UNDERSTANDING MYELOMAUNDERSTANDING MYELOMA

Brian G.M. Durie, M.D.Brian G.M. Durie, M.D.

ChairmanChairman

International Myeloma International Myeloma FoundationFoundation

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

Diagnosis

BoneMarrow

Imaging

Electro-pheresis

Bone Lesions In MyelomaBone Lesions In MyelomaBone Lesions In MyelomaBone Lesions In Myeloma

Lytic lesions

Lytic lesions

LEG ELBOW

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 /DL

B – Creatinine B – Creatinine >> 2mg/DL 2mg/DL

SOLITARY PLASMACYTOMA

T1-wt MRI STIR – wt MRI Sagittal CTSagittal FDG PET

STAGING WITH FDG PET

FL on PET & MRI:Multiple Myeloma FDG PET: Severe Diffuse (D) and Focal (F) Disease

DD

DD

DD

DD

DD

FF

FF

FF

FF

DD

MRI – STIR weighted of thoracic spine

FDG PET scanof thoracic spine

Pretreatment 3 months later

Confirmation of Remission

Plasmacytomas

MYELOMA PROTEIN “SPIKE”MYELOMA PROTEIN “SPIKE”

Low Albumin Spike

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

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

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, AML1B

WNT10B, ARHE, LNHR, SLAM, TACI, PIM1, IL6R, BIK, BAX, CFLAR

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

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 …

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

Next StepsNext Steps

HarvestingHarvesting ““Consolidation”Consolidation”

Auto stem cell transplantAuto stem cell transplant““Mini-allo”Mini-allo”

MaintenanceMaintenance

Clear Recommendation Required

Mutual Agreement is Essential

MENTAL HEALTHMENTAL HEALTH

Stress reductionStress reduction Confidence in treatment planConfidence in treatment plan Expectation of remissionExpectation of remission Future plansFuture plans HOPEHOPE

YOUR DOCTORYOUR DOCTOR

InformedInformed CooperativeCooperative Open to discussing optionsOpen to discussing options Caring for Caring for YOUYOU

Caring and Trust are Crucial

Help Others When You Can