Multiple myeloma: 2016 update on diagnosis, risk-stratification, and management

Abstract

Multiple myeloma accounts for approximately 10% of hematologic malignancies.The diagnosis requires ≥10% clonal bone marrow plasma cells or a biopsy proven plasmacytoma plus evidence of one or more multiple myeloma defining events (MDE): CRAB (hypercalcemia, renal failure, anemia, or lytic bone lesions) features felt related to the plasma cell disorder, bone marrow clonal plasmacytosis ≥60%, serum involved/uninvolved free light chain (FLC) ratio ≥100 (provided involved FLC is ≥100 mg/L), or >1 focal lesion on magnetic resonance imaging. Patients with del(17p), t(14;16), and t(14;20) have high-risk multiple myeloma. Patients with t(4;14) translocation and gain(1q) have intermediate-risk. All others are considered standard-risk. Initial treatment consists of bortezomib, lenalidomide, dexamethasone (VRD). In high-risk patients, carfilzomib, lenalidomide, dexamethasone (KRD) is an alternative to VRD. In eligible patients, initial therapy is given for approximately 3-4 months followed by autologous stem cell transplantation (ASCT). Standard risk patients can opt for delayed ASCT at first relapse. Patients not candidates for transplant are treated with Rd until progression, or alternatively, a triplet regimen such as VRD for approximately 12-18 months. After ASCT, lenalidomide maintenance is considered for standard risk patients especially in those who are not in very good partial response or better, while maintenance with a bortezomib-based regimen is needed for patients with intermediate or high-risk disease. Patients with indolent relapse can be treated with 2-drug or 3-drug combinations. Patients with more aggressive relapse require a triplet regimen or a combination of multiple active agents. Am. J. Hematol. 91:720-734, 2016. © 2016 Wiley Periodicals, Inc.

Figure 1

Approach to the treatment of newly diagnosed multiple myeloma in transplant eligible (A) and transplant ineligible (B) patients Abbreviations: VRD, bortezomib, lenalidomide, dexamethasone; KRD, carfilzomib, lenalidomide, dexamethasone; Rd, lenalidomide plus dexamethasone; VCD, bortezomib, cyclophosphamide, dexamethasone; ASCT, autologous stem cell transplantation; CR, complete response; VGPR, very good partial response Reproduced from: Rajkumar SV. Multiple myeloma: 2014 Update on diagnosis, risk-stratification, and management. Am J Hematol 2014;89:998–1009.

Figure 1

Approach to the treatment of newly diagnosed multiple myeloma in transplant eligible (A) and transplant ineligible (B) patients Abbreviations: VRD, bortezomib, lenalidomide, dexamethasone; KRD, carfilzomib, lenalidomide, dexamethasone; Rd, lenalidomide plus dexamethasone; VCD, bortezomib, cyclophosphamide, dexamethasone; ASCT, autologous stem cell transplantation; CR, complete response; VGPR, very good partial response Reproduced from: Rajkumar SV. Multiple myeloma: 2014 Update on diagnosis, risk-stratification, and management. Am J Hematol 2014;89:998–1009.

Figure 2

Suggested options for the treatment of relapsed multiple myeloma in first relapse (A) and second or higher relapse (B) Abbreviations: Rd, lenalidomide, dexamethasone; PD, pomalidomide, dexamethasone; Rd, lenalidomide plus dexamethasone; VCD, bortezomib, cyclophosphamide, dexamethasone; VD, bortezomib, dexamethasone; ASCT, autologous stem cell transplantation

Figure 2

Suggested options for the treatment of relapsed multiple myeloma in first relapse (A) and second or higher relapse (B) Abbreviations: Rd, lenalidomide, dexamethasone; PD, pomalidomide, dexamethasone; Rd, lenalidomide plus dexamethasone; VCD, bortezomib, cyclophosphamide, dexamethasone; VD, bortezomib, dexamethasone; ASCT, autologous stem cell transplantation