum and urine.[1,2,3,4]
About 25% of patients have serum and/or urine M protein; this should disappear following adequate radiation.
Extramedullary plasmacytoma is a highly curable disease with progression-free survival ranging from 70% to 87% at 10 to 14 years after treatment with radiation therapy (with or without previous resection).[1,2,5]
Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with extramedullary plasmacytoma. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
Treatment for Multiple Myeloma
The initial approach to the patient is to evaluate the following parameters:
|1.||Detection of a monoclonal (or myeloma) protein (M protein) in the serum or urine.|
|2.||Detection of more than 10% of plasma cells on a bone marrow examination.|
|3.||Detection of lytic bone lesions or generalized osteoporosis in skeletal x-rays.|
|4.||Presence of soft tissue plasmacytomas.|
|5.||Serum albumin and beta-2-microglobulin levels.|
|6.||Detection of free kappa and lambda serum immunoglobulin light chain.|
Treatment selection is influenced by the age and general health of the patient, prior therapy, and the presence of complications of the disease.
The choice of induction therapy is unclear at the present time; however, the current basic categories include the use of steroids, thalidomide, and lenalidomide.
Several questions are raised when therapy is being chosen for a patient with symptomatic myeloma at first presentation, including the following:
|1.||Is the patient eligible for a clinical trial? The sequence and combinations of new and older therapies can only be determined by prospective clinical trials.|
|2.||Is autologous stem cell transplantation a possible consolidation option for this patient? If so, alkylating agents should be avoided during induction therapy to avoid compromise of stem cell collection and to lessen leukemogenic risk.|
|3.||Does the patient have comorbidities? Age, organ dysfunction, and risk of cardiovascular and thrombotic complications would influence the choice of induction therapies as well as the choice of whether to consider consolidation therapies.|
Induction therapy agents
Multiple therapeutic agents are available for induction therapy, either alone or in combinations. These include the following:
- Steroids (e.g., dexamethasone, prednisone).
- Alkylating agents (e.g., melphalan, cyclophosphamide).
- Other cytotoxic drugs (e.g., vincristine, doxorubicin, liposomal doxorubicin).
Clinical trials are needed to establish the regimens with the best efficacy and least long-term toxicity. (Refer to the Combination therapy section of this summary for a list of current clinical trials.)
Guidelines for choosing induction therapy
Until results become available, outside the context of a clinical trial, clinicians may choose induction therapy based on the following guidelines:
|1.||In patients younger than 70 years, alkylators are avoided up front to avoid stem cell toxicity with subsequent risks for cytopenias, secondary malignancies, or poor stem cell harvesting if transplantation is considered for consolidation therapy.|
|2.||Bortezomib or lenalidomide is combined with dexamethasone for at least 8 months or until best response if consolidation therapy is planned.[5,6] (Refer to the Lenalidomide and Bortezomib sections of this summary for more information.)|
|3.||The choice of bortezomib or lenalidomide is based on side-effect profile and route of administration. |
|4.||Patients with standard-risk disease, as defined in the Stage Information section of this summary, might receive induction therapy alone, followed by careful observation after best response.|
|5.||Patients with high-risk disease might receive induction therapy until best response, followed by consolidation therapy with allogeneic or autologous stem cell transplantation.|
These guidelines require validation by ongoing clinical trials; participation in clinical trials is the preferred choice, when possible.
Since the mid-1980s, dexamethasone has been administered at a dose of 40 mg orally for 4 consecutive days, which is the same schedule used with the vincristine plus doxorubicin plus dexamethasone (VAD) regimen. Response rates of 60% to 70% in previously untreated patients appeared to be as high as those in patients treated with VAD.[12,13][Level of evidence: 3iiiDiv]
A prospective trial randomly assigned 488 patients older than 65 years to receive dexamethasone alone, melphalan plus dexamethasone, dexamethasone plus interferon-alpha, and melphalan plus prednisone.
- With a median follow-up of 7.1 years, no difference was observed in overall survival (OS) (median survival times were 32–40 mo).[Level of evidence: 1iiA]
- The patients on the dexamethasone-based arms had significantly more infections, glucose intolerance, gastrointestinal symptoms, and psychiatric complaints. (For more information on gastrointestinal symptoms, refer to the PDQ summary on Gastrointestinal Complications.)
There has never been a randomized trial comparing single-agent oral dexamethasone at a traditional high dose (40 mg a day for 4 days, repeated after 4 days off) with a lower dose (≤40 mg weekly). This issue of dexamethasone dose has been evaluated in two of the following prospective randomized trials:
- In the context of melphalan, as evaluated in a National Cancer Institute of Canada trial (CAN-NCIC-MY7).
- Compared with standard-dose steroids, high-dose dexamethasone was associated with an increased risk of infection in the melphalan trial, but there was no difference in efficacy.
- In the context of lenalidomide, as evaluated in an Eastern Cooperative Oncology Group trial (ECOG-E4A03); this trial was published in abstract form only.
- The lenalidomide study questioned the safety and efficacy of high-dose dexamethasone. (Refer to the Lenalidomide section of this summary for more information.)
Almost all ongoing clinical trials in the United States and Europe have implemented the low-dose dexamethasone schedule with or without other therapeutic agents.
Nine randomized prospective studies (including E-E1A00 and HOVON 50) involving more than 3,500 patients have been published in final or preliminary abstract form examining the introduction of thalidomide as induction therapy for previously untreated symptomatic patients with multiple myeloma.[16,17,18,19,20,21,22,23,24]
- All of the trials reported improved response rates with the introduction of thalidomide and no hematopoietic damage, allowing adequate stem cell collection when applicable or allowing combinations with other myelosuppressive agents.
- Only three of the nine randomized studies reported a survival advantage using thalidomide. In these trials, the patients older than 65 years at the 2-year follow-ups showed 44- to 56-month median OS for melphalan plus prednisone plus thalidomide versus 28- to 30-month median OS for melphalan plus prednisone (MP) (P < .03 in all three studies).[21,25][Level of evidence: 1iiA]
- A possible explanation is that these three trials used a lower dose of thalidomide than the other studies (100 mg vs. ≥200 mg), a lower dose of steroids (60 mg of prednisone vs. high-dose dexamethasone), and involved the use of alkylating agents.
As previously described in the section on corticosteroids, high-dose dexamethasone can complicate interpretation of clinical trials by worsening cardiopulmonary toxicity and deaths, especially in the context of thalidomide or lenalidomide, both of which are thrombogenic agents.
Factors that have been implicated to worsen the risk of DVT include the use of high-dose dexamethasone, concomitant erythropoietic growth factors, and concomitant doxorubicin, liposomal doxorubicin, or alkylating agents.
Personal cardiovascular risk factors can also influence the rate of DVT. Various clinical trials have included different DVT prophylaxis measures, including aspirin (81 mg–100 mg a day), warfarin, or low-molecular-weight heparin, but the validity of these measures has not been studied prospectively in a randomized study.[21,22,27,28,29,30,31]
Prospective electrophysiologic monitoring provides no clear benefit over clinical evaluation for the development of clinically significant neuropathy while on thalidomide.
|1.||A prospective randomized study of 351 relapsed patients compared lenalidomide, an analogue of thalidomide, plus high-dose dexamethasone with high-dose dexamethasone plus placebo.|
|2.||Similarly, another randomized prospective trial (NCT00179647) of 353 previously treated patients favors the lenalidomide plus high-dose dexamethasone arm versus dexamethasone plus placebo.|
|3.||A prospective randomized study (ECOG-E4A03) of 445 untreated symptomatic patients, published in abstract form only, compared lenalidomide and high-dose dexamethasone (40 mg on days 1–4, 9–12, and 17–20, every 28 days) with lenalidomide and low-dose dexamethasone (40 mg on days 1, 8, 15, and 22, every 28 days).|
Lenalidomide has substantially greater myelosuppression but less neuropathy than seen with thalidomide; however, both have the same tendency for DVT.[5,32,33] DVT prophylaxis with 81 mg of aspirin has been proposed, but randomized clinical trials have not confirmed any benefit for this recommendation.
|1.||A prospective randomized trial (VISTA) of 682 previously untreated symptomatic patients who were not candidates for stem cell transplantation because of age (one-third of patients >75 years) compared bortezomib combined with melphalan and prednisone with melphalan and prednisone alone.|
|2.||A prospective randomized study of 669 patients with relapsing myeloma, who had been treated previously with steroids, compared intravenous bortezomib with high-dose oral dexamethasone.|
|3.||A prospective randomized trial (NCT00103506) of 646 previously treated patients compared bortezomib plus pegylated liposomal doxorubicin with bortezomib alone.|
When bortezomib was incorporated with induction therapy, patients with unfavorable molecular cytogenetics did not show any difference in PFS or OS compared with patients with more favorable risk factors. The benefit from bortezomib appears to be maintained across risk groups.[38,39,40,41][Level of evidence: 3iiiD]
Because bortezomib is metabolized and cleared by the liver, it appears active and well tolerated in patients with renal impairment.
- No randomized studies support the widespread use of this regimen in untreated patients.
- This regimen avoids early exposure to alkylating agents, thereby minimizing any problems with stem cell collection (if needed) and any future risks for myelodysplasia or secondary leukemia.
- Disadvantages include the logistics for a 96-hour infusion of doxorubicin and a low complete response rate.
- An alternative version of VAD substitutes pegylated liposomal doxorubicin for doxorubicin, eliminates the need for an infusion, and provides comparable response rates.[46,47][Level of evidence: 3iiiDiv]
Evidence is not strong that any alkylating agent is superior to any other. All standard doses and schedules produce equivalent results. The two most common regimens historically have been oral MP and oral cyclophosphamide plus prednisone.[48,49,50]
Combinations, such as those used in EST-2479, of alkylating agents and prednisone, administered simultaneously or alternately, have not proven to be superior to therapy with MP.[51,52,53,54][Level of evidence: 1iiA]
A meta-analysis of studies comparing melphalan plus prednisone with drug combinations concluded that both forms of treatment were equally effective.[Level of evidence: 1iiA] Patients who relapsed after initial therapy with cyclophosphamide and prednisone had no difference in OS (median OS 17 mo) when randomly assigned to receive vincristine plus carmustine plus melphalan plus cyclophosphamide plus prednisone or VAD.
Several national and international trials have been implemented to define the optimal combination regimens. Participation in these trials should be the preferred approach, when feasible. The combination regimens in these trials represent the most successful from numerous phase II reports during the last several years.
- ECOG-E1A05: Bortezomib + dexamethasone versus lenalidomide + bortezomib + dexamethasone.
- SWOG-SO777: Lenalidomide + dexamethasone versus lenalidomide + bortezomib + dexamethasone.
- EVOLUTION trial: Bortezomib + lenalidomide + dexamethasone versus bortezomib + cyclophosphamide + dexamethasone versus bortezomib + lenalidomide + cyclophosphamide + dexamethasone.
- U.S. Intergroup/IFM trial: Lenalidomide + bortezomib + dexamethasone for three cycles; responders are then randomly assigned to five more cycles of lenalidomide + bortezomib + dexamethasone or high-dose melphalan + stem cell transplantation.
Options for combination regimens:
|1.||Bortezomib + dexamethasone (as demonstrated in ECOG-E1A05).[38,56]|
|2.||Lenalidomide + dexamethasone (as demonstrated in SWOG-SO777).[5,32,33]|
|3.||Bortezomib + lenalidomide + dexamethasone (as demonstrated in ECOG-E1A05, SWOG-SO777, EVOLUTION trial, and U.S. Intergroup/IFM trial).[38,56,57]|
|4.||Bortezomib + cyclophosphamide + dexamethasone (as demonstrated in the EVOLUTION trial).[58,59]|
|5.||Bortezomib + lenalidomide + cyclophosphamide + dexamethasone (as demonstrated in the EVOLUTION trial).|
|6.||Lenalidomide + cyclophosphamide + dexamethasone.|
|7.||Bortezomib + melphalan + prednisone.|
|8.||Bortezomib + liposomal doxorubicin.|
|9.||Melphalan + prednisone + thalidomide.[18,25]|
|10.||Melphalan + prednisone.[18,25]|
High-dose chemotherapy: Autologous bone marrow or peripheral stem cell transplantation
The failure of conventional therapy to cure the disease has led investigators to test the effectiveness of much higher doses of drugs such as melphalan. The development of techniques for harvesting hemopoietic stem cells, from marrow aspirates or the peripheral blood of the patient, and infusing these cells to promote hemopoietic recovery made it possible for investigators to test very large doses of chemotherapy.
Based on the experience of treating thousands of patients in this way, it is possible to draw a few conclusions, including the following:
- The risk of early death caused by treatment-related toxic effects has been reduced to less than 3% in highly selected populations.
- Chemotherapy patients can now be treated as outpatients.
- Extensive prior chemotherapy, especially with alkylating agents, compromises marrow hemopoiesis and may make the harvesting of adequate numbers of hemopoietic stem cells impossible.
- Younger patients in good health tolerate high-dose therapy better than patients with a poor performance status.[63,64,65]
Single autologous bone marrow or peripheral stem cell transplantation
While some prospective randomized trials, such as the U.S. Intergroup trial SWOG-9321, have shown improved survival for patients who received autologous peripheral stem cell or bone marrow transplantation after induction chemotherapy versus chemotherapy alone,[66,67,68][Level of evidence: 1iiA] other trials have not shown any survival advantage.[69,70,71,72][Level of evidence: 1iiA]
Tandem autologous bone marrow or peripheral stem cell transplantation
|1.||A meta-analysis of six randomized clinical trials enrolling 1,803 patients compared single autologous hematopoietic cell transplantation with tandem autologous hematopoietic cell transplantation.|
|2.||In a trial of 194 previously untreated patients aged 50 to 70 years, the patients were randomly assigned to either conventional oral melphalan and prednisone or VAD for two cycles followed by two sequential episodes of high-dose therapy (melphalan 100 mg/m2) with stem cell support.|
|3.||Three different groups have compared two tandem autologous transplants with one autologous transplant followed by a reduced-intensity conditioning allograft from an HLA-identical sibling; treatment assignment was based on the presence or absence of an HLA-identical sibling. The results have been discordant for survival in these nonrandomized trials.|
|4.||A trial of 195 patients younger than 60 years with newly diagnosed myeloma randomly compared two tandem transplants with a single autologous stem cell transplant followed by 6 months of maintenance therapy with thalidomide.|
Interferon maintenance after stem cell transplantation
|1.||In a randomized study of 84 patients following autologous bone marrow transplantation, maintenance therapy with interferon showed a benefit in PFS (46 mo vs. 27 mo, P < .025) and OS (75% vs. 50%, P < .01).[Level of evidence: 1iiA]|
|2.||A larger randomized trial of 805 patients showed no difference in PFS or OS with interferon given after peripheral stem cell transplantation or conventional chemotherapy.[Level of evidence: 1iiA]|
High-dose chemotherapy: Allogeneic bone marrow or peripheral stem cell transplantation
In a registry of 162 patients who underwent allogeneic matched sibling-donor transplants, the actuarial OS rate was 28% at 7 years.[Level of evidence: 3iiiA]
Favorable prognostic features included the following:
- Low tumor burden.
- Responsive disease before transplant.
- Application of transplantation after first-line therapy.
Many patients are not young enough or healthy enough to undergo these intensive approaches. A definite graft-versus-myeloma effect has been demonstrated, including regression of myeloma relapses following the infusion of donor lymphocytes.[90,91,92,93]
Allogeneic marrow transplants have significant toxic effects (15%–40% mortality), but the possibility of a potent and possibly curative graft-versus-myeloma effect makes this procedure attractive.[93,94]
Further research is required to make allogeneic transplants less dangerous and to find methods for initiating an autoimmune response to the myeloma cells. Nonmyeloablative allogeneic stem cell transplant is under development.[95,96,97] Such strategies aim to maintain efficacy (so called graft-versus-tumor effect) while reducing transplant-related mortality.[98,99]
Myeloma patients who respond to treatment show a progressive fall in the M protein until a plateau is reached; subsequent treatment with conventional doses does not result in any further improvement. This has led investigators to question how long treatment should be continued.
|1.||In a single study, it was observed that maintenance therapy with MP prolonged the initial remission duration (31 mo) compared with no maintenance treatment (23 mo).|
|2.||Maintenance interferon-alpha therapy has been reported in several studies to prolong initial remission duration.[101,102,103,104] While the impact of interferon maintenance on disease-free survival and OS has significantly varied among trials, a meta-analysis of 1,543 patients treated on 12 trials randomizing between interferon maintenance and observation indicated that interferon maintenance was associated with improved relapse-free survival (27% vs. 19% at 3 years, P < .001) and OS (12% odds reduction, P = .04). Toxic effects in this population may be substantial and must be balanced against the potential benefits in response duration.|
|3.||Maintenance therapy with interferon showed a benefit in PFS (46 mo vs. 27 mo, P < .025) and OS (75% vs. 50%, P < .01) in a randomized study of 84 patients following autologous bone marrow transplantation.[Level of evidence: 1iiA] A larger randomized trial of 805 patients showed no difference in PFS or OS with interferon given after peripheral stem cell transplantation or conventional chemotherapy.[Level of evidence: 1iiA]|
|4.||A study of 125 responding patients with first-line VAD induction who were randomly assigned to maintenance corticosteroids at 10 mg or 50 mg on alternate days showed improved PFS (14 mo vs. 5 mo, P = .003) and OS (36 mo vs. 26 mo, P = .05) for the patients receiving the higher-dose corticosteroids.[Level of evidence: 1iiA]|
|5.||In a larger trial by the National Cancer Institute of Canada (CAN-NCIC-MY7) of 585 patients treated with first-line MP, 292 patients were randomly assigned to pulse dexamethasone (40 mg a day for 4 days monthly) versus no maintenance. |
|6.||Two months after autologous transplantation, 597 patients younger than 65 years were randomly assigned to no maintenance, pamidronate, or pamidronate plus thalidomide.|
|7.||After autologous transplantation, 129 patients were randomly assigned to indefinite prednisone versus indefinite prednisone with 12 months of thalidomide.|
|1.||A randomized, double-blind study of patients with stage III myeloma showed that monthly intravenous pamidronate significantly reduced pathologic fractures, bone pain, spinal cord compression, and the need for bone radiation therapy (38% skeletal-related events were reported in the treatment group vs. 51% in the placebo group after 21 mo of therapy, P = .015).[Level of evidence: 1iDiii] (For more information on bisphosphonate therapy, refer to the PDQ summary on Pain.)|
|2.||A randomized comparison of pamidronate versus zoledronic acid in 518 patients with multiple myeloma showed equivalent efficacy in regard to skeletal-related complications.[Level of evidence: 1iDiii]|
Bisphosphonates are associated with infrequent long-term complications (in 3%–5% of patients), including osteonecrosis of the jaw and avascular necrosis of the hip.[112,113] (For more information on osteonecrosis of the jaw, refer to the PDQ summary on Oral Complications of Chemotherapy and Head/Neck Radiation.) These side effects must be balanced against the potential benefits of bisphosphonates when bone metastases are evident.
Lytic lesions of the spine should be radiated if any of the following are true:
- If they are associated with an extramedullary (paraspinal) plasmacytoma.
- If a painful destruction of a vertebral body occurred.
- If computed tomography or MRI scans present evidence of spinal cord compression.
Back pain caused by osteoporosis and small compression fractures of the vertebrae responds best to chemotherapy. (For more information on back pain, refer to the PDQ summary on Pain.)
Extensive radiation of the spine or long bones for diffuse osteoporosis may lead to prolonged suppression of hemopoiesis and is rarely indicated.
Bisphosphonates are useful for slowing or reversing the osteopenia that is common in myeloma patients.
Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with multiple myeloma. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
Refractory Multiple Myeloma
There are two main types of refractory myeloma patients:
- Primary refractory patients who never achieve a response and progress while still on induction chemotherapy.
- Secondary refractory patients who do respond to induction chemotherapy but do not respond to treatment after relapse.
A subgroup of patients who do not achieve a response to induction chemotherapy have stable disease and enjoy a survival prognosis that is as good as that for responding patients.[1,2] When the stable nature of the disease becomes established, these types of patients can discontinue therapy until the myeloma begins to progress again. Others with primary refractory myeloma and progressive disease require a change in therapy. (Refer to the Treatment for Multiple Myeloma section of this summary for more information.)
The myeloma growth rate, as measured by the monoclonal (or myeloma) protein-doubling time, for patients who respond to their initial therapy increases progressively with each subsequent relapse, and remission durations become shorter and shorter. Marrow function becomes increasingly compromised as patients develop pancytopenia and enter a refractory phase; occasionally, the myeloma cells dedifferentiate and extramedullary plasmacytomas develop. The myeloma cells may still be sensitive to chemotherapy, but the regrowth rate during relapse is so rapid that progressive improvement is not observed.
Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with refractory multiple myeloma. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
Get More Information From NCI
For more information, U.S. residents may call the National Cancer Institute's (NCI's) Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237) Monday through Friday from 8:00 a.m. to 8:00 p.m., Eastern Time. A trained Cancer Information Specialist is available to answer your questions.
The NCI's LiveHelp® online chat service provides Internet users with the ability to chat online with an Information Specialist. The service is available from 8:00 a.m. to 11:00 p.m. Eastern time, Monday through Friday. Information Specialists can help Internet users find information on NCI Web sites and answer questions about cancer.
Write to us
For more information from the NCI, please write to this address:
|NCI Public Inquiries Office|
|6116 Executive Boulevard, MSC8322|
|Bethesda, MD 20892-8322|
Search the NCI Web site
The NCI Web site provides online access to information on cancer, clinical trials, and other Web sites and organizations that offer support and resources for cancer patients and their families. For a quick search, use the search box in the upper right corner of each Web page. The results for a wide range of search terms will include a list of "Best Bets," editorially chosen Web pages that are most closely related to the search term entered.
There are also many other places to get materials and information about cancer treatment and services. Hospitals in your area may have information about local and regional agencies that have information on finances, getting to and from treatment, receiving care at home, and dealing with problems related to cancer treatment.
The NCI has booklets and other materials for patients, health professionals, and the public. These publications discuss types of cancer, methods of cancer treatment, coping with cancer, and clinical trials. Some publications provide information on tests for cancer, cancer causes and prevention, cancer statistics, and NCI research activities. NCI materials on these and other topics may be ordered online or printed directly from the NCI Publications Locator. These materials can also be ordered by telephone from the Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237).
Changes to This Summary (01 / 28 / 2011)
The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.
This summary has been reformatted. The content has been reorganized, and some content has been added.
- PDQ® - NCI's Comprehensive Cancer Database.
Full description of the NCI PDQ database.
Additional PDQ Summaries
- PDQ® Cancer Information Summaries: Adult Treatment
Treatment options for adult cancers.
- PDQ® Cancer Information Summaries: Pediatric Treatment
Treatment options for childhood cancers.
- PDQ® Cancer Information Summaries: Supportive and Palliative Care
Side effects of cancer treatment, management of cancer-related complications and pain, and psychosocial concerns.
- PDQ® Cancer Information Summaries: Screening/Detection (Testing for Cancer)
Tests or procedures that detect specific types of cancer.
- PDQ® Cancer Information Summaries: Prevention
Risk factors and methods to increase chances of preventing specific types of cancer.
- PDQ® Cancer Information Summaries: Genetics
Genetics of specific cancers and inherited cancer syndromes, and ethical, legal, and social concerns.
- PDQ® Cancer Information Summaries: Complementary and Alternative Medicine
Information about complementary and alternative forms of treatment for patients with cancer.
This information is intended mainly for use by doctors and other health care professionals. If you have questions about this topic, you can ask your doctor, or call the Cancer Information Service at 1-800-4-CANCER (1-800-422-6237).
About This PDQ Summary
Purpose of This Summary
This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about treatment of plasma cell neoplasms (including multiple myeloma). It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.
Reviewers and Updates
This summary is reviewed regularly and updated as necessary by the PDQ Adult Treatment Editorial Board. Board members review recently published articles each month to determine whether an article should:
- be discussed at a meeting,
- be cited with text, or
- replace or update an existing article that is already cited.
Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary.
The lead reviewers for Plasma Cell Neoplasms (Including Multiple Myeloma) Treatment are:
- Steven D. Gore, MD (Johns Hopkins University)
- Mark J. Levis, MD, PhD (Johns Hopkins University)
- Eric J. Seifter, MD (Johns Hopkins University)
Any comments or questions about the summary content should be submitted to Cancer.gov through the Web site's Contact Form. Do not contact the individual Board Members with questions or comments about the summaries. Board members will not respond to individual inquiries.
Levels of Evidence
Some of the reference citations in this summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ Adult Treatment Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations.
Permission to Use This Summary
PDQ is a registered trademark. Although the content of PDQ documents can be used freely as text, it cannot be identified as an NCI PDQ cancer information summary unless it is presented in its entirety and is regularly updated. However, an author would be permitted to write a sentence such as "NCI's PDQ cancer information summary about breast cancer prevention states the risks succinctly: [include excerpt from the summary]."
The preferred citation for this PDQ summary is:
National Cancer Institute: PDQ® Plasma Cell Neoplasms (Including Multiple Myeloma) Treatment. Bethesda, MD: National Cancer Institute. Date last modified <MM/DD/YYYY>. Available at: http://www.cancer.gov/cancertopics/pdq/treatment/myeloma/healthprofessional. Accessed <MM/DD/YYYY>.
Images in this summary are used with permission of the author(s), artist, and/or publisher for use within the PDQ summaries only. Permission to use images outside the context of PDQ information must be obtained from the owner(s) and cannot be granted by the National Cancer Institute. Information about using the illustrations in this summary, along with many other cancer-related images, is available in Visuals Online, a collection of over 2,000 scientific images.
Based on the strength of the available evidence, treatment options may be described as either "standard" or "under clinical evaluation." These classifications should not be used as a basis for insurance reimbursement determinations. More information on insurance coverage is available on Cancer.gov on the Coping with Cancer: Financial, Insurance, and Legal Information page.
More information about contacting us or receiving help with the Cancer.gov Web site can be found on our Contact Us for Help page. Questions can also be submitted to Cancer.gov through the Web site's Contact Form.
Last Revised: 2011-01-28
Healthwise, Healthwise for every health decision, and the Healthwise logo are trademarks of Healthwise, Incorporated.