Multiple Myeloma and Plasma Cell Disorders Flashcards
What is the definition of MGUS?
Less than 10% plasma cells in bone marrow, less than 3g/dl on SPEP, AND no crab features
What is the definition of Smoldering Myeloma?
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
What are myeloma defining events?
60% or more plasma cells, K/L>100, and more than one focal lesion on MRI, CRAB features
What are the high risk features that are assoc with a poor prognosis?
(4;14), (14;16), (14;20), del 17p, gain 1q
Daratumumab works by targeting what?
CD-38
What is the concept for maintenance therapy after receiving first line treatment?
All patients get Lenalidomide maintenance therapy. For those that are high risk, they get Velcade and Lenalidomide or Carfilzomib plus Lenalidomide.
What is the mechanism of action of Lenalidomide?
It’s a immunomodulator agent (inhibits cytokines). It inhibits hematopoietic cell proliferation.
What is the mechanism of action of Elotuzumab?
It is a SLAM-F7 monoclonal antibody. It causes direct activation of NK cells and targets cells for ADCC
What line of therapy is CAR-T approved for and which two products have been approved?
CAR-T is approved in the fourth line. Cilta-cel and Ide-cel.
What line of therapy are bi-specific antibodies approved for and which ones have been approved?
It is approved in the 4th line setting. Elrantamab, Talquetamab, Teclistamab
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
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
What are some options that can be used in the second line setting of Multiple Myeloma for those that are Velcade refractory?
Dara/Len/Dex
Dara/Kyrpolis/Dex
Kyprolis/Len/Dex
Dara/Pom/Dex (after tx with Len and one PI)
When using Isatuximab in the second line setting what do the NCCN guidelines state?
It can be used with Pom and Dex only after two prior therapies including Lenalidomide and PI
When using Venetoclax in the second/third line setting what is the indication?
It can only be used for a t(11;14) in combination with Dex +/- Daratumumab or PI
When using Cyclophosphamide/Pom/Dex or Pom/Dex in the relapsed setting what is the indication for this?
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.
How long should patients receive bone directed therapy?
2 years with either Zometa or Denosumab.
When using the IMPEDE score what is the recommendation for AC when treating Multiple Myeloma?
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.
Name some IMPEDE factors that you may not intuitively think about?
Current pelvic, hip, femur fracture. BMI greater than or equal to 25. Central venous or tunneled line.
What is the initial treatment for patients who develop CRS toxicity from CAR-T? What if they are refractory to primary management?
Tocilizumab, mAB against IL-6.
If they are refractory to this you use Solumedrol.
What is the indication to use Dex in CAR-T neuro toxicity?
Grade 3 neuro toxicity lasting 24 hours or more except headache. Grade 4 neuro toxicity of any duration. Seizure alone is an indication.
What is the mechanism of action of Belantamab? What line of treatment is it used for?
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
What are the category 1 recommendations for first line tx if they are transplant ineligible?
VRD
Dara-RD
Dara/Bortezomib/Melphalan/Prednisone
Lenalidomide/Low Dose Dex
What defines Stage III R-ISS?
Both must be met: beta 2 microglobulin greater than or equal to 5.5 and Elevated LDH and/or high risk cytogenetic features
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?
Stage I disease. All others go into stage II.
