Myeloma   

Can you explain when would you consider light chain amyloidosis work up with fat pad biopsy?

Can you elaborate on reasons for a non-quantifiable SPEP and how does one follow the paraprotein?

Most patients with PGNMID have no detectable disease in their marrow or blood and urine protein cannot adequately be monitored.

Does a certain level of free light chain ratio reassure you against the possibility of AL amyloid? Is there a certain level that makes you more concer...

Do the recently published IMROZ and BENEFIT trials inform maintenance treatment in transplant-in-eligible patients with NDMM?

Since free light chains are removed by dialysis and SPEP can also be impacted, is there a reliable way to monitor patients with ESRD and MM?

E.g. frequency of Bortezomib, dosing of Bortezomib, length of cycles.

When would you consider a bone marrow biopsy?

What does it add beyond a serum electrophoresis or light chain testing? Are there certain types of patients where monitoring immunoglobulins is parti...

For example, how do you address tendency to "over-order" these tests in patients with common aches/pains but no structural abnormalities on advanced i...

Would you transplant a patient over the age of 70 with newly diagnosed myeloma? Does the risk category impact your decision?

E.g., for a patient with myeloma, s/p induction therapy, and high-dose chemotherapy, followed by autologous rescue with inappropriate antibody respons...

Is there benefit to radiation on top of systemic therapy?

Is the therapeutic purpose of the proteasome inhibitor to maximize total dosage per week or number of infusions per week?

Presuming the patient is not a transplant candidate due to comorbidities, PS, and age.

If there are light chain deposits on the kidney, is that conclusive of MGRS?

Triplet v. Quadruplet? Do you opt for VRd, DaraRD, CyBorD, Dara-RVd or another regimen?  How would this change for a patient with high risk cyt...

How frequently and what type of testing/sample are you performing MRD assessment? Does your approach differ between transplant-eligible and transplan...

Several patients with inability to access oral cyclophosphamide or lenalidomide, have attempted assistance and grants to no avail.

Given recent retrospective study showing potential lack of benefit with bortezomib-based maintenance therapy (Bumma et al., PMID 37021929).High-risk a...

Which PI and at what dosing intervals? Dexamethasone or not? Emory has now published data with VRd consolidation as well as KPd consolidation, while ...

Assuming there is clear laboratory and/or imaging evidence of disease progression, and assuming FISH data is already available from a prior biopsy, do...

Patient with stable disease on maintenance therapy with lenalidomide and dexamethasone

Normal CBC, CMP, SPEP, serum light chains, and FISH. Young otherwise fit patient.

E.g. in a patient with tenuous cardiac function, would starting treatment several weeks earlier potentially improve outcomes?

Regimen currently 25 mg lenalidomide D1-21 of D28 day cycles, Daratumumab 16 mg/kg every 2 weeks.

Does it assist in prognosis in any way?

Do you have a certain immunoglobulin level which you would use to determine this?

If so, when do you think this might occur?

E.g. a patient with monoclonal protein with mild light chain ratio elevation. Do we need to get a BM biopsy in all such patients?

Other than in the setting of disease progression or significant treatment-related adverse event?

Infection is not part of the criteria for starting treatment both in UpToDate and in NCCN guidelines. 

Given the rarity of this diagnosis (5-7% of all AL amyloidosis cases), and the prognostic and clinical differences when compared to non IgM-AL am...

We know the longer we expose patients to lenalidomide, the harder collection will be. Would you collect now or switch to an alternative regimen to ach...

Does measuring serum free-light chains make a 24-hour UPEP unnecessary?

What agents would have sufficient efficacy overlap to treat both?

Would you avoid imid's given reported association with transplant rejection?

For pts w/ eGFR between 30-60

Are the early results of CASSIOPEIA (Abst 8003) from ASCO 2019 practice changing? What about the GRIFFIN results in 2020?

Do you modify the aspirin dose based off the lenalidomide dose? Do you ever use higher dose aspirin in lieu of an anticoagulant? The NCCN guidelines s...

CAR-T (any specific preference of product?) vs bispecific antibodies vs any other specific agents not previously utilized?

Is a repeatedly abnormal serum immunofixation all it takes for MGUS?

Would you continue with daratumumab maintenance per ANDROMEDA or switch regimen?

After 3-4 cycles of RVD, would you automatically take the patient to transplant if he has achieved at least a partial response, or is there any benefi...

If you do recommend resuming carfilzomib, what dose and frequency would you use?

Can you expand on this by sharing exactly what this routine workup should include? What additional tests outside of evaluating for POEMS and amyloidos...

Insurance won't pay for harvesting if the transplant is not done within a year.

Recommendations in guidelines are discordant (ASCO vs NCCN vs UptoDate).

If yes would you delay initiation of antineoplastic therapy to allow time for the vaccine to start acting?

When do you start treatment in this case?

How is this impacted by patient features, cytogenetics/disease biology, depth of response, or other factors? What would compel you to continue 3 drugs...

How do you factor in patient age, frailty, patients with underlying organ dysfunction, or other clinical features? Do you still consider CyBorD or R...

In your experience, do certain regimens have more cumulative toxicity, financial impact, or patient convenience factors?

Are there scenarios where you would use a higher dose of lenalidomide in a novel doublet or triplet (eg. relapse on lenalidomide maintenance)?

Excluding clinical trials

For example, in cold agglutinin disease or AIHA, antibodies can be detected via DAT, but are often not observed on assays for monoclonal gammopathies.

Is there any data justifying the use of systemic therapy over localized therapy (e.g. radiation or surgery) in this situation prior to a progression e...

For example, for joing replacement surgery? Do you hold the revlimid for certain about of time before and after?

Would your approach change based on the type of reaction (eg. Stevens-Johnson syndrome vs DRESS)? How would you address maintenance (if any) post-tra...

To me, the recent NEJM study is flawed in that the control arm did not have maintenance treatment while the experimental arm used maintenance Dar...

Would you proceed to autologous transplant, or switch to an alternate regimen (eg. daratumumab-based) first? Would the type or degree of organ involv...

If so, what is your approach to laboratory and clinical testing?

Once a tissue biopsy has confirmed light chain amyloid, what additional tests do you perform as part of a standard workup? In whom should treatment b...

Do these events mandate discontinuation of lenalidomide therapy or switching to a different agent? Can appropriate therapy for these skin cancers be r...

Given the PFS benefit seen in the most recent ECOG-ACRIN, and the prior study of Rd showing an OS benefit, is your practice to put any high-risk SMM p...

For example - Would you offer tandem transplantation in a young, fit patient in a CR after first transplant, but with MRD detectable?

Although the MMR vaccine is contraindicated in immunosuppressed patients on anticancer treatment according to CDC/ACIP and IDSA guidelines, data on sa...

Given the recent results presented from the Griffin trial, would you choose a daratumumab-based regimen (eg. D-VRd) over other salvage options (V...

Has the recent data presented at ASH affected your choice of regimen? Would your choice differ between transplant-eligible and transplant-ineligible ...

Would MRD assessments affect your clinical decision making for MM patients outside of a clinical trial?

Specifically, what regimen would you choose in a patient with new renal failure but not requiring dialysis?

Does the choice of initial induction regimen affect your decision for when to employ lenalidomide maintenance? Are there situations where you would c...

Would you change to an alternative triplet therapy, or switch to maintenance therapy? Are there variations in depth of response short of CR that woul...

Would you observe until progression or would you place the patient on maintenance?

Once you decide to begin treatment, any special precautions you would use for protein levels starting that high.

Subq has been shown to have lower risk of neuropathy. Is there any reason to use weekly IV still?

In a patient with multiple poor risk features including TP53 mutation, 1q amplification, stage III, and circulating plasma cells, would you consider a...

For example, how significant does the M protein have to increase for you to begin a conversation about new therapy?

Specifically, to you lean towards elotuzumab or a daratumumab-based regimen?

Would you ever give another IMiD?

At what point is the neuropathy a contraindication to further bortezomib therapy?