Clinician-to-Clinician Update Clinician-to-Clinician Update

Autologous Stem Cell Transplant Sends Patient’s Myeloma into Remission

April 2017

Contributed by Brian McClune, DO

In the last decade, advances in drug development and therapies for multiple myeloma have significantly changed treatment options. University of Minnesota Health physicians have been closely engaged in these efforts. In this case, a patient diagnosed with stage I myeloma receives treatment informed by findings in the care team’s clinical trial research.

Patient

A 52-year-old man with no major illnesses in his medical history was referred for consultation after a work-up for back pain revealed lytic bone lesions in the ribs and vertebrae. Biochemical data revealed a small M-spike of 0.1 g/dL, identified as kappa light chains. Free light-chain quantitation showed an elevation in serum-free kappa light chain levels to 113 mg/L (normal, 0.33-1.94), lambda light chains of 0.3 mg/L, with an abnormal ratio of 377. While his complete blood count, metabolic panel results, and beta- 2 microglobulin showed no abnormalities, a bone marrow biopsy demonstrated 20%-30% involvement of the marrow with a monoclonal plasma cell population. Fluorescent in situ hybridization (FISH) testing of these cells showed an abnormal pattern consisting of an IGH/CCND1 gene fusion and only one chromosome 13 signal present in 86% of the cells, supporting classification as standard cytogenetic risk myeloma. Skeletal imaging showed lytic lesions in numerous vertebrae, rib fractures, and multiple lesions in the calvarium. Based on this information, a diagnosis of stage I kappa light chain myeloma was made. The multidisciplinary team of specialists in hematology/oncology, radiation oncology, blood and marrow transplantation, and orthopaedics discussed the case and recommended a treatment regimen consisting of radiation therapy and system chemotherapy.

Treatment

Treatment consisted initially of radiation therapy to painful sites in the patient’s back and ribs, followed by multiagent chemotherapy utilizing lenalidomide, bortezomib, and dexamethasone. Supportive care measures included monthly zolendronic acid infusions. By the end of 4 cycles of therapy, the patient’s kappa light chains levels had returned to normal, and his University of Minnesota Health physicians felt that his condition had improved enough for him to undergo autologous stem cell transplantation. The patient agreed to the procedure. His stem cells were collected and then divided to provide enough cells for a second transplant if one would subsequently be needed.

The patient received the chemotherapy drug melphalan as a conditioning regimen before receiving his autologous stem cell transplantation. Aside from the usual low blood counts and fatigue following the procedure and a readmission for neutropenic fever, he did very well and upon evaluation after transplant, remained in a stringent complete remission at day 100.

Physicians discussed maintenance therapy with the patient and recommended that he receive lenalidomide at 10 mg per day. Currently, at more than 3 years since his transplant, the patient remains in complete remission with only lenalidomide maintenance.

Discussion

Treatment regimens for multiple myeloma have evolved rapidly in the past 10 years, owing to emerging research findings. This patient’s maintenance regimen was based on data derived from a randomized phase III national cooperative group trial in which the Masonic Cancer Center, University of Minnesota was a key center.1

References

  1. Stadtmauer EA, Pasquini MC, Blackwell B, Knust K, Bashey A, Devine SM, et al. Comparison of Autologous Hematopoietic Cell Transplant (autoHCT), Bortezomib, Lenalidomide (Len) and Dexamethasone (RVD) Consolidation with Len Maintenance (ACM), Tandem Autohct with Len Maintenance (TAM) and Autohct with Len Maintenance (AM) for Up-Front Treatment of Patients with Multiple Myeloma (MM). Blood. 2016;128(22):LBA-1.
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