UNDERSTANDING MYELOMA
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UNDERSTANDING MYELOMAUNDERSTANDING MYELOMA
Brian G.M. Durie, M.D.Brian G.M. Durie, M.D.ChairmanChairman
International Myeloma International Myeloma FoundationFoundation
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Most Common Initial ProblemsMost Common Initial Problems
Bone painBone pain Anemia/FatigueAnemia/Fatigue NONO Problems: Incidental finding Problems: Incidental finding
during routine examduring routine exam Kidney problemKidney problem OtherOther
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Diagnosis
BoneMarrow
Imaging
Electro-pheresis
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Bone Lesions In MyelomaBone Lesions In Myeloma
Lytic lesions
Lytic lesions
LEG ELBOW
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StagingStaging
Single lesionSingle lesionSolitary plasmacytomaSolitary plasmacytomaStage IStage I
Multiple lesionsMultiple lesionsStages II / III A/BStages II / III A/B
A – Creatinine < 2mg /DLA – Creatinine < 2mg /DLB – Creatinine B – Creatinine >> 2mg/DL 2mg/DL
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SOLITARY PLASMACYTOMA
T1-wt MRI STIR – wt MRI Sagittal CTSagittal FDG PET
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STAGING WITH FDG PET
FL on PET & MRI:Multiple Myeloma FDG PET: Severe Diffuse (D) and Focal (F) Disease
DDDD
DD
DD
DD
FF
FF
FF
FF
DD
MRI – STIR weighted of thoracic spine
FDG PET scanof thoracic spine
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Pretreatment 3 months later
Confirmation of Remission
Plasmacytomas
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MYELOMA PROTEIN “SPIKE”MYELOMA PROTEIN “SPIKE”
Low Albumin Spike
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International Staging SystemInternational Staging System22M / S. AlbM / S. Alb
Stage 1Stage 1 Low Low 22M < 3.5M < 3.5** plusplus
S. AlbuminS. Albumin**** >> 3.5 G/DL 3.5 G/DL
Stage 2Stage 2 22M < 3.5 M < 3.5 butbut albumin < 3.5 albumin < 3.5 Or Or 22M or higher: 3.5 – < 5.5 M or higher: 3.5 – < 5.5
Stage 3Stage 3 High High 22M M >> 5.5mg/DL 5.5mg/DL
* mg/DL* mg/DL** Gm/DL** Gm/DL
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Other FactorsOther Factors Impact of Impact of AGEAGE C-Reactive Protein (CRP)C-Reactive Protein (CRP) LDHLDH Chromosome 13Chromosome 13
Cytogenetic deletionCytogenetic deletionFISH analysisFISH analysis
Micro array classificationMicro array classification
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Genetic Studies in Myeloma
Gene Array: Normal vs MM MM +/- Bone Disease
Sky Karyotype
No Lytic Lesions > 3 Lytic Lesions
Normal Bone MarrowCells
Clonally restricted PCw/o Chromosome 13 deletion
Clonally restricted PC w / Chr. 13 deletion
D13S31 D10S2142
anti-kappa
NPC MM
High
Gene Expression
Low
120 genes
NL Myeloma
CA13 – Tri-FISH
DKK1, FRZB, CENPA, TYMS, TTK, MAD2L1, PCNA, PRKDC, CCNF, AML1BWNT10B, ARHE, LNHR, SLAM, TACI, PIM1, IL6R, BIK, BAX, CFLAR
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Starting TreatmentStarting Treatment
Supportive Measures – for pain, Supportive Measures – for pain, anemia, infection …anemia, infection …
Systemic Therapy – oral and/or I.V. Systemic Therapy – oral and/or I.V. treatmenttreatment
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Supportive CareSupportive Care
Bone – Aredia or ZometaBone – Aredia or Zometa Anemia – EPOAnemia – EPO Procrit/EpogenProcrit/Epogen Other – radiation, antibiotics, fluids, Other – radiation, antibiotics, fluids,
pain, medication …pain, medication …
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First TherapyFirst TherapyInduction or FrontlineInduction or Frontline
Saving Stem CellsSaving Stem CellsVADVADDEXDEXThalidomide/DexamethasoneThalidomide/DexamethasoneCytoxanCytoxan
NOT NOT Saving Stem CellsSaving Stem CellsM/PM/POther combosOther combos
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Next StepsNext Steps
HarvestingHarvesting ““Consolidation”Consolidation”
Auto stem cell transplantAuto stem cell transplant““Mini-allo”Mini-allo”
MaintenanceMaintenance
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Clear Recommendation Required
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Mutual Agreement is Essential
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MENTAL HEALTHMENTAL HEALTH
Stress reductionStress reduction Confidence in treatment planConfidence in treatment plan Expectation of remissionExpectation of remission Future plansFuture plans HOPEHOPE
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YOUR DOCTORYOUR DOCTOR
InformedInformed CooperativeCooperative Open to discussing optionsOpen to discussing options Caring for Caring for YOUYOU
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Caring and Trust are Crucial
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Help Others When You Can