Multiple Myeloma and Plasma Cell Disorders

Question 1

What is the definition of MGUS?

Answer 1

Less than 10% plasma cells in bone marrow, less than 3g/dl on SPEP, AND no crab features

Question 2

What is the definition of Smoldering Myeloma?

Answer 2

Greater than 10% plasma cells in bone marrow or greater than 3g/dl of M-spike on SPEP or greater than or equal to 500mg/L of urine M protein in 24 hours AND no CRAB features

Question 3

What are myeloma defining events?

Answer 3

60% or more plasma cells, K/L>100, and more than one focal lesion on MRI, CRAB features

Question 4

What are the high risk features that are assoc with a poor prognosis?

Answer 4

(4;14), (14;16), (14;20), del 17p, gain 1q

Question 5

Daratumumab works by targeting what?

Answer 5

CD-38

Question 6

What is the concept for maintenance therapy after receiving first line treatment?

Answer 6

All patients get Lenalidomide maintenance therapy. For those that are high risk, they get Velcade and Lenalidomide or Carfilzomib plus Lenalidomide.

Question 7

What is the mechanism of action of Lenalidomide?

Answer 7

It’s a immunomodulator agent (inhibits cytokines). It inhibits hematopoietic cell proliferation.

Question 8

What is the mechanism of action of Elotuzumab?

Answer 8

It is a SLAM-F7 monoclonal antibody. It causes direct activation of NK cells and targets cells for ADCC

Question 9

What line of therapy is CAR-T approved for and which two products have been approved?

Answer 9

CAR-T is approved in the fourth line. Cilta-cel and Ide-cel.

Question 10

What line of therapy are bi-specific antibodies approved for and which ones have been approved?

Answer 10

It is approved in the 4th line setting. Elrantamab, Talquetamab, Teclistamab

Question 11

For those patients who develop relapsed disease on Lenalidomide what are some treatment options (so progression on maintenance tx)? The goal here is to have a general idea of the treatment principle

Answer 11

You can use Dara with either Kyprolis or Velcade with Dex. Isatuximab with kyrprolis and Dex. Selinexor or Pomalidomide with Velcade/Dex. Elo/Pom/Dex

Question 12

What are some options that can be used in the second line setting of Multiple Myeloma for those that are Velcade refractory?

Answer 12

Dara/Len/Dex
Dara/Kyrpolis/Dex
Kyprolis/Len/Dex
Dara/Pom/Dex (after tx with Len and one PI)

Question 13

When using Isatuximab in the second line setting what do the NCCN guidelines state?

Answer 13

It can be used with Pom and Dex only after two prior therapies including Lenalidomide and PI

Question 14

When using Venetoclax in the second/third line setting what is the indication?

Answer 14

It can only be used for a t(11;14) in combination with Dex +/- Daratumumab or PI

Question 15

When using Cyclophosphamide/Pom/Dex or Pom/Dex in the relapsed setting what is the indication for this?

Answer 15

You can only use this combination after two prior therapies including a ImiD and PI with disease progression on/within 60 days of the last therapy.

Question 16

How long should patients receive bone directed therapy?

Answer 16

2 years with either Zometa or Denosumab.

Question 17

When using the IMPEDE score what is the recommendation for AC when treating Multiple Myeloma?

Answer 17

If the score is 3 or less you give these patients aspirin 81-325mg daily. If it is 4 or more you start prophylactic dose of anticoagulant.

Question 18

Name some IMPEDE factors that you may not intuitively think about?

Answer 18

Current pelvic, hip, femur fracture. BMI greater than or equal to 25. Central venous or tunneled line.

Question 19

What is the initial treatment for patients who develop CRS toxicity from CAR-T? What if they are refractory to primary management?

Answer 19

Tocilizumab, mAB against IL-6.
If they are refractory to this you use Solumedrol.

Question 20

What is the indication to use Dex in CAR-T neuro toxicity?

Answer 20

Grade 3 neuro toxicity lasting 24 hours or more except headache. Grade 4 neuro toxicity of any duration. Seizure alone is an indication.

Question 21

What is the mechanism of action of Belantamab? What line of treatment is it used for?

Answer 21

It is a monoclonal antibody directed against the BCMA (B cell maturation antigen) conjugated with MMAE, disrupts microtubles leading to cell death. So antibody drug conjugate. Fourth line

Question 22

What are the category 1 recommendations for first line tx if they are transplant ineligible?

Answer 22

VRD
Dara-RD
Dara/Bortezomib/Melphalan/Prednisone
Lenalidomide/Low Dose Dex

Question 23

What defines Stage III R-ISS?

Answer 23

Both must be met: beta 2 microglobulin greater than or equal to 5.5 and Elevated LDH and/or high risk cytogenetic features

Question 24

If the albumin is 3.5 or higher and the beta 2 microglobulin is less than 3.5 what stage are these patients assuming the LDH is normal and cytogenetics are normal?

Answer 24

Stage I disease. All others go into stage II.