Anup J Devasia
Multiple myeloma is a malignant neoplasm characterised by clonal disorder of terminally differentiated plasma cells. Dramatic advancements have happened in the treatment algorithm in the last 2 decades which has led to improvement in survival and overall outcomes in patients with multiple myeloma. The arrival of numerous more active “new novel agents” and the possible multiple combinations with them has made the treatment of myeloma exciting and at the same time confusing.
Treatment of newly diagnosed myeloma: Treatment algorithm of newly diagnosed myeloma includes induction, consolidation and maintenance.
Patients who are transplant eligible are to be treated with 4-6 cycles of non-alkylator based novel agent-based triplet induction regimen followed by consolidation with an autologous stem cell transplantation. In patients who are transplant ineligible, a long (9-12 cycles) dual or triplet induction is the standard of care followed by maintenance. Eligibility for auto-transplant in myeloma is dependent on the age, comorbidity and performance status of the patients.
Consolidation therapy in myeloma is generally by an autologous stem cell transplantation with high dose melphalan in eligible patients. There is a lot of controversy on whether a single or two autologous transplantation (tandem transplantation) is needed in myeloma. Data compiled from various phase III European trials have shown that patients who have high risk cytogenetics or with suboptimal induction responses benefit from a tandem autologous stem cell transplantation. Non transplant consolidation is still not a standard recommendation.
Maintenance therapy is standard of care and the usual agents used are Lenalidomide, Bortezomib or Thalidomide. There is controversy on how long to continue maintenance, definite versus till progression/ tolerated.
The treatment of relapsed myeloma depends on the duration and depth of the initial response, aggressiveness of the relapse, patient comorbidities and the side effect profile of the drug. The use of allogeneic stem cell transplantation is largely confined to young patients who are relapsed refractory or who have an early relapse post autologous stem cell transplantation.
Correspondence: Dr. Anup J Devasia, Associate Professor, Department of Haematology, Christian Medical College, Vellore 632004, India. Email: [email protected]