Novel therapies delay the progression of smoldering multiple myeloma: Case report and discussion

Abstract

This clinical vignette illustrates how our therapeutic approaches to early stages of multiple myeloma have changed over the past decade with novel therapies reducing disease and preventing disease progression. Recent paradigms of multiple myeloma describe the disease as a spectrum of clinical stages, including asymptomatic 'smoldering' states that progress to symptomatic states. The average 5-year survival rate of patients with multiple myeloma diagnosed between 1996 and 2004 according to surveillance epidemiology and end results (SEER) data is 35.9%. Here, we describe the use of novel therapeutic agents including bortezomib, lenalidomide, bisphosphonates, Doxil/Caelyx, and dexamethasone, and their success in affecting the course of disease. Multiple trials have shown an increased benefit of these newer agents over prior multiple myeloma treatment regimens. At 13 years and 8 months from diagnosis, our patient is doing well, and thus is a model of how long-term control of multiple myeloma prolongs survival.

Figure 1:

LVEF over time. A normal LVEF by echocardiography was documented in April 2000 after two cycles of free doxorubicin and at the onset of Doxil/Caelyx. The patient had no signs and symptoms of cardiac disease until bortezomib was added to Doxil/Caelyx (February 2004) and simultaneously with a marked drop in IgA. The Doxil/Caelyx was discontinued and after medical management of hypertension and heart failure, the LVEF rose towards baseline in January 2006.

Figure 2:

IgA and total protein over time in relation to treatments underwent by patient. The patient’s IgA has been stable between 2000 and 3000 mg/dl since the addition of bortezomib in 2003. The total protein has been stable between 8.0 and 9.0 g/dl with treatment. Treatments are starred as following: *1 = melphalan and dexamethasone; *2 = carmustine and doxorubicin; *3 = pegylated liposomal doxorubicin; *4 = bortezomib; *5 = lenalidomide added to continued bortezomib.