Plasma Cell Myeloma and Plasmacytoma Flashcards
Plasma Cell Myeloma and Plasmacytoma
What is the most common plasma cell neoplasm?
Multiple myeloma
Plasma Cell Myeloma and Plasmacytoma
Multiple myeloma is more common in (males vs females)?
Males
Plasma Cell Myeloma and Plasmacytoma
Little is known about the cause of multiple myeloma. However, according to reports, this environmental exposure has been associated with the development of the disease.
petroleum products
Plasma Cell Myeloma and Plasmacytoma
All cases of myeloma are preceded by MGUS.
TRUE or FALSE?
True
Plasma Cell Myeloma and Plasmacytoma
The bone disease that
arises in myeloma appears to be mediated in part by the inhibition of the RANK
pathway and the amplification of the Wnt signaling pathway.
TRUE or FALSE?
False.
other way around
Plasma Cell Myeloma and Plasmacytoma
Re: Spectrum of myeloma:
Clinical finding in MGUS?
No organ damage
Plasma Cell Myeloma and Plasmacytoma
Re: Spectrum of myeloma:
Clinical finding in smoldering multiple myeloma?
No myeloma-defining events or amyloidosis
Plasma Cell Myeloma and Plasmacytoma
Re: Spectrum of myeloma:
Clinical finding in multiple myeloma?
One or more myeloma-defining events
Plasma Cell Myeloma and Plasmacytoma
Re: Spectrum of myeloma:
Clinical finding in plasma cell leukemia
Organ damage
leukocytosis
high tumor burden
high proliferation rate
Plasma Cell Myeloma and Plasmacytoma
Re: Spectrum of myeloma:
Status of Marrow disease/M-protein features
MGUS
<10% clonal plasma cells
Plasma Cell Myeloma and Plasmacytoma
Re: Spectrum of myeloma:
Status of Marrow disease/M-protein features
smoldering multiple myeloma
10 to 60% clonal plasma cells
and/or
M-protein ≥30 g/L (or urinary M-protein ≥500 mg per 24 h)
Plasma Cell Myeloma and Plasmacytoma
Re: Spectrum of myeloma:
Status of Marrow disease/M-protein features
multiple myeloma
> 10% clonal plasma cells or biopsy-proven plasmactyoma
Plasma Cell Myeloma and Plasmacytoma
Re: Spectrum of myeloma:
Status of Marrow disease/M-protein features
plasma cell leukemia
Plasma cells in peripheral blood
≥2 x 10^9/L or ≥20%
Immature plasma cells in bone marrow
Plasma Cell Myeloma and Plasmacytoma
Re: Spectrum of myeloma:
Management
MGUS
Monitor
Plasma Cell Myeloma and Plasmacytoma
Re: Spectrum of myeloma:
Management
smoldering multiple myeloma
Close follow-up
Plasma Cell Myeloma and Plasmacytoma
Re: Spectrum of myeloma:
Management
multiple myeloma
Chemotherapy
Plasma Cell Myeloma and Plasmacytoma
Re: Spectrum of myeloma:
Management
Plasma cell leukemia
High-dose chemotherapy
Plasma Cell Myeloma and Plasmacytoma
Re: Spectrum of myeloma:
Transformation rate
MGUS
0.5% to 1% per year
Plasma Cell Myeloma and Plasmacytoma
Re: Spectrum of myeloma:
Management
smoldering multiple myeloma
10% per year (up to 20)
Plasma Cell Myeloma and Plasmacytoma
Multiple Myeloma
When is the diagnosis made?
Criteria
> 10% clonal plasma cells (BM) or biopsy proven bone or extramedullary plasmactyoma
+
one or more myeloma-defining events
Plasma Cell Myeloma and Plasmacytoma
Multiple Myeloma
What are the myeloma-defining events?
end-organ damage attributed to myeloma
CRAB
C-hypercalcemia (>2.75 mmol/L)
R-renal insufficiency (crea >177umol/L or CrCl <40mL/min)
A-anemia (<10 g/dL or >20 g/L below lower limit of normal)
B-bone lesions (one or more osteolytic lesions on x-rays, CT, or PET scan)
Plasma Cell Myeloma and Plasmacytoma
Multiple Myeloma
In the absence of myeloma-defining events, what are the alternatives to diagnosis?
one or more biomarkers for malignancy
SLiM (sixty percent, light chains, MRI)
clonal bone marrow plasma ≥60%
involved:uninvolved light chain ratio ≥100,
1 focal lesions on MRI (≥5mm in size)
Plasma Cell Myeloma and Plasmacytoma
Where is the most common location of solitary plasmacytoma?
Vertebra
Plasma Cell Myeloma and Plasmacytoma
Standard initial imaging?
Skeletal survey
Plasma Cell Myeloma and Plasmacytoma
What is the historical staging system used for myeloma?
Durie Salmon Staging
Plasma Cell Myeloma and Plasmacytoma
Identify the criteria for historical stage 3 (using Durie Salmon)
Hemoglobin <8.5 g/dL
Serum calcium >12 mg/dL
Advanced lytic bone lesions
High M component (IgG > 7 g/dL, IgA > 3 g/dL, and urine light chains >12
g/24 h)
Plasma Cell Myeloma and Plasmacytoma
Identify the criteria for the R-ISS Staging of Multiple Myeloma
Stage I
Serum β2 microglobulin <3.5 mg/L
and
Serum albumin ≥35 g/L
and
standard risk chromosomal abnormalities by iFish
and
normal LDH
Plasma Cell Myeloma and Plasmacytoma
Identify the criteria for the R-ISS Staging of Multiple Myeloma
Stage II
Neither R-ISS stage I nor III
Plasma Cell Myeloma and Plasmacytoma
Identify the criteria for the R-ISS Staging of Multiple Myeloma
Stage III
Serum β2 microglobulin ≥5.5 mg/L
and
either high-risk chromosomal abnormality (by
iFISH)
“OR” high LDH
Plasma Cell Myeloma and Plasmacytoma
What is an important unfavorable factor with respect to local control after RT in SP?
tumor bulk
Tumors <5 cm achieved a high level of local control with 35 Gy, whereas
those ≥5 cm had a local failure rate of 58% (7 of 12 patients, total dose range 25
to 50 Gy).
Plasma Cell Myeloma and Plasmacytoma
An extramedullary presentation has been
consistently demonstrated to have a significantly higher risk of subsequent
development of myeloma with a 10-year rate of 76% compared with a bony presentation where the 10-year rate was 36%
TRUE or FALSE?
false.
bony > extramedullary
Plasma Cell Myeloma and Plasmacytoma
Where there was an elevation of M protein pretreatment, persistence of the M
protein following radiation therapy (RT) predicts for progression to
myeloma.
TRUE or FALSE?
True
Plasma Cell Myeloma and Plasmacytoma
What are the cytogenetic abnormalities that are considered poor prognostic factors in myeloma as detected by FISH?
del(17p)
t(14;16)
t(4;14)
Plasma Cell Myeloma and Plasmacytoma
What is the standard treatment for SP?
RT
Plasma Cell Myeloma and Plasmacytoma
Is RT still indicated for a completely excised(GTR) SP of the spine?
Yes.
RT is still
indicated because of a high likelihood of microscopic residual disease.
Plasma Cell Myeloma and Plasmacytoma
In multiple myeloma, what is the preferred initial treatment for patients that are candidates for ASCT?
Bortezomib
Plasma Cell Myeloma and Plasmacytoma
Most common adverse reaction to Bortezomib?
neuropathy
Plasma Cell Myeloma and Plasmacytoma
Most common adverse reaction to Thalidomide?
DVT
Plasma Cell Myeloma and Plasmacytoma
Multiple Myeloma
In patients not eligible for transplant, what chemotherapy (alklyating agent) is used in treatment in combination with bortezomib?
Melphalan+Prednisone (MP)
Plasma Cell Myeloma and Plasmacytoma
Multiple Myeloma
In patients not eligible for transplant, what is the preferred treatment when an alkylating agent use is not applicable due to its toxicity?
lenalidomide+dexamethasone (LD)
FIRST trial
Plasma Cell Myeloma and Plasmacytoma
In multiple myeloma, what is the preferred combination treatment + conditioning for patients that are candidates for ASCT?
conditioning: melphalan
chemo: RVD (lenalidomide, bortezomib + dexamethasone)
Plasma Cell Myeloma and Plasmacytoma
In multiple myeloma, what group of patients benefit the most in tandem transplantation?
those who did not achieve a 90% reduction of disease after the first ASCT.
Plasma Cell Myeloma and Plasmacytoma
In multiple myeloma, what is the maintenance therapy post ASCT?
1 y lenalidomide
Plasma Cell Myeloma and Plasmacytoma
In multiple myeloma, what is the most commonly used chemotherapy in relapse after ASCT (median 2 years)?
Bortezomib and Lenalidomide
Plasma Cell Myeloma and Plasmacytoma
Relapsed Multiple Myeloma
What is a novel lMiD that has also demonstrated efficacy in relapsed myeloma, even in patients refractory both to bortezomib and lenalidomide?
Pomalidomide
Plasma Cell Myeloma and Plasmacytoma
What is the monoclonal antibody targeting a glycoprotein SLAMF-7 used in relapsed multiple myeloma?
Elotuzumab
Plasma Cell Myeloma and Plasmacytoma
What is the monoclonal antibody targeting CD38 used in relapsed multiple myeloma?
Daratumumab
Plasma Cell Myeloma and Plasmacytoma
TBI is now rarely used in multiple myeloma as a conditioning prior to ASCT due to toxicity concerns.
However, for historical/theoretic purposes, what dose will you prescribe if the need arises?
8 Gy in 4 fractions
A phase III French study (IFM [Intergroupe Francophone du Mye’lome] trial 9502) examined melphalan 200 mg/m2 alone (M200) versus melphalan 140 mg/m2 with TBI, (M140/TBI), and found that patients in the TBI-containing arm suffered more grade 3 or 4 mucosal toxicity, heavier transfusion requirement, and longer hospitalization stay.
There was a higher toxic death rate in the M140/TBI arm (3.6% vs. 0% for the M200 arm).
Plasma Cell Myeloma and Plasmacytoma
What is the usual total dose for palliation of bone pain in multiple myeloma?
25 Gy
When RT is given for pain because of disease involving a long bone, a local
field suffices. It is unnecessary to treat the entire bone.
Doses of 10 to 20 Gy
(in 5 to 10 fractions) are effective, although the pain relief is often partial.
Leigh et al. found a symptomatic response rate of 97% (complete pain relief
in 26% and partial relief in 71%) after an average dose of 25 Gy given to 306
sites in 101 patients. There was no dose–response relationship above 10 Gy.
Recurrence of symptoms requiring further treatment was seen in 6% of sites
after a median of 16 months. Similar results are also reported by Matuschek et
al., with complete pain relief in 31% and partial relief in 54%, with median RT
dose of 25 Gy.
Plasma Cell Myeloma and Plasmacytoma
When using RT for SP, when do you include nodal irradiation if there are no gross nodes involved?
EMP (extramedullary)
bulky disease close to draining lymph node station.
For EMP, nodal involvement
at presentation is observed in 10% to 20%, and occasional nodal failure in the
literature led to a common practice of extending the RT coverage to the draining
lymph node region.
Plasma Cell Myeloma and Plasmacytoma
What is the target for RT of bone SP?
gross tumor with margin.
not necessarily entire bone
Plasma Cell Myeloma and Plasmacytoma
Expansion to GTV for RT of SP?
Generally 1 to 3 cm
0.5 to 1 cm in the axial plaine
2-3 cm proximal and distal in long bones
Plasma Cell Myeloma and Plasmacytoma
SP
What is the total RT dose range for small tumors? (<5 cm)
35 to 40 Gy
Plasma Cell Myeloma and Plasmacytoma
SP
What is the total RT dose range for bulky tumors? (>5 cm)
45 to 50 Gy
