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How we manage smoldering multiple myeloma.

Smoldering myeloma (SMM) is an asymptomatic stage characterized by bone marrow plasma cells infiltration between 10-60% in absence of myeloma-defining events and organ damage. Until the revision of criteria of MM to require treatment, two main prognostic models, not overlapping each other, were proposed and used differently in Europe and in US. Novel manageable drugs, like lenalidomide and monoclonal antibodies, with high efficacy and limited toxicity, improvement in imaging and prognostication, challenge physicians to offer early treatment to highrisk SMM. Taking advantage from the debates of

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… Prognosis of asymptomatic multiple myeloma . Arch Intern Med . 1988 ; 148 ( 9 ): 1963 - 1965 . 2458080 52. Dimopoulos MA Moulopoulos A Smith T Delasalle KB Alexanian R. Risk of disease progression in asymptomatic multiple myeloma . … Mateos MV Hernandez MT Giraldo P Lenalidomide plus dexamethasone for high-risk smoldering multiple myeloma . N Engl J Med . 2013 ; 369 ( 5 ): 438 - 447 . 23902483 10.1056/NEJMoa1300439 99. Mateos MV When to initiate treatment in smoldering multiple myeloma . …

Dissecting racial disparities in multiple myeloma.

Multiple myeloma (MM) is a fatal plasma cell dyscrasia with a median overall survival of 5 to 10 years. MM progresses from the more common but often subclinical precursor states of monoclonal gammopathy of undetermined significance (MGUS), and smoldering multiple myeloma (SMM) to overt MM. There are large racial disparities in all stages of the disease. Compared with Whites, Blacks have an increased MGUS and MM risk and higher mortality rate, and have not experienced the same survival gains over time. The roots of this disparity are likely multifactorial in nature. Comparisons of Black and Whi…

Orbital ecthyma gangrenosum in multiple myeloma.

Ecthyma gangrenosum is a rare and highly lethal cutaneous infection classically associated with Pseudomonas aeruginosa bacteremia. We report a 58-year-old man with multiple myeloma receiving chemotherapy who presented with 2 days of painless left periorbital swelling that rapidly progressed to a blackish eschar. His absolute neutrophil count was 0.10/mm3; platelet count, 14,000/mm3; and hemoglobin, 6 g/dL. Computed tomography showed diffuse left periorbital cellulitis. Blood cultures grew pan-sensitive Pseudomonas aeruginosa, and the patient died from sepsis and multiorgan failure.

Front-line treatment of multiple myeloma.

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… International Myeloma Working Group updated criteria for the diagnosis of multiple myeloma . Lancet Oncol 2014 ; 15 : e538 – e548 . 25439696 10.1016/S1470-2045(14)70442-5 2. Zweegman S Engelhardt M Larocca A . Elderly patients with multiple myeloma: towards a frailty approach? … Multiple myeloma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up . Ann Oncol 2017 ; 28 (suppl_4) : 1 – 11 . 10.1093/annonc/mdx096 28453614 7. Kumar SK Buadi FK Rajkumar SV . Pros and cons of frontline autologous transplant in multiple myeloma: the debate over timing . …

Managing multiple myeloma in elderly patients.

Multiple myeloma (MM) is a plasma cell neoplasm that affects elderly individuals with two-thirds of patients over 65 years at diagnosis. However, data available are derived from clinical trials conducted in younger patients. Fewer studies investigated treatment options in the elderly. This review summarizes the clinical outcomes and toxicities associated with therapeutic regimens in older patients including doublet, triplet and high dose therapyin newly diagnosed patients and relapsed patients with MM. We highlight the importance of an approach tailored to individuals, incorporates the geriatr…

Multiple Myeloma Presenting as Thyroid Plasmacytoma.

Thyroid gland and thyroid cartilage infiltration in multiple myeloma (MM) are rare. Here, we discuss a patient who presented with hoarseness of voice and was found to have a hypodense lesion in right lobe of thyroid involving thyroid and cricoid cartilage. Fine-needle aspiration cytology with immunohistochemistry revealed extramedullary plasmacytoma of thyroid. MM was ruled out initially by serum protein electrophoresis, immunofixation, and bone marrow biopsy. Later, lytic lesions were found in multiple bones on radiation planning scan and he was finally diagnosed as case of MM with thyroid in…

Recent advances in understanding multiple myeloma.

There have been major recent advancements in the understanding and management of multiple myeloma. Diagnostic criteria have been revised and former ultra-high-risk smoldering multiple myeloma is now considered multiple myeloma in need of treatment. Understanding clonal progression, evolution, and tides not only has helped elucidate the disease behavior but might help expand therapeutic choices in order to select appropriate treatment for patients. Unprecedented response rates with modern triplet induction therapies containing proteasome inhibitor and immunomodulators have made this approach st…

The Danish National Multiple Myeloma Registry.

AimThe Danish National Multiple Myeloma Registry (DMMR) is a population-based clinical quality database established in January 2005. The primary aim of the database is to ensure that diagnosis and treatment of plasma cell dyscrasia are of uniform quality throughout the country. Another aim is to support research. Patients are registered with their unique Danish personal identification number, and the combined use of DMMR, other Danish National registries, and the Danish National Cancer Biobank offers a unique platform for population-based translational research.Study populationAll newly diagno…

Multiple myeloma presenting as mandibular pain.

INTRODUCTION: Multiple myeloma (MM) is a systemic malignancy of plasma cells defined by monoclonal production of circulating immunoglobulins. Bone pain is a presenting feature in the majority of cases. Treatment may involve intravenous use of bisphosphonates, chemotherapy or haematopoietic stem cell transplantation. Here, we illustrate a first presentation of MM in a patient with mandibular pain and discuss radiographic, diagnostic and treatment challenges of orofacial issues in patients with MM. CASE REPORT: A 69-year-old lady presented to an emergency oral surgery clinic with a month-long h…

Novel Induction Regimens in Multiple Myeloma.

Multiple myeloma is the second most common hematologic malignancy and predominantly affects the elderly. The introduction of novel agents such as thalidomide, lenalidomide, and bortezomib has improved progression-free survival, overall survival, and quality of life in myeloma patients. Next generation agents such as carfilzomib hold further promise for increased depth and length of remission. Autologous stem cell transplant remains a useful tool in the treatment of multiple myeloma, but not all patients are eligible for this procedure. As therapy becomes more effective, determination of the ri…

Evolving diagnostic criteria for multiple myeloma.

Multiple myeloma (MM) is a plasma cell malignancy historically defined by the presence of end-organ damage, specifically, hypercalcemia, renal failure, anemia, and bone lesions (CRAB features) that can be attributed to the neoplastic process. In 2014, the International Myeloma Working Group (IMWG) updated the diagnostic criteria for MM to add specific biomarkers that can be used to make the diagnosis of the disease in patients who did not have CRAB features. In addition, the update allows modern imaging methods including computed tomography (CT) and positron emission tomography-CT to diagnose …

Multiple myeloma presenting as mediastinal mass.

Plasmacytomas can be classified as osseous (medullary) or non-osseous (extramedullary). Extramedullary plasmacytomas (EMP) are uncommon and may be primary or associated with multiple myeloma (MM). EMP arising from the mediastinum is extremely rare. We report two patients who presented with symptomatic mediastinal masses. On evaluation, these turned out to be EMP with coexisting MM.These two cases are being presented for their rarity and to highlight the unusual presentations of MM.

Immunotherapeutic approaches to treat multiple myeloma.

Cellular immunotherapy can be an effective adjuvant treatment for multiple myeloma (MM), as demonstrated by induction of durable remissions after allogeneic stem cell transplantation. However, anti-myeloma immunity is often hampered by suppressive mechanisms in the tumor micro-environment resulting in relapse or disease progression. To overcome this immunosuppression, new cellular immunotherapies have been developed, based on the important effector cells in anti-myeloma immunity, namely T cells and natural killer cells. These effectors can be modulated to improve their functionality, activated…

Long-term survival in multiple myeloma.

Key clinical messageThe survival of multiple myeloma patients has improved very significantly over the last decade. Still median overall survival is inferior to 5 years. A small proportion of patients survive longer than 10 years. In this paper we discuss four cases illustrating the nonhomogeneous clinical presentation and evolution of this subset of patients. Surprisingly, these long survivors do not always have deep responses and some require frequent treatments, which include autologous stem cell transplantation and novel drugs. The authors discuss several aspects of these clinical historie…

[Multiple myeloma predominantly involving the spleen].

Extramedullary disease is an uncommon manifestation in multiple myeloma (MM) and can be observed at onset or develop at disease progression or relapse. Splenic involvement is very rare. The paper describes a 52-year-old female patient with MM who in 1990 was diagnosed with monoclonal gammopathy of undetermined significance with IgGkappa secretion and a considerably enlarged spleen. Specific therapy with bortezomib and dexamethasone was initiated in 2006 and proved to be inefficient. After splenectomy there was a 50% reduction in IgGkappa concentration. Splenic histological examination revealed…

Multiple myeloma: from diagnosis to treatment.

BACKGROUND: Multiple myeloma is characterised by the proliferation of malignant plasma cells within the bone marrow, which produce an abnormal monoclonal paraprotein and evidence of end organ damage. OBJECTIVE: Multiple myeloma can pose a diagnostic challenge and this article highlights issues in diagnosis and provides an overview of management. DISCUSSION: Multiple myeloma can present with a wide constellation of symptoms including hypercalcaemia, anaemia, renal impairment and/or bony pain. A combination of these symptoms, particularly if unexpected or unexplained, should prompt diagnostic …

Multiple myeloma presenting as gingival hyperplasia.

Multiple myeloma is a malignant neoplasm that is characterized by a monoclonal proliferation of plasma cells. Oral and maxillofacial manifestations as an initial sign or symptom of multiple myeloma are rare. A 58-year-old male patient presented with generalized gingival enlargement for last 6 months. Based on clinical presentation, a diagnosis of gingival hyperplasia was made. After Phase I therapy, excisional biopsy was taken in anterior mandibular region and excised tissue was sent for histopathological examination. The histopathology report revealed a lining of stratified squamous epitheliu…