National Cancer Institute National Cancer Institute
U.S. National Institutes of Health National Cancer Institute
Send to Printer
Multiple Myeloma and Other Plasma Cell Neoplasms Treatment (PDQ®)     
Last Modified: 09/08/2008
Health Professional Version
Table of Contents

Purpose of This PDQ Summary
General Information
Cellular Classification
Stage Information
Multiple Myeloma
Isolated Plasmacytoma of Bone
Extramedullary Plasmacytoma
Macroglobulinemia
Monoclonal Gammopathy of Undetermined Significance
Treatment Option Overview
Amyloidosis
Current Clinical Trials
Multiple Myeloma
Induction Therapy
        Corticosteroids
        Thalidomide
        Lenalidomide
        Bortezomib
        Conventional-dose chemotherapy
Consolidation Chemotherapy
        High-dose chemotherapy: autologous bone marrow or peripheral stem cell transplantation
        High-dose chemotherapy: allogeneic bone marrow or peripheral stem cell transplantation
Maintenance Therapy
Supportive Care
        Bisphosphonate therapy
Current Clinical Trials
Isolated Plasmacytoma of Bone
Current Clinical Trials
Extramedullary Plasmacytoma
Current Clinical Trials
Waldenström Macroglobulinemia (Lymphoplasmacytic Lymphoma)
Monoclonal Gammopathy of Undetermined Significance
Current Clinical Trials
Refractory Plasma Cell Neoplasm
Current Clinical Trials
Get More Information From NCI
Changes to This Summary (09/08/2008)
More Information

Purpose of This PDQ Summary

This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the treatment of multiple myeloma and other plasma cell neoplasms. This summary is reviewed regularly and updated as necessary by the PDQ Adult Treatment Editorial Board 1.

Information about the following is included in this summary:

  • Diagnosis.
  • Cellular classification.
  • Staging.
  • Treatment options for different types of disorders.

This summary is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.

Some of the reference citations in the summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ Adult Treatment Editorial Board uses a formal evidence ranking system 2 in developing its level-of-evidence designations. Based on the strength of the available evidence, treatment options are described as either "standard" or "under clinical evaluation." These classifications should not be used as a basis for reimbursement determinations.

This summary is also available in a patient version 3, which is written in less-technical language, and in Spanish 4.

General Information

Note: Estimated new cases and deaths from multiple myeloma in the United States in 2008:[1]

  • New cases: 19,920.
  • Deaths: 10,690.

Multiple myeloma is a systemic malignancy of plasma cells that is highly treatable but rarely curable. It is potentially curable when it presents as a solitary plasmacytoma of bone or as an extramedullary plasmacytoma. The median survival in the prechemotherapy era was about 7 months. After the introduction of chemotherapy, prognosis improved significantly with a median survival of 24 to 30 months and a 10-year survival of 3%. Even further improvements in prognosis have occurred because of the introduction of newer therapies such as pulse corticosteroids, thalidomide, bortezomib, and autologous and allogeneic stem cell transplantation. The disease is staged by estimating the myeloma tumor cell mass on the basis of the amount of monoclonal (or myeloma) protein (M protein) in the serum and/or urine, along with various clinical parameters, such as the hemoglobin and serum calcium concentrations, the number of lytic bone lesions, and the presence or absence of renal failure. The stage of the disease at presentation is a strong determinant of survival, but it has little influence on the choice of therapy since almost all patients, except for rare patients with solitary bone tumors or extramedullary plasmacytomas, have generalized disease. Treatment selection is influenced by the age and general health of the patient, prior therapy, and the presence of complications of the disease.[2]

The initial approach to the patient is to establish the diagnosis by:

  1. Detection of an M protein in the serum or urine.
  2. Detection of greater than 10% of plasma cells on a bone marrow examination.
  3. Detection of lytic bone lesions or generalized osteoporosis in skeletal x-rays.
  4. Presence of soft tissue plasmacytomas.

References

  1. American Cancer Society.: Cancer Facts and Figures 2008. Atlanta, Ga: American Cancer Society, 2008. Also available online. 5 Last accessed October 1, 2008. 

  2. Rajkumar SV, Kyle RA: Multiple myeloma: diagnosis and treatment. Mayo Clin Proc 80 (10): 1371-82, 2005.  [PUBMED Abstract]

Cellular Classification

Diseases associated with a monoclonal (or myeloma) protein (M protein) included in this presentation are:

  1. Asymptomatic plasma cell neoplasia with minimal evidence of disease aside from the presence of an M protein (monoclonal gammopathy of undetermined significance [MGUS]).[1] (Usually IgG kappa or lambda, IgA kappa or lambda.)


  2. Symptomatic plasma cell neoplasia. (Usually IgG kappa or gamma, IgA kappa or gamma.)
    1. Primarily affecting bones:
      1. Multiple myeloma (94%).
      2. Solitary plasmacytoma (3%).
    2. Extramedullary plasmacytoma (3%).

      These usually occur in the nasopharynx, tonsils, or paranasal sinuses.[2]



  3. Macroglobulinemia.

    Patients often have lymphadenopathy and hepatosplenomegaly; less than 5% of patients have lytic bone lesions. (Usually IgM kappa or gamma.)

    1. Asymptomatic.
    2. Symptomatic.[3]

    This entity is called lymphoplasmacytic lymphoma or Waldenström macroglobulinemia. (Refer to the PDQ summary on Adult Non Hodgkin Lymphoma Treatment 6 for more information.)



References

  1. Kyle RA, Bladé J, Rajkumar SV: Monoclonal gammopathies of undetermined significance. In: Malpas JS, Bergsagel DE, Kyle RA, et al.: Myeloma: Biology and Management. 3rd ed. Philadelphia, Pa: WB Saunders Co, 2004, pp 315-52. 

  2. Knowling MA, Harwood AR, Bergsagel DE: Comparison of extramedullary plasmacytomas with solitary and multiple plasma cell tumors of bone. J Clin Oncol 1 (4): 255-62, 1983.  [PUBMED Abstract]

  3. Kyle RA, Garton JP: The spectrum of IgM monoclonal gammopathy in 430 cases. Mayo Clin Proc 62 (8): 719-31, 1987.  [PUBMED Abstract]

Stage Information



Multiple Myeloma

The International Myeloma Working Group studied 11,171 patients, of whom 2,901 received high-dose therapy and 8,270 received only standard-dose therapy.[1] An International Staging System was derived as follows:

Stage I multiple myeloma: Beta-2-microglobulin less than 3.5 and albumin greater than or equal to 3.5 (median survival of 62 months).

Stage II multiple myeloma: Beta-2-microglobulin less than 3.5 and albumin less than 3.5 or beta-2-microglobulin 3.5 to less than 5.5 (median survival of 44 months).

Stage III multiple myeloma: Beta-2-microglobulin greater than or equal to 5.5 (median survival of 29 months).

Impaired renal function worsens prognosis regardless of stage. Genetic aberrations detected by interphase fluorescence in situ hybridization (FISH) may define prognostic groups in retrospective and prospective analyses.[2,3] Short survival and shorter duration of response to therapy have been reported with t(4;14)(p16;q32), t(14;16)(q32;q23), cytogenetic deletion of 13q-14, and deletion of 17p13 (p53 locus).[2-6] Whether choice of therapy based on FISH analysis can influence outcome must await further prospective trials.

Newer clinical investigations are stratifying patients with multiple myeloma into a so-called standard-risk group, which accounts for 75% of patients, with a median survival of 3 to 6 years, and a high-risk group, which has a median survival of less than 3 years.[2-7] This stratification, based on cytogenetic findings, has been derived from retrospective analyses and requires prospective validation.[7] Bone marrow samples are sent for cytogenetic and FISH analysis.

Standard risk is defined as any one of the following cytogenetic findings:

  • No adverse FISH or cytogenetics.
  • Hyperdiploidy.
  • t (11;14) by FISH.
  • t (6;14) by FISH.

These patients most often have disease that expresses IgG kappa monoclonal gammopathies, and they present with lytic bone lesions.

High risk is defined as any one of the following cytogenetic findings:

  • del 17p by FISH.
  • t (4;14) by FISH.
  • t (14;16) by FISH.
  • Cytogenetic del 13.
  • Hypodiploidy.

These patients often have disease that expresses IgA lambda monoclonal gammopathies and less often have skeletal-related complications.

Isolated Plasmacytoma of Bone

If a solitary lytic lesion of plasma cells is found on skeletal survey in an otherwise asymptomatic patient, and a bone marrow examination from an uninvolved site contains less than 5% to 10% plasma cells, the patient has an isolated plasmacytoma of bone.[8-10] About 25% of patients have a serum and/or urine M protein; this should disappear following adequate radiation of the lytic lesion. When clinically indicated, magnetic resonance imaging may reveal unsuspected bony lesions that were undetected on standard radiographs.

Extramedullary Plasmacytoma

Patients with isolated plasma cell tumors of soft tissues, most commonly occurring in the tonsils, nasopharynx, or paranasal sinuses, should have skeletal x-rays and bone marrow biopsy.[11-13] If these tests are negative, the patient has extramedullary plasmacytoma. About 25% of patients have serum and/or urine M protein; this should disappear following adequate radiation.

Macroglobulinemia

Macroglobulinemia is a proliferation of plasmacytoid lymphocytes secreting an IgM M protein. Patients often have lymphadenopathy and hepatosplenomegaly, but bony lesions are uncommon. No generally accepted staging system exists.

The term macroglobulinemia describes an increase in the serum concentration of a monoclonal IgM.[14] Most patients are asymptomatic and do not require treatment. The most common symptoms and signs are fatigue, manifestations of hyperviscosity (e.g., headache, epistaxis, and visual disturbances), and neurologic abnormalities. Serum or plasma viscosity (relative to water) measures the risk of symptoms. The normal viscosity level is 1.7 to 2.1; symptoms may rarely appear between 3.0 and 4.0 but more commonly appear above 4.0. Emergent therapy (i.e., plasmapheresis and chemotherapy) is usually required above a viscosity level of 4.0. Lymphadenopathy and splenomegaly are found in about 33% of patients. The increased intravascular concentration of high molecular weight IgM leads to an expansion of the plasma volume, a dilutional anemia, and in extreme cases, congestive heart failure. Sludging of the blood can be seen in conjunctival and retinal veins with dilatation and segmentation of vessels (i.e., a link of sausage appearance), retinal hemorrhages, and papilledema. Similar problems with the circulation of blood in the central nervous system can cause ataxia, nystagmus, vertigo, confusion, and disturbances of consciousness.

The various disorders associated with the appearance of a monoclonal IgM include:

  1. Monoclonal Gammopathy of Undetermined Significance (MGUS). Patients are asymptomatic, the M protein is stable, and no lymphadenopathy, splenomegaly, or bony lesions are present.
  2. Waldenström Macroglobulinemia (WM). This entity is called lymphoplasmacytic lymphoma in the World Health Organization/Revised European-American Lymphoma classification system. Patients are symptomatic, have lymphoplasmacytic marrow infiltration, and a rising serum IgM concentration, and may have lymphadenopathy or splenomegaly. Rarely, patients with WM have lytic bone lesions. (Refer to the PDQ summary on Adult Non Hodgkin Lymphoma Treatment 7 for more information.)
  3. Absolute lymphocyte count exceeding 5,000 cells/mm3. The patient may be classified as having chronic lymphocytic leukemia (CLL) if the lymphocytes are of the small, well-differentiated variety. CLL must be differentiated from the lymphoplasmacytosis that may occur as a peripheral blood manifestation of WM. (Refer to the PDQ summary on Chronic Lymphocytic Leukemia Treatment 8 for more information.)
  4. Chronic cold agglutinin disease. Patients have a high cold agglutinin titer and no morphologic evidence of neoplasia. These patients often have a hemolytic anemia that is aggravated by cold exposure. The IgM has kappa light chains in more than 90% of these types of patients.
Monoclonal Gammopathy of Undetermined Significance

Patients with MGUS have an M protein in the serum without findings of multiple myeloma, macroglobulinemia, amyloidosis, or lymphoma, and with less than 10% of plasma cells in the bone marrow.[14-16] These types of patients are asymptomatic and should not be treated. They must, however, be followed carefully since about 1% to 2% per year will progress to develop one of the symptomatic B-cell neoplasms and may then require therapy.[17,18] Risk factors predicting progression include an abnormal serum-free light chain ratio, non-IgG class MGUS, and a high serum M protein level (≥15 g/L).[19]

References

  1. Greipp PR, San Miguel J, Durie BG, et al.: International staging system for multiple myeloma. J Clin Oncol 23 (15): 3412-20, 2005.  [PUBMED Abstract]

  2. Fonseca R, Blood E, Rue M, et al.: Clinical and biologic implications of recurrent genomic aberrations in myeloma. Blood 101 (11): 4569-75, 2003.  [PUBMED Abstract]

  3. Avet-Loiseau H, Attal M, Moreau P, et al.: Genetic abnormalities and survival in multiple myeloma: the experience of the Intergroupe Francophone du Myélome. Blood 109 (8): 3489-95, 2007.  [PUBMED Abstract]

  4. Gertz MA, Lacy MQ, Dispenzieri A, et al.: Clinical implications of t(11;14)(q13;q32), t(4;14)(p16.3;q32), and -17p13 in myeloma patients treated with high-dose therapy. Blood 106 (8): 2837-40, 2005.  [PUBMED Abstract]

  5. Gutiérrez NC, Castellanos MV, Martín ML, et al.: Prognostic and biological implications of genetic abnormalities in multiple myeloma undergoing autologous stem cell transplantation: t(4;14) is the most relevant adverse prognostic factor, whereas RB deletion as a unique abnormality is not associated with adverse prognosis. Leukemia 21 (1): 143-50, 2007.  [PUBMED Abstract]

  6. Sagaster V, Ludwig H, Kaufmann H, et al.: Bortezomib in relapsed multiple myeloma: response rates and duration of response are independent of a chromosome 13q-deletion. Leukemia 21 (1): 164-8, 2007.  [PUBMED Abstract]

  7. Dispenzieri A, Rajkumar SV, Gertz MA, et al.: Treatment of newly diagnosed multiple myeloma based on Mayo Stratification of Myeloma and Risk-adapted Therapy (mSMART): consensus statement. Mayo Clin Proc 82 (3): 323-41, 2007.  [PUBMED Abstract]

  8. Ozsahin M, Tsang RW, Poortmans P, et al.: Outcomes and patterns of failure in solitary plasmacytoma: a multicenter Rare Cancer Network study of 258 patients. Int J Radiat Oncol Biol Phys 64 (1): 210-7, 2006.  [PUBMED Abstract]

  9. Dimopoulos MA, Moulopoulos LA, Maniatis A, et al.: Solitary plasmacytoma of bone and asymptomatic multiple myeloma. Blood 96 (6): 2037-44, 2000.  [PUBMED Abstract]

  10. Dimopoulos MA, Hamilos G: Solitary bone plasmacytoma and extramedullary plasmacytoma. Curr Treat Options Oncol 3 (3): 255-9, 2002.  [PUBMED Abstract]

  11. Tournier-Rangeard L, Lapeyre M, Graff-Caillaud P, et al.: Radiotherapy for solitary extramedullary plasmacytoma in the head-and-neck region: A dose greater than 45 Gy to the target volume improves the local control. Int J Radiat Oncol Biol Phys 64 (4): 1013-7, 2006.  [PUBMED Abstract]

  12. Michalaki VJ, Hall J, Henk JM, et al.: Definitive radiotherapy for extramedullary plasmacytomas of the head and neck. Br J Radiol 76 (910): 738-41, 2003.  [PUBMED Abstract]

  13. Alexiou C, Kau RJ, Dietzfelbinger H, et al.: Extramedullary plasmacytoma: tumor occurrence and therapeutic concepts. Cancer 85 (11): 2305-14, 1999.  [PUBMED Abstract]

  14. Kyle RA, Bladé J, Rajkumar SV: Monoclonal gammopathies of undetermined significance. In: Malpas JS, Bergsagel DE, Kyle RA, et al.: Myeloma: Biology and Management. 3rd ed. Philadelphia, Pa: WB Saunders Co, 2004, pp 315-52. 

  15. Kyle RA, Therneau TM, Rajkumar SV, et al.: Prevalence of monoclonal gammopathy of undetermined significance. N Engl J Med 354 (13): 1362-9, 2006.  [PUBMED Abstract]

  16. International Myeloma Working Group.: Criteria for the classification of monoclonal gammopathies, multiple myeloma and related disorders: a report of the International Myeloma Working Group. Br J Haematol 121 (5): 749-57, 2003.  [PUBMED Abstract]

  17. Attal M, Harousseau JL, Stoppa AM, et al.: A prospective, randomized trial of autologous bone marrow transplantation and chemotherapy in multiple myeloma. Intergroupe Français du Myélome. N Engl J Med 335 (2): 91-7, 1996.  [PUBMED Abstract]

  18. Kyle RA, Therneau TM, Rajkumar SV, et al.: A long-term study of prognosis in monoclonal gammopathy of undetermined significance. N Engl J Med 346 (8): 564-9, 2002.  [PUBMED Abstract]

  19. Rajkumar SV, Kyle RA, Therneau TM, et al.: Serum free light chain ratio is an independent risk factor for progression in monoclonal gammopathy of undetermined significance. Blood 106 (3): 812-7, 2005.  [PUBMED Abstract]

Treatment Option Overview

Monoclonal gammopathy of undetermined significance or smoldering myeloma must be distinguished from progressive myeloma. Asymptomatic patients with multiple myeloma who have no lytic bone lesions and normal renal function may be initially observed safely outside the context of a clinical trial.[1-3] Treatment should be given to patients with symptomatic advanced disease. Treatment should be directed at reducing the tumor cell burden and reversing any complications of disease, such as renal failure, infection, hyperviscosity, or hypercalcemia with appropriate medical management. Response criteria have been developed for patients on clinical trials.[4]

References

  1. He Y, Wheatley K, Clark O, et al.: Early versus deferred treatment for early stage multiple myeloma. Cochrane Database Syst Rev (1): CD004023, 2003.  [PUBMED Abstract]

  2. Riccardi A, Mora O, Tinelli C, et al.: Long-term survival of stage I multiple myeloma given chemotherapy just after diagnosis or at progression of the disease: a multicentre randomized study. Cooperative Group of Study and Treatment of Multiple Myeloma. Br J Cancer 82 (7): 1254-60, 2000.  [PUBMED Abstract]

  3. Hjorth M, Hellquist L, Holmberg E, et al.: Initial versus deferred melphalan-prednisone therapy for asymptomatic multiple myeloma stage I--a randomized study. Myeloma Group of Western Sweden. Eur J Haematol 50 (2): 95-102, 1993.  [PUBMED Abstract]

  4. Durie BG, Harousseau JL, Miguel JS, et al.: International uniform response criteria for multiple myeloma. Leukemia 20 (9): 1467-73, 2006.  [PUBMED Abstract]

Amyloidosis

Primary amyloidosis can result in severe organ dysfunction especially in the kidney, heart, or peripheral nerves. Two randomized trials showed prolonged overall survival (OS) with the use of oral chemotherapy with melphalan with or without colchicine versus colchicine alone.[1,2][Level of evidence: 1iiA] A randomized prospective study of 100 patients with immunoglobulin amyloidosis light chain (AL) compared melphalan plus high-dose dexamethasone with high-dose melphalan plus autologous stem-cell rescue.[3] After a median follow-up of 3 years, median OS favored the nontransplant arm (56.9 mo vs. 22.2 mo; P = .04).[3][Level of evidence: 1iiA] The 24% transplant-related mortality in this series and others reflects the difficulties involved with high-dose chemotherapy in older patients with organ dysfunction.[3-6] A randomized trial confirming the benefit of autologous transplantation is not anticipated.[7] As is true for all plasma cell dyscrasias, anecdotal responses for amyloidosis have been reported, as in the Southwest Oncology Group's (SWOG-9628 9) trial, for dexamethasone alone and in combination with thalidomide and cyclophosphamide or lenalidomide.[8-11] An anecdotal series describes full-intensity and reduced-intensity allogeneic stem cell transplantation.[12]

Elevated serum levels of cardiac troponins and brain natriuretic peptide are poor prognostic factors. A proposed staging system for primary systemic amyloidosis based on these serum levels requires independent and prospective confirmation.[13]

Current Clinical Trials

Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with multiple myeloma and other plasma cell neoplasms 10. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.

General information about clinical trials is also available from the NCI Web site 11.

References

  1. Kyle RA, Gertz MA, Greipp PR, et al.: A trial of three regimens for primary amyloidosis: colchicine alone, melphalan and prednisone, and melphalan, prednisone, and colchicine. N Engl J Med 336 (17): 1202-7, 1997.  [PUBMED Abstract]

  2. Skinner M, Anderson J, Simms R, et al.: Treatment of 100 patients with primary amyloidosis: a randomized trial of melphalan, prednisone, and colchicine versus colchicine only. Am J Med 100 (3): 290-8, 1996.  [PUBMED Abstract]

  3. Jaccard A, Moreau P, Leblond V, et al.: High-dose melphalan versus melphalan plus dexamethasone for AL amyloidosis. N Engl J Med 357 (11): 1083-93, 2007.  [PUBMED Abstract]

  4. Dispenzieri A, Kyle RA, Lacy MQ, et al.: Superior survival in primary systemic amyloidosis patients undergoing peripheral blood stem cell transplantation: a case-control study. Blood 103 (10): 3960-3, 2004.  [PUBMED Abstract]

  5. Skinner M, Sanchorawala V, Seldin DC, et al.: High-dose melphalan and autologous stem-cell transplantation in patients with AL amyloidosis: an 8-year study. Ann Intern Med 140 (2): 85-93, 2004.  [PUBMED Abstract]

  6. Leung N, Leung TR, Cha SS, et al.: Excessive fluid accumulation during stem cell mobilization: a novel prognostic factor of first-year survival after stem cell transplantation in AL amyloidosis patients. Blood 106 (10): 3353-7, 2005.  [PUBMED Abstract]

  7. Mehta J, Gerta MA, Dispenzieri A: High-dose therapy for amyloidosis: the end of the beginning? Blood 103 (10): 3612-3, 2004. 

  8. Dhodapkar MV, Hussein MA, Rasmussen E, et al.: Clinical efficacy of high-dose dexamethasone with maintenance dexamethasone/alpha interferon in patients with primary systemic amyloidosis: results of United States Intergroup Trial Southwest Oncology Group (SWOG) S9628. Blood 104 (12): 3520-6, 2004.  [PUBMED Abstract]

  9. Wechalekar AD, Goodman HJ, Lachmann HJ, et al.: Safety and efficacy of risk-adapted cyclophosphamide, thalidomide, and dexamethasone in systemic AL amyloidosis. Blood 109 (2): 457-64, 2007.  [PUBMED Abstract]

  10. Dispenzieri A, Lacy MQ, Zeldenrust SR, et al.: The activity of lenalidomide with or without dexamethasone in patients with primary systemic amyloidosis. Blood 109 (2): 465-70, 2007.  [PUBMED Abstract]

  11. Sanchorawala V, Wright DG, Rosenzweig M, et al.: Lenalidomide and dexamethasone in the treatment of AL amyloidosis: results of a phase 2 trial. Blood 109 (2): 492-6, 2007.  [PUBMED Abstract]

  12. Schönland SO, Lokhorst H, Buzyn A, et al.: Allogeneic and syngeneic hematopoietic cell transplantation in patients with amyloid light-chain amyloidosis: a report from the European Group for Blood and Marrow Transplantation. Blood 107 (6): 2578-84, 2006.  [PUBMED Abstract]

  13. Dispenzieri A, Gertz MA, Kyle RA, et al.: Serum cardiac troponins and N-terminal pro-brain natriuretic peptide: a staging system for primary systemic amyloidosis. J Clin Oncol 22 (18): 3751-7, 2004.  [PUBMED Abstract]

Multiple Myeloma

Note: Some citations in the text of this section are followed by a level of evidence. The PDQ editorial boards use a formal ranking system to help the reader judge the strength of evidence linked to the reported results of a therapeutic strategy. (Refer to the PDQ summary on Levels of Evidence 2 for more information.)

Idiotypic myeloma cells can be found in the blood of myeloma patients in all stages of the disease.[1,2] For this reason, when treatment is indicated, systemic treatment must be considered for all patients with symptomatic plasma cell neoplasms. Patients with monoclonal gammopathy of undetermined significance (MGUS) or asymptomatic, smoldering myeloma do not require immediate treatment but must be followed carefully for signs of disease progression.

Patients with a monoclonal (or myeloma) protein (M protein) in the serum and/or urine are evaluated as follows:

  1. Measure and follow the serum M protein by serum electrophoresis or by specific immunoglobulin assays; however, specific immunoglobulin quantification always overestimates the M protein because normal immunoglobulins are included in the result. For this reason, baseline and follow-up measurements of the M protein should be done by the same method.[3]


  2. Measure and follow the amount of M protein light chains excreted in the urine per 24 hours. Measure the total amount of protein excreted per 24 hours and multiply this value by the percentage of urine protein that is M protein as determined by electrophoresis of concentrated urine protein. An easier, but less accurate, method uses a spot-urine protein electrophoresis.


  3. Identify the heavy- and light-chain of the M protein by immunofixation electrophoresis.


  4. Measure the hemoglobin, leukocyte, platelet, and differential counts.


  5. Determine the percentage of marrow plasma cells. Be aware that marrow plasma cell distribution may vary in different sites.


  6. Take needle aspirates of a solitary lytic bone lesion, extramedullary tumor(s), or enlarged lymph node(s) to determine whether these are plasmacytomas.


  7. Evaluate renal function with serum creatinine and a creatinine clearance. Electrophoresis of concentrated urine protein is very helpful in differentiating glomerular lesions from tubular lesions. Glomerular lesions, such as those resulting from glomerular deposits of amyloid or light chain deposition disease, result in the nonselective leakage of all serum proteins into the urine; the electrophoresis pattern of this urine resembles the serum pattern with a preponderance of albumin. In most myeloma patients, the glomeruli function normally allowing only the small molecular weight proteins, such as light chains, to filter into the urine. The concentration of protein in the tubules increases as water is reabsorbed. This leads to precipitation of proteins and the formation of tubular casts, which may injure the tubular cells. With tubular lesions, the typical electrophoresis pattern shows a small albumin peak and a larger light chain peak in the globulin region; this tubular pattern is the usual pattern found in myeloma patients.


  8. Measure serum levels of calcium, alkaline phosphatase, lactic dehydrogenase, and, when indicated by clinical symptoms, cryoglobulins, and serum viscosity.


  9. Obtain radiographs of the skull, ribs, vertebrae, pelvis, shoulder girdle, and long bones. Whole-body, low-dose, nonenhanced multidetector computed tomography (CT) and magnetic resonance imaging (MRI) are being evaluated as measures for therapy response monitoring.[4,5] MRI of the spine or long bones is more sensitive in detecting lytic lesions, but any prognostic or therapeutic value for this information remains to be determined.[5]


  10. Perform MRI if a paraspinal mass is detected or if symptoms suggest spinal cord or nerve root compression.


  11. If amyloidosis is suspected, do a needle aspiration of subcutaneous abdominal fat and stain the bone marrow biopsy for amyloid as the easiest and safest way to confirm the diagnosis.[6]


  12. Measure serum albumin and beta-2-microglobulin as independent prognostic factors.[7,8]


  13. A high plasma cell labeling index (≥3%) and the presence of circulating myeloma cells are considered poor prognostic factors.[9]


These initial studies should be compared with subsequent values at a later time, when it is necessary to decide whether the disease is stable or progressive, responding to treatment, or getting worse. The major challenge is to separate the stable asymptomatic group of patients who do not require treatment from patients with progressive, symptomatic myeloma who should be treated immediately.[10,11]

Patients with MGUS have an M protein in the serum and/or urine and less than 10% plasma cells in the marrow but no other signs or symptoms of disease. The patients with smoldering myeloma have similar characteristics but may have greater than 10% of marrow plasma cells. Since 1% to 2% of MGUS patients per year will progress to develop myeloma (most commonly), amyloidosis, a lymphoma, or chronic lymphocytic leukemia, these types of patients must be followed carefully.[12] Treatment is delayed until the disease progresses to the stage that symptoms or signs appear. Patients with MGUS or smoldering myeloma do not respond more frequently, achieve longer remissions, or have improved survival if chemotherapy is started early while they are still asymptomatic as opposed to waiting for progression before treatment is initiated.[10,11,13,14]

Current therapy for patients with symptomatic myeloma can be divided into categories of induction therapies, consolidation therapies (which are less applicable for the very elderly), maintenance therapies, and supportive care (such as bisphosphonates). Several questions are raised when choosing therapy for a patient with symptomatic myeloma at first presentation:

  • Is the patient eligible for a clinical trial? The sequence and combinations of new and older therapies can only be determined by prospective clinical trials.
  • Is autologous stem cell transplantation a possible consolidation option for this patient? If so, alkylating agents should be avoided during induction therapy to avoid compromise of stem cell collection and to lessen leukemogenic risk.
  • Does the patient have comorbidities? Age, organ dysfunction, and risk of cardiovascular and thrombotic complications would influence the choice of induction therapies as well as the choice of whether to consider consolidation therapies.
Induction Therapy

Corticosteroids

Since the mid-1980s, dexamethasone has been administered at a dose of 40 mg orally for 4 consecutive days in the same schedule as administered with the vincristine plus doxorubicin plus dexamethasone (VAD) regimen.[15] Response rates of 60% to 70% in previously untreated patients appeared as high as those in patients treated with VAD.[15,16][Level of evidence: 3iiiDiv] A prospective trial randomly assigned 488 patients older than 65 years to receive dexamethasone alone, melphalan plus dexamethasone, dexamethasone plus interferon-alpha, and melphalan plus prednisone; with a median follow-up of 7.1 years, no difference was observed in overall survival (OS) (median survival times were 32 to 40 months).[17][Level of evidence: 1iiA] The patients on the dexamethasone-based arms had significantly more infections, glucose intolerance, gastrointestinal symptoms, and psychiatric complaints.

There has never been a randomized trial comparing single-agent oral dexamethasone at a traditional high dose (40 mg a day for 4 days, repeated after 4 days off) versus a lower dose (40 mg or less weekly). This issue of dexamethasone dose has been evaluated in two prospective randomized trials, one in the context of melphalan from the National Cancer Institute of Canada (CAN-NCIC-MY7 12), and the other in the context of lenalidomide from the Eastern Cooperative Oncology Group (E-4A03 13) and published only in abstract form.[18,19] High-dose dexamethasone was associated with an increased risk of infection in the melphalan trial, but with no difference in efficacy compared to standard dose steroids.[18] The lenalidomide study questioned the safety and efficacy of high-dose dexamethasone (refer to the Lenalidomide 14 section of this summary for more information).[19] Almost all ongoing clinical trials in the United States and Europe have implemented the low-dose dexamethasone schedule with or without other therapeutic agents.

Thalidomide

Eight randomized prospective studies (including E-E1A00 15 and the Commissie Voor Klinisch Toegepast Onderzoek trial [HOVON 50 16]) involving more than 3,000 patients have been published in final or preliminary abstract form examining the introduction of thalidomide as induction therapy for previously untreated symptomatic patients with multiple myeloma.[20-27] All of the trials reported improved response rates with the introduction of thalidomide and no hematopoietic damage, allowing adequate stem cell collection when applicable or allowing combinations with other myelosuppressive agents. Only two of the eight randomized studies reported a survival advantage using thalidomide. In both trials, the patients older than 65 years at the 2-year follow-ups showed 45-month to 56-month median overall survival (OS) for melphalan plus prednisone plus thalidomide (MPT) versus 28-month to 30-month median OS for melphalan plus prednisone (MP) (P = .0008 in both studies).[25,28][Level of evidence: 1iiA] A possible explanation is that these two trials used a lower dose of thalidomide than the other studies (100 mg instead of 200 mg or higher), a lower dose of steroids (60 mg of prednisone instead of high-dose dexamethasone), and involved the use of alkylating agents. As previously described in the section on corticosteroids, high-dose dexamethasone can complicate interpretation of clinical trials by worsening cardiopulmonary toxicity and deaths, especially in the context of thalidomide or lenalidomide, both of which are thrombogenic agents.

Factors that have been implicated to worsen the risk of deep venous thrombosis (DVT) include high-dose dexamethasone, concomitant erythropoietic growth factors, or concomitant use of doxorubicin, liposomal doxorubicin, or alkylating agents. Personal cardiovascular risk factors can also influence the rate of DVT. Various clinical trials have included different DVT prophylaxis measures, including aspirin (81 mg–100 mg a day), warfarin, or low-molecular-weight heparin, but the validity of these measures has not been studied prospectively.[22,25,26,29-31] Prospective electrophysiologic monitoring provides no clear benefit versus clinical evaluation for the development of clinically significant neuropathy while on thalidomide.

Lenalidomide

A prospective randomized study of 351 relapsed patients compared lenalidomide, an analogue of thalidomide, plus high-dose dexamethasone to high-dose dexamethasone plus placebo.[32] The lenalidomide combination showed a significantly higher time-to-tumor-progression (11.3 months vs. 4.7 months, P < .001) with a 16-month median follow-up, and median OS had not been reached, versus 20.6 months in the placebo group (hazard ratio = 0.66, 95% confidence interval, 0.45–0.96, P = .03).[Level of evidence: 1iiDiii][32][Level of evidence: 1iA] The lenalidomide-containing arm had more DVT (11.4% vs. 4.6%).[32] Similarly, another randomized prospective trial CC-5013 17 of 353 previously treated patients favored the lenalidomide plus high-dose dexamethasone arm versus dexamethasone plus placebo; with a median follow-up of 26 months, the median time-to-progression was 11.1 months versus 4.7 months (P < .001) and the median OS was 29.6 versus 20.2 months (P < .001).[33][Level of evidence: 1iA] A prospective randomized study (E-4A03 13) of 445 untreated symptomatic patients, published in abstract form only, compared lenalidomide and high-dose dexamethasone (40 mg D1–4, 9–12, 17–20 every 28 days) to lenalidomide and low-dose dexamethasone (40 mg D1, 8, 15, 22 every 28 days).[19] With a median follow-up of 25 months, this trial showed improved OS for patients in the low-dose dexamethasone arm (87% vs. 75% at 2 years, P = .006), despite no difference in progression-free survival.[19][Level of evidence: 1iiA] The extra deaths on the high-dose dexamethasone arm were attributed to cardiopulmonary toxicity and faster progression with subsequent therapies. DVTs were also more frequent in the high-dose arm (25% vs. 9%). OS favored the low-dose arm with a 2-year survival of 87% (low-dose) versus 75% (high-dose) (P = .006.)[19][Level of evidence: 1iiA] The low-dose dexamethasone arm with lenalidomide had less than 5% DVT with aspirin alone. Lenalidomide has substantially greater myelosuppression but less neuropathy than seen with thalidomide, but both have the same tendency for DVT.[19,32,33]

Bortezomib

A prospective randomized study of 669 patients with relapsing myeloma, who had been treated previously with steroids, compared intravenous bortezomib with high-dose oral dexamethasone; OS at 1 year favored bortezomib (80% vs. 66%) (P = .003).[34][Level of evidence: 1iiA] Bortezomib-associated peripheral neuropathy is reversible in most patients after dose reduction or discontinuation.[35,36]

A prospective randomized Doxorubicin HCl Injection of Liposome (DOXIL-MMY-3001 18) trial of 646 previously treated patients compared bortezomib plus pegylated liposomal doxorubicin with bortezomib alone.[37] With a median follow-up of 7 months, the combination was better in both median time-to-progression (9.3 mo vs. 6.5 mo, P < .001) and in OS (82% vs. 75%, P = .05).[37][Level of evidence: 1iiA]

Patients with unfavorable molecular cytogenetics did not show any difference in progression-free or OS compared with patients with more favorable risk factors when bortezomib was incorporated with induction therapy. The benefit from bortezomib appears to be maintained across risk groups.[34,38-40][Level of evidence: 3iiiD]

Conventional-dose chemotherapy

The VAD regimen has shown activity in previously treated and in untreated patients with response rates ranging from 60% to 80%.[41-44][Level of evidence: 3iiiDiv] No randomized studies support the widespread use of this regimen in untreated patients. This regimen avoids early exposure to alkylating agents, thereby minimizing any problems with stem cell collection (if needed) and any future risks for myelodysplasia or secondary leukemia. Disadvantages include the logistics for a 96-hour infusion of doxorubicin and a low complete response rate. An alternative version of VAD substitutes pegylated liposomal doxorubicin for doxorubicin, eliminates the need for an infusion, and provides comparable response rates.[45,46]Level of evidence: 3iiiDiv]

Evidence is not strong that any alkylating agent is superior to any other. All standard doses and schedules produce equivalent results.[47] The two most common regimens historically have been oral MP and oral cyclophosphamide plus prednisone.[47-49]

Combinations such as those used in E-2479 19, of alkylating agents and prednisone, administered simultaneously or alternately, have not proven to be superior to therapy with MP.[50-53][Level of evidence: 1iiA] A meta-analysis of studies comparing melphalan plus prednisone with drug combinations concluded that both forms of treatment were equally effective.[47][Level of evidence: 1iiA] Patients who relapsed after initial therapy with cyclophosphamide and prednisone had no difference in OS (median 17 months) when randomly assigned to receive vincristine plus carmustine plus melphalan plus cyclophosphamide plus prednisone (VBMCP) or VAD.[54]

Consolidation Chemotherapy

High-dose chemotherapy: autologous bone marrow or peripheral stem cell transplantation

The failure of conventional therapy to cure the disease has led investigators to test the effectiveness of much higher doses of drugs such as melphalan. The development of techniques for harvesting hemopoietic stem cells, from marrow aspirates or the peripheral blood of the patient, and infusing these cells to promote hemopoietic recovery made it possible for investigators to test very large doses of chemotherapy. From the experience with thousands of patients treated in this way, it is possible to draw a few conclusions. The risk of early death caused by treatment-related toxic effects has been reduced to less than 3% in highly selected populations.[55] Chemotherapy patients can now be treated as outpatients. Extensive prior chemotherapy, especially with alkylating agents, compromises marrow hemopoiesis and may make the harvesting of adequate numbers of hemopoietic stem cells impossible.[56] Younger patients in good health tolerate high-dose therapy better than patients with poor performance status.[57-59]

While some prospective randomized trials such as the U.S. Intergroup trial SWOG-9321 20, have shown improved survival for patients who received autologous peripheral stem cell or bone marrow transplantation after induction chemotherapy versus chemotherapy alone,[12,60,61][Level of evidence: 1iiA] other trials have not shown any survival advantage.[62-65][Level of evidence: 1iiA] A meta-analysis of 575 patients with individual data showed no survival advantage.[66][Level of evidence: 1iiA] Even the trials suggesting improved survival showed no signs of a slowing in the relapse rate or a plateau to suggest that any of these patients had been cured.[12,60,61]

Another approach to high-dose therapy has been the use of two sequential episodes of high-dose therapy with stem cell support (tandem transplants).[67-69] In a trial of 399 previously untreated patients younger than 60 years, the patients were randomly assigned to a single or double (tandem) autologous stem-cell transplantation.[70] With a median follow-up of more than 6 years, the double-transplant group had a superior EFS (20% vs. 10% at 7 years, P = .03) and OS (42% vs. 21% at 7 years, P = .01).[70][Level of evidence: 1iiA] Patients with a reduction of paraprotein of greater than 90% after the first transplant (the best responders) had the least incremental benefit from the second transplant (retrospective subgroup analysis).[70] In a trial of 321 previously untreated patients under 60 years, patients were randomly assigned to a single or tandem transplant; with a median follow-up of 55 months, the double transplant group had superior EFS (35 months vs. 23-month median, P = .001), but there was no difference in 7-year survival (43% vs. 46%, P = .90).[71][Level of evidence: 1iiA] In a trial of 194 previously untreated patients aged 50 to 70 years, the patients were randomly assigned to conventional oral melphalan and prednisone versus VAD for two cycles followed by two sequential episodes of high-dose therapy (melphalan 100 mg/m2) with stem cell support.[61] With a median follow-up of greater than 3 years, the double transplant group had superior EFS (37% vs. 16% at 3 years, P < .001) and OS (77% vs. 62%, P < .001).[61][Level of evidence: 1iiA] A trial of 162 consecutive newly diagnosed patients compared two tandem autologous transplants versus one autologous transplant followed by an allograft from an HLA-identical sibling (assignment was based on the presence or absence of an HLA-identical sibling); with a median follow-up of 45 months, the median OS was 54 months for the tandem autologous grafts versus 80 months for the allogeneic arm (P = .01).[72][Level of evidence: 3iiA]

Maintenance therapy with interferon showed a benefit in progression-free survival (PFS) (46 vs. 27 months, P < .025) and OS (75% vs. 50%, P < .01) in a randomized study of 84 patients following autologous bone marrow transplantation.[73][Level of evidence: 1iiA] A larger randomized trial of 805 patients showed no difference in PFS or OS with interferon applied after peripheral stem cell transplantation or conventional chemotherapy.[74][Level of evidence: 1iiA]

High-dose chemotherapy: allogeneic bone marrow or peripheral stem cell transplantation

In a registry of 162 patients who underwent allogeneic matched sibling-donor transplants, the actuarial OS rate was 28% at 7 years.[75][Level of evidence: 3iiiA] Favorable prognostic features included low tumor burden, responsive disease before transplant, and application of transplantation after first-line therapy. Many patients are not young enough or healthy enough to undergo these intensive approaches. A definite graft-versus-myeloma effect has been demonstrated, including regression of myeloma relapses following the infusion of donor lymphocytes.[76-79] Allogeneic marrow transplants have significant toxic effects (15%–40% mortality), but the possibility of a potent and possibly curative graft-versus-myeloma reaction makes this procedure attractive.[79,80] Further research is required to make allogeneic transplants less dangerous and to find methods for initiating an autoimmune response to the myeloma cells. Nonmyeloablative allogeneic stem cell transplant is under development.[81-83] Such strategies aim to maintain efficacy (so called graft-versus-tumor-effective) while reducing transplant-related mortality.[84] Early reports indicate that significant graft-versus-host disease and transplant-related mortality remain challenges with this approach.[82,85] In one phase II prospective study, high-risk patients (beta-2-microglobulin >3 mg/dl or chromosome 13 deletion) with an HLA-identical sibling donor underwent nonmyeloablative allogeneic stem cell transplantation after autologous stem cell transplantation.[86] This approach requires further evaluation.

Maintenance Therapy

Myeloma patients who respond to treatment show a progressive fall in the M protein until a plateau is reached; subsequent treatment with conventional doses does not result in any further improvement. This has led investigators to question how long treatment should be continued. In a single study,[87] it was observed that maintenance therapy with MP prolonged the initial remission duration (31 months) compared to no maintenance treatment (23 months). No effect on OS was found because the majority of patients who relapsed in the no maintenance arm responded again to MP, while those on maintenance MP did not respond to further treatment. The Canadian group [87] suggests that induction chemotherapy be continued as long as the M protein continues to fall; therapy can be discontinued after the M protein reaches a plateau that remains stable for 4 months.

Maintenance interferon-alpha therapy has been reported in several studies to prolong initial remission duration.[88-91] While the impact of interferon maintenance on disease-free survival and OS has significantly varied among trials, a meta-analysis of 1,543 patients treated on 12 trials randomizing between interferon maintenance and observation indicated that interferon maintenance was associated with improved relapse-free survival (27% vs. 19% at 3 years, P < .001) and OS (12% odds reduction, P = .04).[92] Toxic effects in this population may be substantial and must be balanced against the potential benefits in response duration.[93]

A study of 125 responding patients with first-line VAD induction who were randomly assigned to maintenance corticosteroids at 10 mg or 50 mg on alternate days showed improved PFS (14 months vs. 5 months, P = .003) and OS (36 months vs. 26 months, P = .05) for the patients receiving the higher-dose corticosteroids.[94][Level of evidence: 1iiA] In a larger trial by the National Cancer Institute of Canada (NCIC-CTG-MY.7 12) of 585 patients treated with first-line MP, 292 patients were randomly assigned to pulse dexamethasone (40 mg a day for 4 days monthly) versus no maintenance; PFS favored the dexamethasone maintenance (2.8 vs. 2.1 years, P = .0002), but there was no difference in OS (4.1 years vs. 3.8 years, P = .4).[18][Level of evidence: 1iiDiii]

Two months after autologous transplantation, 597 patients younger than 65 years were randomly assigned to no maintenance, pamidronate, or pamidronate plus thalidomide; the thalidomide arm was favored by EFS (36% vs. 37% vs. 52%, P < .009) and OS at 4 years (77% vs. 74% vs. 87%, P < .04), while no differences were seen for skeletal events.[95][Level of evidence: 1iiA]

Supportive Care

Bisphosphonate therapy

A randomized, double-blind study of patients with stage III myeloma showed that monthly intravenous pamidronate significantly reduces pathologic fractures, bone pain, spinal cord compression, and the need for bone radiation therapy (38% skeletal-related events were reported in the treated group vs. 51% in the placebo group after 21 months of therapy, P = .015).[96][Level of evidence: 1iDiii]

A randomized comparison of pamidronate versus zoledronic acid in 518 patients with multiple myeloma showed equivalent efficacy in regard to skeletal-related complications.[97][Level of evidence: 1iDiii] However, bisphosphonates are associated with infrequent long-term complications (in 3%–5% of patients) including osteonecrosis of the jaw and avascular necrosis of the hip.[98,99] These side effects must be balanced against the potential benefits of bisphosphonates when bone metastases are evident.[100]

Lytic lesions of the spine should be radiated if they are associated with an extramedullary (paraspinal) plasmacytoma, if a painful destruction of a vertebral body occurred, or if CT or MRI scans present evidence of spinal cord compression.[101]

Back pain caused by osteoporosis and small compression fractures of the vertebrae responds best to chemotherapy. Extensive radiation of the spine or long bones for diffuse osteoporosis may lead to prolonged suppression of hemopoiesis and is rarely indicated.[102] Bisphosphonates are useful for slowing or reversing the osteopenia that is common in myeloma patients.[96]

Current Clinical Trials

Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with multiple myeloma 21. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.

General information about clinical trials is also available from the NCI Web site 11.

References

  1. Zandecki M, Facon T, Preudhomme C, et al.: Significance of circulating plasma cells in multiple myeloma. Leuk Lymphoma 14 (5-6): 491-6, 1994.  [PUBMED Abstract]

  2. Billadeau D, Van Ness B, Kimlinger T, et al.: Clonal circulating cells are common in plasma cell proliferative disorders: a comparison of monoclonal gammopathy of undetermined significance, smoldering multiple myeloma, and active myeloma. Blood 88 (1): 289-96, 1996.  [PUBMED Abstract]

  3. Riches PG, Sheldon J, Smith AM, et al.: Overestimation of monoclonal immunoglobulin by immunochemical methods. Ann Clin Biochem 28 ( Pt 3): 253-9, 1991.  [PUBMED Abstract]

  4. Horger M, Kanz L, Denecke B, et al.: The benefit of using whole-body, low-dose, nonenhanced, multidetector computed tomography for follow-up and therapy response monitoring in patients with multiple myeloma. Cancer 109 (8): 1617-26, 2007.  [PUBMED Abstract]

  5. Walker R, Barlogie B, Haessler J, et al.: Magnetic resonance imaging in multiple myeloma: diagnostic and clinical implications. J Clin Oncol 25 (9): 1121-8, 2007.  [PUBMED Abstract]

  6. Gertz MA, Li CY, Shirahama T, et al.: Utility of subcutaneous fat aspiration for the diagnosis of systemic amyloidosis (immunoglobulin light chain). Arch Intern Med 148 (4): 929-33, 1988.  [PUBMED Abstract]

  7. Greipp PR: Advances in the diagnosis and management of myeloma. Semin Hematol 29 (3 Suppl 2): 24-45, 1992.  [PUBMED Abstract]

  8. Durie BG, Stock-Novack D, Salmon SE, et al.: Prognostic value of pretreatment serum beta 2 microglobulin in myeloma: a Southwest Oncology Group Study. Blood 75 (4): 823-30, 1990.  [PUBMED Abstract]

  9. Greipp PR, Witzig T: Biology and treatment of myeloma. Curr Opin Oncol 8 (1): 20-7, 1996.  [PUBMED Abstract]

  10. He Y, Wheatley K, Clark O, et al.: Early versus deferred treatment for early stage multiple myeloma. Cochrane Database Syst Rev (1): CD004023, 2003.  [PUBMED Abstract]

  11. Kyle RA, Remstein ED, Therneau TM, et al.: Clinical course and prognosis of smoldering (asymptomatic) multiple myeloma. N Engl J Med 356 (25): 2582-90, 2007.  [PUBMED Abstract]

  12. Attal M, Harousseau JL, Stoppa AM, et al.: A prospective, randomized trial of autologous bone marrow transplantation and chemotherapy in multiple myeloma. Intergroupe Français du Myélome. N Engl J Med 335 (2): 91-7, 1996.  [PUBMED Abstract]

  13. Hjorth M, Hellquist L, Holmberg E, et al.: Initial versus deferred melphalan-prednisone therapy for asymptomatic multiple myeloma stage I--a randomized study. Myeloma Group of Western Sweden. Eur J Haematol 50 (2): 95-102, 1993.  [PUBMED Abstract]

  14. Riccardi A, Mora O, Tinelli C, et al.: Long-term survival of stage I multiple myeloma given chemotherapy just after diagnosis or at progression of the disease: a multicentre randomized study. Cooperative Group of Study and Treatment of Multiple Myeloma. Br J Cancer 82 (7): 1254-60, 2000.  [PUBMED Abstract]

  15. Alexanian R, Dimopoulos MA, Delasalle K, et al.: Primary dexamethasone treatment of multiple myeloma. Blood 80 (4): 887-90, 1992.  [PUBMED Abstract]

  16. Kumar S, Lacy MQ, Dispenzieri A, et al.: Single agent dexamethasone for pre-stem cell transplant induction therapy for multiple myeloma. Bone Marrow Transplant 34 (6): 485-90, 2004.  [PUBMED Abstract]

  17. Facon T, Mary JY, Pégourie B, et al.: Dexamethasone-based regimens versus melphalan-prednisone for elderly multiple myeloma patients ineligible for high-dose therapy. Blood 107 (4): 1292-8, 2006.  [PUBMED Abstract]

  18. Shustik C, Belch A, Robinson S, et al.: A randomised comparison of melphalan with prednisone or dexamethasone as induction therapy and dexamethasone or observation as maintenance therapy in multiple myeloma: NCIC CTG MY.7. Br J Haematol 136 (2): 203-11, 2007.  [PUBMED Abstract]

  19. Rajkumar SV, Jacobus S, Callander N, et al.: A randomized trial of lenalidomide plus high-dose dexamethasone (RD) versus lenalidomide plus low-dose dexamethasone (Rd) in newly diagnosed multiple myeloma (E4A03): a trial coordinated by the Eastern Cooperative Oncology Group. [Abstract] Blood 110 (11): A-74, 2007. 

  20. Rajkumar SV, Blood E, Vesole D, et al.: Phase III clinical trial of thalidomide plus dexamethasone compared with dexamethasone alone in newly diagnosed multiple myeloma: a clinical trial coordinated by the Eastern Cooperative Oncology Group. J Clin Oncol 24 (3): 431-6, 2006.  [PUBMED Abstract]

  21. Barlogie B, Tricot G, Anaissie E, et al.: Thalidomide and hematopoietic-cell transplantation for multiple myeloma. N Engl J Med 354 (10): 1021-30, 2006.  [PUBMED Abstract]

  22. Palumbo A, Bringhen S, Caravita T, et al.: Oral melphalan and prednisone chemotherapy plus thalidomide compared with melphalan and prednisone alone in elderly patients with multiple myeloma: randomised controlled trial. Lancet 367 (9513): 825-31, 2006.  [PUBMED Abstract]

  23. Goldschmidt H, Sonneveld P, Breitkreuz I, et al.: HOVON 50/GMMG-HD3-trial: phase III study on the effect of thalidomide combined with high dose melphalan in myeloma patients up to 65 years. [Abstract] Blood 106 (11): A-424, 2005. 

  24. Facon T, Mary J, Harousseau J, et al.: Superiority of melphalan-prednisone (MP) + thalidomide (THAL) over MP and autologous stem cell transplantation in the treatment of newly diagnosed elderly patients with multiple myeloma. [Abstract] J Clin Oncol 24 (Suppl 18): A-1, 2006. 

  25. Hulin C, Facon T, Rodon P, et al.: Melphalan-prednisone-thalidomide (MP-T) demonstrates a significant survival advantage in elderly patients 75 years with multiple myeloma compared with melphalan-prednisone (MP) in a randomized, double-blind, placebo-controlled trial, IFM 01/01. [Abstract] Blood 110 (11): A-75, 2007. 

  26. Waage A, Gimsing P, Juliusson G, et al.: Melphalan-prednisone-thalidomide to newly diagnosed patients with multiple myeloma: a placebo controlled randomised phase 3 trial. [Abstract] Blood 110 (11): A-78, 2007. 

  27. Ludwig H, Tothova E, Hajek R, et al.: Thalidomide-dexamethasone vs. melphalan-prednisone as first Line treatment and thalidomide-interferon vs. interferon maintenance therapy in elderly patients with multiple myeloma. [Abstract] Blood 110 (11): A-529, 2007. 

  28. Facon T, Mary JY, Hulin C, et al.: Melphalan and prednisone plus thalidomide versus melphalan and prednisone alone or reduced-intensity autologous stem cell transplantation in elderly patients with multiple myeloma (IFM 99-06): a randomised trial. Lancet 370 (9594): 1209-18, 2007.  [PUBMED Abstract]

  29. Weber D, Rankin K, Gavino M, et al.: Thalidomide alone or with dexamethasone for previously untreated multiple myeloma. J Clin Oncol 21 (1): 16-9, 2003.  [PUBMED Abstract]

  30. Zangari M, Barlogie B, Thertulien R, et al.: Thalidomide and deep vein thrombosis in multiple myeloma: risk factors and effect on survival. Clin Lymphoma 4 (1): 32-5, 2003.  [PUBMED Abstract]

  31. Baz R, Li L, Kottke-Marchant K, et al.: The role of aspirin in the prevention of thrombotic complications of thalidomide and anthracycline-based chemotherapy for multiple myeloma. Mayo Clin Proc 80 (12): 1568-74, 2005.  [PUBMED Abstract]

  32. Dimopoulos M, Spencer A, Attal M, et al.: Lenalidomide plus dexamethasone for relapsed or refractory multiple myeloma. N Engl J Med 357 (21): 2123-32, 2007.  [PUBMED Abstract]

  33. Weber DM, Chen C, Niesvizky R, et al.: Lenalidomide plus dexamethasone for relapsed multiple myeloma in North America. N Engl J Med 357 (21): 2133-42, 2007.  [PUBMED Abstract]

  34. Richardson PG, Sonneveld P, Schuster MW, et al.: Bortezomib or high-dose dexamethasone for relapsed multiple myeloma. N Engl J Med 352 (24): 2487-98, 2005.  [PUBMED Abstract]

  35. Richardson PG, Briemberg H, Jagannath S, et al.: Frequency, characteristics, and reversibility of peripheral neuropathy during treatment of advanced multiple myeloma with bortezomib. J Clin Oncol 24 (19): 3113-20, 2006.  [PUBMED Abstract]

  36. Mitchell BS: The proteasome--an emerging therapeutic target in cancer. N Engl J Med 348 (26): 2597-8, 2003.  [PUBMED Abstract]

  37. Orlowski RZ, Nagler A, Sonneveld P, et al.: Randomized phase III study of pegylated liposomal doxorubicin plus bortezomib compared with bortezomib alone in relapsed or refractory multiple myeloma: combination therapy improves time to progression. J Clin Oncol 25 (25): 3892-901, 2007.  [PUBMED Abstract]

  38. Jagannath S, Richardson PG, Sonneveld P, et al.: Bortezomib appears to overcome the poor prognosis conferred by chromosome 13 deletion in phase 2 and 3 trials. Leukemia 21 (1): 151-7, 2007.  [PUBMED Abstract]

  39. Sagaster V, Ludwig H, Kaufmann H, et al.: Bortezomib in relapsed multiple myeloma: response rates and duration of response are independent of a chromosome 13q-deletion. Leukemia 21 (1): 164-8, 2007.  [PUBMED Abstract]

  40. Chang H, Trieu Y, Qi X, et al.: Bortezomib therapy response is independent of cytogenetic abnormalities in relapsed/refractory multiple myeloma. Leuk Res 31 (6): 779-82, 2007.  [PUBMED Abstract]

  41. Alexanian R, Barlogie B, Tucker S: VAD-based regimens as primary treatment for multiple myeloma. Am J Hematol 33 (2): 86-9, 1990.  [PUBMED Abstract]

  42. Segeren CM, Sonneveld P, van der Holt B, et al.: Vincristine, doxorubicin and dexamethasone (VAD) administered as rapid intravenous infusion for first-line treatment in untreated multiple myeloma. Br J Haematol 105 (1): 127-30, 1999.  [PUBMED Abstract]

  43. Anderson H, Scarffe JH, Ranson M, et al.: VAD chemotherapy as remission induction for multiple myeloma. Br J Cancer 71 (2): 326-30, 1995.  [PUBMED Abstract]

  44. Browman GP, Belch A, Skillings J, et al.: Modified adriamycin-vincristine-dexamethasone (m-VAD) in primary refractory and relapsed plasma cell myeloma: an NCI (Canada) pilot study. The National Cancer Institute of Canada Clinical Trials Group. Br J Haematol 82 (3): 555-9, 1992.  [PUBMED Abstract]

  45. Dimopoulos MA, Pouli A, Zervas K, et al.: Prospective randomized comparison of vincristine, doxorubicin and dexamethasone (VAD) administered as intravenous bolus injection and VAD with liposomal doxorubicin as first-line treatment in multiple myeloma. Ann Oncol 14 (7): 1039-44, 2003.  [PUBMED Abstract]

  46. Rifkin RM, Gregory SA, Mohrbacher A, et al.: Pegylated liposomal doxorubicin, vincristine, and dexamethasone provide significant reduction in toxicity compared with doxorubicin, vincristine, and dexamethasone in patients with newly diagnosed multiple myeloma: a Phase III multicenter randomized trial. Cancer 106 (4): 848-58, 2006.  [PUBMED Abstract]

  47. Combination chemotherapy versus melphalan plus prednisone as treatment for multiple myeloma: an overview of 6,633 patients from 27 randomized trials. Myeloma Trialists' Collaborative Group. J Clin Oncol 16 (12): 3832-42, 1998.  [PUBMED Abstract]

  48. Gregory WM, Richards MA, Malpas JS: Combination chemotherapy versus melphalan and prednisolone in the treatment of multiple myeloma: an overview of published trials. J Clin Oncol 10 (2): 334-42, 1992.  [PUBMED Abstract]

  49. Bergsagel DE, Stewart AK: Conventional-dose chemotherapy of myeloma. In: Malpas JS, Bergsagel DE, Kyle RA, et al.: Myeloma: Biology and Management. 3rd ed. Philadelphia, Pa: WB Saunders Co, 2004, pp 203-17. 

  50. Pavlovsky S, Corrado C, Santarelli MT, et al.: An update of two randomized trials in previously untreated multiple myeloma comparing melphalan and prednisone versus three- and five-drug combinations: an Argentine Group for the Treatment of Acute Leukemia Study. J Clin Oncol 6 (5): 769-75, 1988.  [PUBMED Abstract]

  51. Bladé J, San Miguel JF, Alcalá A, et al.: Alternating combination VCMP/VBAP chemotherapy versus melphalan/prednisone in the treatment of multiple myeloma: a randomized multicentric study of 487 patients. J Clin Oncol 11 (6): 1165-71, 1993.  [PUBMED Abstract]

  52. Oken MM, Harrington DP, Abramson N, et al.: Comparison of melphalan and prednisone with vincristine, carmustine, melphalan, cyclophosphamide, and prednisone in the treatment of multiple myeloma: results of Eastern Cooperative Oncology Group Study E2479. Cancer 79 (8): 1561-7, 1997.  [PUBMED Abstract]

  53. Gertz MA, Lacy MQ, Lust JA, et al.: Prospective randomized trial of melphalan and prednisone versus vincristine, carmustine, melphalan, cyclophosphamide, and prednisone in the treatment of primary systemic amyloidosis. J Clin Oncol 17 (1): 262-7, 1999.  [PUBMED Abstract]

  54. Mineur P, Ménard JF, Le Loët X, et al.: VAD or VMBCP in multiple myeloma refractory to or relapsing after cyclophosphamide-prednisone therapy (protocol MY 85). Br J Haematol 103 (2): 512-7, 1998.  [PUBMED Abstract]

  55. Bladé J, Vesole DH, Gertz Morie: High-dose therapy in multiple myeloma. Blood 102 (10): 3469-70, 2003.  [PUBMED Abstract]

  56. Goldschmidt H, Hegenbart U, Wallmeier M, et al.: Factors influencing collection of peripheral blood progenitor cells following high-dose cyclophosphamide and granulocyte colony-stimulating factor in patients with multiple myeloma. Br J Haematol 98 (3): 736-44, 1997.  [PUBMED Abstract]

  57. Siegel DS, Desikan KR, Mehta J, et al.: Age is not a prognostic variable with autotransplants for multiple myeloma. Blood 93 (1): 51-4, 1999.  [PUBMED Abstract]

  58. Badros A, Barlogie B, Siegel E, et al.: Autologous stem cell transplantation in elderly multiple myeloma patients over the age of 70 years. Br J Haematol 114 (3): 600-7, 2001.  [PUBMED Abstract]

  59. Lenhoff S, Hjorth M, Westin J, et al.: Impact of age on survival after intensive therapy for multiple myeloma: a population-based study by the Nordic Myeloma Study Group. Br J Haematol 133 (4): 389-96, 2006.  [PUBMED Abstract]

  60. Child JA, Morgan GJ, Davies FE, et al.: High-dose chemotherapy with hematopoietic stem-cell rescue for multiple myeloma. N Engl J Med 348 (19): 1875-83, 2003.  [PUBMED Abstract]

  61. Palumbo A, Bringhen S, Petrucci MT, et al.: Intermediate-dose melphalan improves survival of myeloma patients aged 50 to 70: results of a randomized controlled trial. Blood 104 (10): 3052-7, 2004.  [PUBMED Abstract]

  62. Segeren CM, Sonneveld P, van der Holt B, et al.: Overall and event-free survival are not improved by the use of myeloablative therapy following intensified chemotherapy in previously untreated patients with multiple myeloma: a prospective randomized phase 3 study. Blood 101 (6): 2144-51, 2003.  [PUBMED Abstract]

  63. Fermand JP, Katsahian S, Divine M, et al.: High-dose therapy and autologous blood stem-cell transplantation compared with conventional treatment in myeloma patients aged 55 to 65 years: long-term results of a randomized control trial from the Group Myelome-Autogreffe. J Clin Oncol 23 (36): 9227-33, 2005.  [PUBMED Abstract]

  64. Bladé J, Rosiñol L, Sureda A, et al.: High-dose therapy intensification compared with continued standard chemotherapy in multiple myeloma patients responding to the initial chemotherapy: long-term results from a prospective randomized trial from the Spanish cooperative group PETHEMA. Blood 106 (12): 3755-9, 2005.  [PUBMED Abstract]

  65. Barlogie B, Kyle RA, Anderson KC, et al.: Standard chemotherapy compared with high-dose chemoradiotherapy for multiple myeloma: final results of phase III US Intergroup Trial S9321. J Clin Oncol 24 (6): 929-36, 2006.  [PUBMED Abstract]

  66. Lévy V, Katsahian S, Fermand JP, et al.: A meta-analysis on data from 575 patients with multiple myeloma randomly assigned to either high-dose therapy or conventional therapy. Medicine (Baltimore) 84 (4): 250-60, 2005.  [PUBMED Abstract]

  67. Barlogie B, Tricot GJ, van Rhee F, et al.: Long-term outcome results of the first tandem autotransplant trial for multiple myeloma. Br J Haematol 135 (2): 158-64, 2006.  [PUBMED Abstract]

  68. Barlogie B, Tricot G, Rasmussen E, et al.: Total therapy 2 without thalidomide in comparison with total therapy 1: role of intensified induction and posttransplantation consolidation therapies. Blood 107 (7): 2633-8, 2006.  [PUBMED Abstract]

  69. Barlogie B, Zangari M, Bolejack V, et al.: Superior 12-year survival after at least 4-year continuous remission with tandem transplantations for multiple myeloma. Clin Lymphoma Myeloma 6 (6): 469-74, 2006.  [PUBMED Abstract]

  70. Attal M, Harousseau JL, Facon T, et al.: Single versus double autologous stem-cell transplantation for multiple myeloma. N Engl J Med 349 (26): 2495-502, 2003.  [PUBMED Abstract]

  71. Cavo M, Tosi P, Zamagni E, et al.: Prospective, randomized study of single compared with double autologous stem-cell transplantation for multiple myeloma: Bologna 96 clinical study. J Clin Oncol 25 (17): 2434-41, 2007.  [PUBMED Abstract]

  72. Bruno B, Rotta M, Patriarca F, et al.: A comparison of allografting with autografting for newly diagnosed myeloma. N Engl J Med 356 (11): 1110-20, 2007.  [PUBMED Abstract]

  73. Cunningham D, Powles R, Malpas J, et al.: A randomized trial of maintenance interferon following high-dose chemotherapy in multiple myeloma: long-term follow-up results. Br J Haematol 102 (2): 495-502, 1998.  [PUBMED Abstract]

  74. Barlogie B, Kyle R, Anderson K, et al.: Comparable survival in multiple myeloma (MM) with high dose therapy (HDT) employing MEL 140 mg/m2 + TBI 12 Gy autotransplants versus standard dose therapy with VBMCP and no benefit from interferon (IFN) maintenance: results of Intergroup Trial S9321. [Abstract] Blood 102 (11): A-135, 2003. 

  75. Gahrton G, Tura S, Ljungman P, et al.: Prognostic factors in allogeneic bone marrow transplantation for multiple myeloma. J Clin Oncol 13 (6): 1312-22, 1995.  [PUBMED Abstract]

  76. Tricot G, Vesole DH, Jagannath S, et al.: Graft-versus-myeloma effect: proof of principle. Blood 87 (3): 1196-8, 1996.  [PUBMED Abstract]

  77. Verdonck LF, Lokhorst HM, Dekker AW, et al.: Graft-versus-myeloma effect in two cases. Lancet 347 (9004): 800-1, 1996.  [PUBMED Abstract]

  78. Lokhorst HM, Schattenberg A, Cornelissen JJ, et al.: Donor lymphocyte infusions for relapsed multiple myeloma after allogeneic stem-cell transplantation: predictive factors for response and long-term outcome. J Clin Oncol 18 (16): 3031-7, 2000.  [PUBMED Abstract]

  79. Reynolds C, Ratanatharathorn V, Adams P, et al.: Allogeneic stem cell transplantation reduces disease progression compared to autologous transplantation in patients with multiple myeloma. Bone Marrow Transplant 27 (8): 801-7, 2001.  [PUBMED Abstract]

  80. Arora M, McGlave PB, Burns LJ, et al.: Results of autologous and allogeneic hematopoietic cell transplant therapy for multiple myeloma. Bone Marrow Transplant 35 (12): 1133-40, 2005.  [PUBMED Abstract]

  81. Einsele H, Schäfer HJ, Hebart H, et al.: Follow-up of patients with progressive multiple myeloma undergoing allografts after reduced-intensity conditioning. Br J Haematol 121 (3): 411-8, 2003.  [PUBMED Abstract]

  82. Maloney DG, Molina AJ, Sahebi F, et al.: Allografting with nonmyeloablative conditioning following cytoreductive autografts for the treatment of patients with multiple myeloma. Blood 102 (9): 3447-54, 2003.  [PUBMED Abstract]

  83. Badros A, Barlogie B, Morris C, et al.: High response rate in refractory and poor-risk multiple myeloma after allotransplantation using a nonmyeloablative conditioning regimen and donor lymphocyte infusions. Blood 97 (9): 2574-9, 2001.  [PUBMED Abstract]

  84. Crawley C, Lalancette M, Szydlo R, et al.: Outcomes for reduced-intensity allogeneic transplantation for multiple myeloma: an analysis of prognostic factors from the Chronic Leukaemia Working Party of the EBMT. Blood 105 (11): 4532-9, 2005.  [PUBMED Abstract]

  85. Badros A, Barlogie B, Siegel E, et al.: Improved outcome of allogeneic transplantation in high-risk multiple myeloma patients after nonmyeloablative conditioning. J Clin Oncol 20 (5): 1295-303, 2002.  [PUBMED Abstract]

  86. Garban F, Attal M, Michallet M, et al.: Prospective comparison of autologous stem cell transplantation followed by dose-reduced allograft (IFM99-03 trial) with tandem autologous stem cell transplantation (IFM99-04 trial) in high-risk de novo multiple myeloma. Blood 107 (9): 3474-80, 2006.  [PUBMED Abstract]

  87. Belch A, Shelley W, Bergsagel D, et al.: A randomized trial of maintenance versus no maintenance melphalan and prednisone in responding multiple myeloma patients. Br J Cancer 57 (1): 94-9, 1988.  [PUBMED Abstract]

  88. Mandelli F, Avvisati G, Amadori S, et al.: Maintenance treatment with recombinant interferon alfa-2b in patients with multiple myeloma responding to conventional induction chemotherapy. N Engl J Med 322 (20): 1430-4, 1990.  [PUBMED Abstract]

  89. Westin J, Rödjer S, Turesson I, et al.: Interferon alfa-2b versus no maintenance therapy during the plateau phase in multiple myeloma: a randomized study. Cooperative Study Group. Br J Haematol 89 (3): 561-8, 1995.  [PUBMED Abstract]

  90. Osterborg A, Björkholm M, Björeman M, et al.: Natural interferon-alpha in combination with melphalan/prednisone versus melphalan/prednisone in the treatment of multiple myeloma stages II and III: a randomized study from the Myeloma Group of Central Sweden. Blood 81 (6): 1428-34, 1993.  [PUBMED Abstract]

  91. Browman GP, Bergsagel D, Sicheri D, et al.: Randomized trial of interferon maintenance in multiple myeloma: a study of the National Cancer Institute of Canada Clinical Trials Group. J Clin Oncol 13 (9): 2354-60, 1995.  [PUBMED Abstract]

  92. The Myeloma Trialists' Collaborative Group.: Interferon as therapy for multiple myeloma: an individual patient data overview of 24 randomized trials and 4012 patients. Br J Haematol 113 (4): 1020-34, 2001.  [PUBMED Abstract]

  93. Zee B, Cole B, Li T, et al.: Quality-adjusted time without symptoms or toxicity analysis of interferon maintenance in multiple myeloma. J Clin Oncol 16 (8): 2834-9, 1998.  [PUBMED Abstract]

  94. Berenson JR, Crowley JJ, Grogan TM, et al.: Maintenance therapy with alternate-day prednisone improves survival in multiple myeloma patients. Blood 99 (9): 3163-8, 2002.  [PUBMED Abstract]

  95. Attal M, Harousseau JL, Leyvraz S, et al.: Maintenance therapy with thalidomide improves survival in patients with multiple myeloma. Blood 108 (10): 3289-94, 2006.  [PUBMED Abstract]

  96. Berenson JR, Lichtenstein A, Porter L, et al.: Long-term pamidronate treatment of advanced multiple myeloma patients reduces skeletal events. Myeloma Aredia Study Group. J Clin Oncol 16 (2): 593-602, 1998.  [PUBMED Abstract]

  97. Rosen LS, Gordon D, Kaminski M, et al.: Long-term efficacy and safety of zoledronic acid compared with pamidronate disodium in the treatment of skeletal complications in patients with advanced multiple myeloma or breast carcinoma: a randomized, double-blind, multicenter, comparative trial. Cancer 98 (8): 1735-44, 2003.  [PUBMED Abstract]

  98. Badros A, Weikel D, Salama A, et al.: Osteonecrosis of the jaw in multiple myeloma patients: clinical features and risk factors. J Clin Oncol 24 (6): 945-52, 2006.  [PUBMED Abstract]

  99. Kademani D, Koka S, Lacy MQ, et al.: Primary surgical therapy for osteonecrosis of the jaw secondary to bisphosphonate therapy. Mayo Clin Proc 81 (8): 1100-3, 2006.  [PUBMED Abstract]

  100. Lacy MQ, Dispenzieri A, Gertz MA, et al.: Mayo clinic consensus statement for the use of bisphosphonates in multiple myeloma. Mayo Clin Proc 81 (8): 1047-53, 2006.  [PUBMED Abstract]

  101. Rades D, Hoskin PJ, Stalpers LJ, et al.: Short-course radiotherapy is not optimal for spinal cord compression due to myeloma. Int J Radiat Oncol Biol Phys 64 (5): 1452-7, 2006.  [PUBMED Abstract]

  102. Catell D, Kogen Z, Donahue B, et al.: Multiple myeloma of an extremity: must the entire bone be treated? Int J Radiat Oncol Biol Phys 40 (1): 117-9, 1998.  [PUBMED Abstract]

Isolated Plasmacytoma of Bone

If a solitary lytic lesion of plasma cells is found on skeletal survey in an otherwise asymptomatic patient, and a bone marrow examination from an uninvolved site contains less than 5% of plasma cells, the patient may have an isolated plasmacytoma of bone.[1] Magnetic resonance imaging scans of the total spine may identify other bony lesions.[2] The survival rate of patients with isolated plasmacytoma of bone treated with radiation of the lesion is greater than 50% at 10 years, which is much better than the survival with disseminated multiple myeloma.[3] Most patients will eventually develop disseminated disease and require chemotherapy; almost 50% will do so within 2 years of diagnosis;[1,2] however, patients with serum paraprotein or Bence Jones protein who have complete disappearance of these proteins after radiation therapy may be expected to remain free of disease for prolonged periods.[2,4] Patients who progress to multiple myeloma tend to have good responses to chemotherapy with a median survival of 63 months after progression.[2,4]

Standard treatment options:

  1. Radiation of the lesion.
  2. If the monoclonal (or myeloma) protein (M protein) increases and other evidence of symptomatic multiple myeloma occurs, chemotherapy is required.
Current Clinical Trials

Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with isolated plasmacytoma of bone 22. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.

General information about clinical trials is also available from the NCI Web site 11.

References

  1. Dimopoulos MA, Moulopoulos LA, Maniatis A, et al.: Solitary plasmacytoma of bone and asymptomatic multiple myeloma. Blood 96 (6): 2037-44, 2000.  [PUBMED Abstract]

  2. Liebross RH, Ha CS, Cox JD, et al.: Solitary bone plasmacytoma: outcome and prognostic factors following radiotherapy. Int J Radiat Oncol Biol Phys 41 (5): 1063-7, 1998.  [PUBMED Abstract]

  3. Tsang RW, Gospodarowicz MK, Pintilie M, et al.: Solitary plasmacytoma treated with radiotherapy: impact of tumor size on outcome. Int J Radiat Oncol Biol Phys 50 (1): 113-20, 2001.  [PUBMED Abstract]

  4. Dimopoulos MA, Goldstein J, Fuller L, et al.: Curability of solitary bone plasmacytoma. J Clin Oncol 10 (4): 587-90, 1992.  [PUBMED Abstract]

Extramedullary Plasmacytoma

Patients with isolated plasma cell tumors of soft tissues, most commonly occurring in the tonsils, nasopharynx, or paranasal sinuses, should have skeletal x-rays and bone marrow biopsy (both of which should be negative), and evaluation for a monoclonal (or myeloma) protein (M protein) in serum and urine.[1-4]

Extramedullary plasmacytoma is a highly curable disease with progression-free survival ranging from 70% to 87% at 10 to 14 years using radiation therapy (with or without previous resection).[2,4,5]

Standard treatment options:

  1. Radiation therapy to the isolated lesion with fields that cover the regional lymph nodes, if possible.[2,4]
  2. In some cases, surgical resection may be considered, but it is usually followed by radiation therapy.[4]
  3. If the monoclonal (or myeloma) protein (M protein) persists or reappears, the patient may need further radiation therapy. In some patients, the plasmacytoma may shrink, but not disappear, and the M protein persists. These types of patients should be followed closely. Surgery should be performed if the plasmacytoma is in a site where it can be removed easily, e.g., in the tonsil; the M protein may disappear from the blood or urine. In other cases, persistence or an increasing M protein may herald progression to multiple myeloma.
  4. Chemotherapy is required if the disease progresses and causes symptoms.
Current Clinical Trials

Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with extramedullary plasmacytoma 23. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.

General information about clinical trials is also available from the NCI Web site 11.

References

  1. Meis JM, Butler JJ, Osborne BM, et al.: Solitary plasmacytomas of bone and extramedullary plasmacytomas. A clinicopathologic and immunohistochemical study. Cancer 59 (8): 1475-85, 1987.  [PUBMED Abstract]

  2. Tsang RW, Gospodarowicz MK, Pintilie M, et al.: Solitary plasmacytoma treated with radiotherapy: impact of tumor size on outcome. Int J Radiat Oncol Biol Phys 50 (1): 113-20, 2001.  [PUBMED Abstract]

  3. Soesan M, Paccagnella A, Chiarion-Sileni V, et al.: Extramedullary plasmacytoma: clinical behaviour and response to treatment. Ann Oncol 3 (1): 51-7, 1992.  [PUBMED Abstract]

  4. Alexiou C, Kau RJ, Dietzfelbinger H, et al.: Extramedullary plasmacytoma: tumor occurrence and therapeutic concepts. Cancer 85 (11): 2305-14, 1999.  [PUBMED Abstract]

  5. Strojan P, Soba E, Lamovec J, et al.: Extramedullary plasmacytoma: clinical and histopathologic study. Int J Radiat Oncol Biol Phys 53 (3): 692-701, 2002.  [PUBMED Abstract]

Waldenström Macroglobulinemia (Lymphoplasmacytic Lymphoma)

Refer to the Waldenström macroglobulinemia 24 section in the PDQ summary on Adult Non-Hodgkin Lymphoma Treatment for more information.

Monoclonal Gammopathy of Undetermined Significance

Patients with monoclonal gammopathy of undetermined significance (MGUS) have a monoclonal (or myeloma) protein (M protein) in the serum without symptoms or findings of multiple myeloma, macroglobulinemia, amyloidosis, or lymphoma and with less than 10% of plasma cells in the bone marrow.[1,2] Multiple myeloma, other plasma cell dyscrasia, or lymphoma will develop in 12% of patients by 10 years, 25% by 20 years, and 30% by 25 years. Unfortunately, patients who will eventually develop plasma cell malignancy or lymphoma cannot be identified on the basis of the level of M protein, peripheral blood count, type of monoclonal immunoglobulin, percentage of plasma cells in the bone marrow, or levels of normal immunoglobulins. Therefore, all patients with MGUS must be kept under observation to detect increases in M protein levels and development of one of the above malignancies; however, higher levels of initial M protein levels correlate with increased risk of progression to multiple myeloma.[2] In a large retrospective report, the risk of progression at 20 years was 14% for an initial monoclonal protein level of 0.5 g/dL or less, 25% for a level of 1.5 g/dL, 41% for a level of 2.0 g/dL, 49% for a level of 2.5 g/dL, and 64% for a level of 3.0 g/dL.[2]

Current Clinical Trials

Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with monoclonal gammopathy of undetermined significance 25. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.

General information about clinical trials is also available from the NCI Web site 11.

References

  1. Kyle RA, Bladé J, Rajkumar SV: Monoclonal gammopathies of undetermined significance. In: Malpas JS, Bergsagel DE, Kyle RA, et al.: Myeloma: Biology and Management. 3rd ed. Philadelphia, Pa: WB Saunders Co, 2004, pp 315-52. 

  2. Kyle RA, Therneau TM, Rajkumar SV, et al.: A long-term study of prognosis in monoclonal gammopathy of undetermined significance. N Engl J Med 346 (8): 564-9, 2002.  [PUBMED Abstract]

Refractory Plasma Cell Neoplasm

There are two main types of refractory myeloma patients:

  • Primary refractory patients who never achieve a response and progress while still on induction chemotherapy.
  • Secondary refractory patients who do respond to induction chemotherapy but do not respond to treatment after relapse.

A subgroup of patients who do not achieve a response to induction chemotherapy have stable disease and enjoy a survival prognosis that is as good as that for responding patients.[1,2] When the stable nature of the disease becomes established, these types of patients can discontinue therapy until the myeloma begins to progress again. Others with primary refractory myeloma and progressive disease require a change in therapy; the options appear in the previous section on Multiple Myeloma Treatment Options 26.

The myeloma growth rate, as measured by the monoclonal (or myeloma) protein-doubling time, for patients who respond to their initial therapy, increases progressively with each subsequent relapse and remission durations become shorter and shorter. Marrow function becomes increasingly compromised as patients develop pancytopenia and enter a refractory phase; occasionally the myeloma cells dedifferentiate and extramedullary plasmacytomas develop. The myeloma cells may still be sensitive to chemotherapy, but the regrowth rate during relapse is so rapid that progressive improvement is not observed.

Current Clinical Trials

Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with refractory plasma cell neoplasm 27. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.

General information about clinical trials is also available from the NCI Web site 11.

References

  1. Riccardi A, Mora O, Tinelli C, et al.: Response to first-line chemotherapy and long-term survival in patients with multiple myeloma: results of the MM87 prospective randomised protocol. Eur J Cancer 39 (1): 31-7, 2003.  [PUBMED Abstract]

  2. Durie BG, Jacobson J, Barlogie B, et al.: Magnitude of response with myeloma frontline therapy does not predict outcome: importance of time to progression in southwest oncology group chemotherapy trials. J Clin Oncol 22 (10): 1857-63, 2004.  [PUBMED Abstract]

Get More Information From NCI

Call 1-800-4-CANCER

For more information, U.S. residents may call the National Cancer Institute's (NCI's) Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237) Monday through Friday from 9:00 a.m. to 4:30 p.m. Deaf and hard-of-hearing callers with TTY equipment may call 1-800-332-8615. The call is free and a trained Cancer Information Specialist is available to answer your questions.

Chat online

The NCI's LiveHelp® 28 online chat service provides Internet users with the ability to chat online with an Information Specialist. The service is available from 9:00 a.m. to 11:00 p.m. Eastern time, Monday through Friday. Information Specialists can help Internet users find information on NCI Web sites and answer questions about cancer.

Write to us

For more information from the NCI, please write to this address:

NCI Public Inquiries Office
Suite 3036A
6116 Executive Boulevard, MSC8322
Bethesda, MD 20892-8322

Search the NCI Web site

The NCI Web site 29 provides online access to information on cancer, clinical trials, and other Web sites and organizations that offer support and resources for cancer patients and their families. For a quick search, use our “Best Bets” search box in the upper right hand corner of each Web page. The results that are most closely related to your search term will be listed as Best Bets at the top of the list of search results.

There are also many other places to get materials and information about cancer treatment and services. Hospitals in your area may have information about local and regional agencies that have information on finances, getting to and from treatment, receiving care at home, and dealing with problems related to cancer treatment.

Find Publications

The NCI has booklets and other materials for patients, health professionals, and the public. These publications discuss types of cancer, methods of cancer treatment, coping with cancer, and clinical trials. Some publications provide information on tests for cancer, cancer causes and prevention, cancer statistics, and NCI research activities. NCI materials on these and other topics may be ordered online or printed directly from the NCI Publications Locator 30. These materials can also be ordered by telephone from the Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237), TTY at 1-800-332-8615.

Changes to This Summary (09/08/2008)

The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.

Multiple Myeloma 26

Editorial changes were made to this summary.

More Information

About PDQ

Additional PDQ Summaries

Important:

This information is intended mainly for use by doctors and other health care professionals. If you have questions about this topic, you can ask your doctor, or call the Cancer Information Service at 1-800-4-CANCER (1-800-422-6237).


Glossary Terms

Level of evidence 1iA
Randomized, controlled, double-blinded clinical trial with total mortality as an endpoint. See Levels of Evidence for Adult and Pediatric Cancer Treatment Studies (PDQ®) for more information.
Level of evidence 1iDiii
Randomized, controlled, double-blinded clinical trial with progression-free survival as an endpoint. See Levels of Evidence for Adult and Pediatric Cancer Treatment Studies (PDQ®) for more information.
Level of evidence 1iiA
Randomized, controlled, nonblinded clinical trial with total mortality as an endpoint. See Levels of Evidence for Adult and Pediatric Cancer Treatment Studies (PDQ®) for more information.
Level of evidence 1iiDiii
Randomized, controlled, nonblinded clinical trial with progression-free survival as an endpoint. See Levels of Evidence for Adult and Pediatric Cancer Treatment Studies (PDQ®) for more information.
Level of evidence 3iiA
Consecutive case series (not population-based) with total mortality as an endpoint. See Levels of Evidence for Adult and Pediatric Cancer Treatment Studies (PDQ®) for more information.
Level of evidence 3iiiA
Nonconsecutive case series with total mortality as an endpoint. See Levels of Evidence for Adult and Pediatric Cancer Treatment Studies (PDQ®) for more information.
Level of evidence 3iiiD
Nonconsecutive case series with indirect surrogates as an endpoint. See Levels of Evidence for Adult and Pediatric Cancer Treatment Studies (PDQ®) for more information.
Level of evidence 3iiiDiv
Nonconsecutive case series with tumor response rate as an endpoint. See Levels of Evidence for Adult and Pediatric Cancer Treatment Studies (PDQ®) for more information.


Table of Links

1http://www.cancer.gov/cancerinfo/pdq/adult-treatment-board
2http://cancer.gov/cancertopics/pdq/levels-evidence-adult-treatment/HealthProfes
sional
3http://cancer.gov/cancertopics/pdq/treatment/myeloma/Patient
4http://cancer.gov/espanol/pdq/tratamiento/mieloma/HealthProfessional
5http://www.cancer.org/downloads/STT/2008CAFFfinalsecured.pdf
6http://cancer.gov/cancertopics/pdq/treatment/adult-non-hodgkins/HealthProfessio
nal/256.cdr#Section_256
7http://cancer.gov/cancertopics/pdq/treatment/adult-non-hodgkins/HealthProfessio
nal
8http://cancer.gov/cancertopics/pdq/treatment/CLL/healthprofessional
9http://cancer.gov/search/viewclinicaltrials.aspx?version= healthpr
ofessional &cdrid=65092
10http://www.cancer.gov/Search/ClinicalTrialsLink.aspx?diagnosis=37974&tt=1&a
mp;format=2&cn=1
11http://www.cancer.gov/clinicaltrials
12http://cancer.gov/search/viewclinicaltrials.aspx?version= healthpr
ofessional &cdrid=64328
13http://cancer.gov/search/viewclinicaltrials.aspx?version= healthpr
ofessional &cdrid=404161
14http://cancer.gov/cancertopics/pdq/treatment/myeloma/HealthProfessional/360.cdr
#Section_360
15http://cancer.gov/search/viewclinicaltrials.aspx?version= healthpr
ofessional &cdrid=69274
16http://cancer.gov/search/viewclinicaltrials.aspx?version= healthpr
ofessional &cdrid=69144
17http://cancer.gov/search/viewclinicaltrials.aspx?version= healthpr
ofessional &cdrid=453086
18http://cancer.gov/search/viewclinicaltrials.aspx?version= healthpr
ofessional &cdrid=420968
19http://cancer.gov/search/viewclinicaltrials.aspx?version= healthpr
ofessional &cdrid=70307
20http://cancer.gov/search/viewclinicaltrials.aspx?version= healthpr
ofessional &cdrid=63310
21http://www.cancer.gov/Search/ClinicalTrialsLink.aspx?diagnosis=42947&tt=1&a
mp;format=2&cn=1
22http://www.cancer.gov/Search/ClinicalTrialsLink.aspx?diagnosis=41558&tt=1&a
mp;format=2&cn=1
23http://www.cancer.gov/Search/ClinicalTrialsLink.aspx?diagnosis=41865&tt=1&a
mp;format=2&cn=1
24http://cancer.gov/cancertopics/pdq/treatment/adult-non-hodgkins/HealthProfessio
nal/59.cdr#Section_59
25http://www.cancer.gov/Search/ClinicalTrialsLink.aspx?diagnosis=40134&tt=1&a
mp;format=2&cn=1
26http://cancer.gov/cancertopics/pdq/treatment/myeloma/HealthProfessional/59.cdr#
Section_59
27http://www.cancer.gov/Search/ClinicalTrialsLink.aspx?diagnosis=41876&tt=1&a
mp;format=2&cn=1
28https://cissecure.nci.nih.gov/livehelp/welcome.asp
29http://cancer.gov
30https://cissecure.nci.nih.gov/ncipubs
31http://cancer.gov/cancerinfo/pdq/cancerdatabase
32http://cancer.gov/cancerinfo/pdq/adulttreatment
33http://cancer.gov/cancerinfo/pdq/pediatrictreatment
34http://cancer.gov/cancerinfo/pdq/supportivecare
35http://cancer.gov/cancerinfo/pdq/screening
36http://cancer.gov/cancerinfo/pdq/prevention
37http://cancer.gov/cancerinfo/pdq/genetics
38http://cancer.gov/cancerinfo/pdq/cam