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Ph RadOnc Residency PBRROE2-3 Review 2021 > Plasma Cell Myeloma and Plasmacytoma > Flashcards

Plasma Cell Myeloma and Plasmacytoma Flashcards

1
Q

Plasma Cell Myeloma and Plasmacytoma

What is the most common plasma cell neoplasm?

A

Multiple myeloma

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2
Q

Plasma Cell Myeloma and Plasmacytoma

Multiple myeloma is more common in (males vs females)?

A

Males

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3
Q

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.

A

petroleum products

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4
Q

Plasma Cell Myeloma and Plasmacytoma

All cases of myeloma are preceded by MGUS.

TRUE or FALSE?

A

True

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5
Q

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?

A

False.

other way around

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6
Q

Plasma Cell Myeloma and Plasmacytoma

Re: Spectrum of myeloma:

Clinical finding in MGUS?

A

No organ damage

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7
Q

Plasma Cell Myeloma and Plasmacytoma

Re: Spectrum of myeloma:

Clinical finding in smoldering multiple myeloma?

A

No myeloma-defining events or amyloidosis

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8
Q

Plasma Cell Myeloma and Plasmacytoma

Re: Spectrum of myeloma:

Clinical finding in multiple myeloma?

A

One or more myeloma-defining events

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9
Q

Plasma Cell Myeloma and Plasmacytoma

Re: Spectrum of myeloma:

Clinical finding in plasma cell leukemia

A

Organ damage
leukocytosis
high tumor burden
high proliferation rate

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10
Q

Plasma Cell Myeloma and Plasmacytoma

Re: Spectrum of myeloma:

Status of Marrow disease/M-protein features

MGUS

A

<10% clonal plasma cells

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11
Q

Plasma Cell Myeloma and Plasmacytoma

Re: Spectrum of myeloma:

Status of Marrow disease/M-protein features

smoldering multiple myeloma

A

10 to 60% clonal plasma cells

and/or

M-protein ≥30 g/L (or urinary M-protein ≥500 mg per 24 h)

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12
Q

Plasma Cell Myeloma and Plasmacytoma

Re: Spectrum of myeloma:

Status of Marrow disease/M-protein features

multiple myeloma

A

> 10% clonal plasma cells or biopsy-proven plasmactyoma

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13
Q

Plasma Cell Myeloma and Plasmacytoma

Re: Spectrum of myeloma:

Status of Marrow disease/M-protein features

plasma cell leukemia

A

Plasma cells in peripheral blood
≥2 x 10^9/L or ≥20%

Immature plasma cells in bone marrow

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14
Q

Plasma Cell Myeloma and Plasmacytoma

Re: Spectrum of myeloma:
Management

MGUS

A

Monitor

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15
Q

Plasma Cell Myeloma and Plasmacytoma

Re: Spectrum of myeloma:
Management

smoldering multiple myeloma

A

Close follow-up

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16
Q

Plasma Cell Myeloma and Plasmacytoma

Re: Spectrum of myeloma:
Management

multiple myeloma

A

Chemotherapy

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17
Q

Plasma Cell Myeloma and Plasmacytoma

Re: Spectrum of myeloma:
Management

Plasma cell leukemia

A

High-dose chemotherapy

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18
Q

Plasma Cell Myeloma and Plasmacytoma

Re: Spectrum of myeloma:
Transformation rate

MGUS

A

0.5% to 1% per year

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19
Q

Plasma Cell Myeloma and Plasmacytoma

Re: Spectrum of myeloma:
Management

smoldering multiple myeloma

A

10% per year (up to 20)

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20
Q

Plasma Cell Myeloma and Plasmacytoma

Multiple Myeloma

When is the diagnosis made?
Criteria

A

> 10% clonal plasma cells (BM) or biopsy proven bone or extramedullary plasmactyoma

+
one or more myeloma-defining events

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21
Q

Plasma Cell Myeloma and Plasmacytoma

Multiple Myeloma

What are the myeloma-defining events?

A

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)

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22
Q

Plasma Cell Myeloma and Plasmacytoma

Multiple Myeloma

In the absence of myeloma-defining events, what are the alternatives to diagnosis?

A

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)

23
Q

Plasma Cell Myeloma and Plasmacytoma

Where is the most common location of solitary plasmacytoma?

A

Vertebra

24
Q

Plasma Cell Myeloma and Plasmacytoma

Standard initial imaging?

A

Skeletal survey

25
Q

Plasma Cell Myeloma and Plasmacytoma

What is the historical staging system used for myeloma?

A

Durie Salmon Staging

26
Q

Plasma Cell Myeloma and Plasmacytoma

Identify the criteria for historical stage 3 (using Durie Salmon)

A

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)

27
Q

Plasma Cell Myeloma and Plasmacytoma

Identify the criteria for the R-ISS Staging of Multiple Myeloma

Stage I

A

Serum β2 microglobulin <3.5 mg/L

and

Serum albumin ≥35 g/L

and

standard risk chromosomal abnormalities by iFish

and

normal LDH

28
Q

Plasma Cell Myeloma and Plasmacytoma

Identify the criteria for the R-ISS Staging of Multiple Myeloma

Stage II

A

Neither R-ISS stage I nor III

29
Q

Plasma Cell Myeloma and Plasmacytoma

Identify the criteria for the R-ISS Staging of Multiple Myeloma

Stage III

A

Serum β2 microglobulin ≥5.5 mg/L

and

either high-risk chromosomal abnormality (by
iFISH)
“OR” high LDH

30
Q

Plasma Cell Myeloma and Plasmacytoma

What is an important unfavorable factor with respect to local control after RT in SP?

A

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).

31
Q

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?

A

false.

bony > extramedullary

32
Q

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?

A

True

33
Q

Plasma Cell Myeloma and Plasmacytoma

What are the cytogenetic abnormalities that are considered poor prognostic factors in myeloma as detected by FISH?

A

del(17p)
t(14;16)
t(4;14)

34
Q

Plasma Cell Myeloma and Plasmacytoma

What is the standard treatment for SP?

A

RT

35
Q

Plasma Cell Myeloma and Plasmacytoma

Is RT still indicated for a completely excised(GTR) SP of the spine?

A

Yes.

RT is still
indicated because of a high likelihood of microscopic residual disease.

36
Q

Plasma Cell Myeloma and Plasmacytoma

In multiple myeloma, what is the preferred initial treatment for patients that are candidates for ASCT?

A

Bortezomib

37
Q

Plasma Cell Myeloma and Plasmacytoma

Most common adverse reaction to Bortezomib?

A

neuropathy

38
Q

Plasma Cell Myeloma and Plasmacytoma

Most common adverse reaction to Thalidomide?

A

DVT

39
Q

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?

A

Melphalan+Prednisone (MP)

40
Q

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?

A

lenalidomide+dexamethasone (LD)

FIRST trial

41
Q

Plasma Cell Myeloma and Plasmacytoma

In multiple myeloma, what is the preferred combination treatment + conditioning for patients that are candidates for ASCT?

A

conditioning: melphalan
chemo: RVD (lenalidomide, bortezomib + dexamethasone)

42
Q

Plasma Cell Myeloma and Plasmacytoma

In multiple myeloma, what group of patients benefit the most in tandem transplantation?

A

those who did not achieve a 90% reduction of disease after the first ASCT.

43
Q

Plasma Cell Myeloma and Plasmacytoma

In multiple myeloma, what is the maintenance therapy post ASCT?

A

1 y lenalidomide

44
Q

Plasma Cell Myeloma and Plasmacytoma

In multiple myeloma, what is the most commonly used chemotherapy in relapse after ASCT (median 2 years)?

A

Bortezomib and Lenalidomide

45
Q

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?

A

Pomalidomide

46
Q

Plasma Cell Myeloma and Plasmacytoma

What is the monoclonal antibody targeting a glycoprotein SLAMF-7 used in relapsed multiple myeloma?

A

Elotuzumab

47
Q

Plasma Cell Myeloma and Plasmacytoma

What is the monoclonal antibody targeting CD38 used in relapsed multiple myeloma?

A

Daratumumab

48
Q

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?

A

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).

49
Q

Plasma Cell Myeloma and Plasmacytoma

What is the usual total dose for palliation of bone pain in multiple myeloma?

A

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.

50
Q

Plasma Cell Myeloma and Plasmacytoma

When using RT for SP, when do you include nodal irradiation if there are no gross nodes involved?

A

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.

51
Q

Plasma Cell Myeloma and Plasmacytoma

What is the target for RT of bone SP?

A

gross tumor with margin.

not necessarily entire bone

52
Q

Plasma Cell Myeloma and Plasmacytoma

Expansion to GTV for RT of SP?

A

Generally 1 to 3 cm

0.5 to 1 cm in the axial plaine

2-3 cm proximal and distal in long bones

53
Q

Plasma Cell Myeloma and Plasmacytoma

SP

What is the total RT dose range for small tumors? (<5 cm)

A

35 to 40 Gy

54
Q

Plasma Cell Myeloma and Plasmacytoma

SP

What is the total RT dose range for bulky tumors? (>5 cm)

A

45 to 50 Gy

Ph RadOnc Residency PBRROE2-3 Review 2021 (57 decks)

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