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Welcome to Dr. Hamid Sanatinia's Virtual Headquarters
Multiple Myeloma

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Should we treat or not???
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MDR

1. Treatments:
----Untreated myeloma
----Resistant myeloma
2. Classification of plasma cell dyscrasias
3. Staging multiple myeloma

MP:

MELPHALAN 8 mg/m2 po + PREDNISONE 100 mg/day PO DAYS 1-4
NOTE: Do not use if patient considered for myeloablative therapy

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VAD:
VINCRISTINE 0.4 mg/day IV
ADRIAMYCIN 9 mg/m2/day IV
BOTH DRUGS TO BE GIVEN BY CONTINUOUS INFUSION ON DAYS 1-4, & WITH DEXAMETHASONE 20 mg/m2 ON DAYS 9-12, & 17-20.

With Spinal XRT:
DEXAMETHASONE 20 mg/m2/day PO on DAYS 1-4, 9-12, 17-20

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RESISTANT MYELOMA

Use alternatives above or

Use Thalidomide:
Thalidomide escalating dosage schedule from 200 mg to 800 mg a day.
Toxicities include: Constipation, sedation, & symptoms of peripheral neuropathy.
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Thalidomide + Decadron

Thalidomide 200 mg/day with
Dexamethasone 40 mg/day orally on days 1-4, 9-12, & 19-20 in the ODD cycles and, on the EVEN cycles, only on days 1-4

RESULTS: RR 64%. Using the cut-off level of a 25% reduction in paraprotein to define response, RR 92%. Complications: DVT in 10% of patients, constipation in 8%, & rash in 6%. Three patients died while on treatment; 1 from pancreatitis, 1 from PE, & 1 from infection.

REF: Rajkumar S, Hayman S, Gertz M, et al. Combination therapy with thalidomide plus dexamethasone (THAL/DEX) for newly diagnosed myeloma (MM). Program and abstracts of the 43rd Annual Meeting of the American Society of Hematology; December 7-11, 2001; Orlando, Florida. Abstract 3525.
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Classification of plasma cell dyscrasias:

MGUS
--Absence of lytic lesions, anemia, hypercalcemia, renal insufficiency, & stability of the monoclonal protein during follow up.
--serum monoclonal protein <3 g/dL
--min or absent light chain excretion

SMOLDERING MYELOMA
--monoclonal paraprotein <5 g/dL
--min marrow plasmacytosis <30%
--mild anemai
--no renal insufficiency or lytic bone lesions

INDOLENT MYELOMA
--Stage I multiple myeloma except patients are asymptomatic & <3 asymptomatic small lytic bone lesions.

EXTRAMEDULLARY OR SOLITARY PLASMACYTOMA OF BONE

PLASMA CELL LEUKEMIA

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STAGE:

I
Hgb>10
Serum Ca=<12
Normal bone or solitary plasmacytoma on X-ray
Low M-component production rate (IgG<5g/dl,IgA<3g/dl,BJ<4g/24hr)

II
Neither I or III!

III
Hgb<8.5
Serum Ca>12
Multiple lytic lesions on X-ray
High M-component production rate(IgG>7, IgA>5, BJ>12)
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Subclassification:
A---normal renal function (serum creat <2.0)
B---abnormal renal function (serum creat >2.0)