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Selection of initial chemotherapy for symptomatic multiple myeloma

Author
S Vincent Rajkumar, MD
Section Editor
Robert A Kyle, MD
Deputy Editor
Rebecca F Connor, MD

INTRODUCTION

Multiple myeloma (MM) is characterized by the neoplastic proliferation of a single clone of plasma cells producing a monoclonal immunoglobulin. MM is distinguished from premalignant plasma cell dyscrasias, namely monoclonal gammopathy of undetermined significance (MGUS) and smoldering multiple myeloma (SMM), by the presence of one or more myeloma-defining events, which include end-organ dysfunction (anemia, hypercalcemia, renal insufficiency, and skeletal lesions) attributed to the malignant clone; ≥60 percent clonal plasma cells in the bone marrow; involved/uninvolved free light chain ratio of 100 or more; and magnetic resonance imaging (MRI) with more than one focal lesion involving bone or bone marrow. Patients with MM are given therapies directed at the underlying plasma cell clone with the goal of preventing further complications. In contrast, active treatment is not routinely indicated for patients with MGUS or SMM. (See "Clinical features, laboratory manifestations, and diagnosis of multiple myeloma".)

The initial chemotherapy for patients with symptomatic MM is discussed here. A general management overview, details regarding the use and timing of autologous hematopoietic cell transplantation (HCT), and the response evaluation are presented separately. In addition, the initial chemotherapy options for patients treated in resource-poor settings are presented separately. (See "Overview of the management of multiple myeloma" and "Management of multiple myeloma in resource-poor settings" and "Autologous hematopoietic cell transplantation in multiple myeloma".)

Discussions of relapsed or resistant myeloma, the treatment of complications of MM (eg, hypercalcemia, renal insufficiency, skeletal lesions), and the use of bisphosphonates are presented separately. (See "Treatment of relapsed or refractory multiple myeloma" and "Treatment of the complications of multiple myeloma" and "The use of bisphosphonates in patients with multiple myeloma".)

OVERVIEW

High-dose chemotherapy followed by autologous hematopoietic cell transplantation (HCT, rescue) is considered a standard of care for eligible patients with newly diagnosed MM. As such, all patients with MM should be assessed at the time of diagnosis to determine whether they are eligible for autologous HCT, and the initial chemotherapy given to patients who are candidates for HCT should avoid agents that may impair stem cell collection (eg, melphalan). (See "Overview of the management of multiple myeloma", section on 'Determining transplant eligibility'.)

Patients who are eligible for HCT are typically treated with two to four cycles of induction therapy followed by autologous stem cell collection. Then a decision is made regarding whether to proceed with autologous HCT (early HCT strategy) or continue the same chemotherapy regimen reserving HCT for first relapse (delayed HCT strategy). Both approaches so far have produced similar overall survival rates, although comparative studies using modern regimens have had limited follow-up data. Therefore the choice is based on patient and physician preference; availability of resources to store stem cells; and patient age, clinical features, and risk stratification. Patients who are not eligible for HCT are treated with chemotherapy alone. (See "Overview of the management of multiple myeloma", section on 'HCT ineligible'.)

                      

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Literature review current through: Nov 2016. | This topic last updated: Mon Nov 07 00:00:00 GMT 2016.
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