From the FDA Drug Label
Complete response (CR) required <5% plasma cells in the marrow, 100% reduction in M-protein, and a negative immunofixation test (IF-). The diagnosis is Multiple Myeloma with lambda-restricted plasma cells. The treatment for multiple myeloma includes bortezomib. Bortezomib is administered by intravenous bolus twice weekly for two weeks on Days 1,4,8, and 11 followed by a ten-day rest period (Days 12 to 21) 1. Key points:
- Diagnosis: Multiple Myeloma
- Treatment: Bortezomib
- Administration: Intravenous bolus twice weekly for two weeks on Days 1,4,8, and 11 followed by a ten-day rest period (Days 12 to 21)
- Response criteria: Complete response (CR) required <5% plasma cells in the marrow, 100% reduction in M-protein, and a negative immunofixation test (IF-) 1
From the Research
The presence of lambda-restricted plasma cells in a bone marrow aspirate is highly suggestive of multiple myeloma, and treatment should be initiated promptly with a triplet regimen of a proteasome inhibitor, an immunomodulatory drug, and dexamethasone, such as VRd (bortezomib, lenalidomide, and dexamethasone) for 3-4 cycles, followed by autologous stem cell transplantation for eligible patients, as recommended by the most recent study 2.
Diagnosis
The diagnosis of multiple myeloma requires the presence of an M-protein in serum and/or urine, increased bone marrow plasma cells, and related organ or tissue impairment, as stated in the study 3. The presence of lambda-restricted plasma cells in the bone marrow aspirate is a key diagnostic feature. Additional testing, including complete blood count, comprehensive metabolic panel, serum and urine protein electrophoresis, serum free light chain assay, skeletal survey or advanced imaging, and cytogenetic studies of the bone marrow, is essential to confirm the diagnosis.
Treatment
For multiple myeloma, standard treatment typically includes a triplet regimen of a proteasome inhibitor (bortezomib, carfilzomib), an immunomodulatory drug (lenalidomide, pomalidomide), and dexamethasone. The study 2 suggests that bortezomib-melphalan-prednisone (VMP) and continuous lenalidomide-dexamethasone (Rd) are effective treatment options for transplant-ineligible patients. Maintenance therapy with lenalidomide 10-15 mg daily is often continued indefinitely.
Key Considerations
- The study 2 highlights the importance of considering the patient's age, performance status, and cytogenetic risk profile when selecting a treatment regimen.
- The use of CD138 immunohistochemistry can aid in the assessment of bone marrow plasma cell infiltrates, as noted in the study 4.
- The study 5 suggests that bone marrow particle enrichment analysis may be a useful tool in the diagnosis of multiple myeloma, particularly in cases where bone marrow aspirates are hemodiluted.
Recommendations
- Initiate treatment with a triplet regimen of a proteasome inhibitor, an immunomodulatory drug, and dexamethasone, such as VRd, for 3-4 cycles, followed by autologous stem cell transplantation for eligible patients.
- Consider the patient's age, performance status, and cytogenetic risk profile when selecting a treatment regimen.
- Use CD138 immunohistochemistry to aid in the assessment of bone marrow plasma cell infiltrates.
- Consider bone marrow particle enrichment analysis in cases where bone marrow aspirates are hemodiluted.