Questions discussed in this category
Specifically, in the setting of patients that have had a PR or VGPR and are not actively progressing.
When do you consider bispecific antibodies?
Can you elaborate on reasons for a non-quantifiable SPEP and how does one follow the paraprotein?
Would your considerations change for a man vs a woman?
Are there specific scenarios where it could be considered?
Can you explain when would you consider light chain amyloidosis work up with fat pad biopsy?
For example, a large iliac or sacral plasmacytoma causing symptoms. Both medical oncologists and radiation oncologists get nervous about RT-related cy...
For example: eyeball test, simplified frailty assessment (Facon et al.), IMWG frailty score, ECOG only?
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 you only offer it for patients with a documented IgG < 400? Do you check the IgG at all, or are you doing primary prophylaxis?
Let's assume they have cardiac involvement and transplant may not be feasible.
The FDA package insert suggests 2.5 mg daily in these settings, while the PrE1003 study demonstrated that a higher dose is feasible. Many oncologists ...
There are some retrospective data that CPCs are associated with worsened outcomes after transplantation. Anecdotally, CPCs could be collected as part ...
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.
Most would argue that gain(1q) in combination with another high-risk feature constitutes ultra-high-risk multiple myeloma, and most would argue (with ...
When would you consider a bone marrow biopsy?
The OS benefit with Zometa was seen only in patients with myeloma bone disease achieving less than or equal to a partial response. SRE risk reduction ...
For many clinical trials, a screening bone marrow biopsy is necessary to get a new baseline. Do you do the same in real-world practice?
Previous questions have focused on the newly diagnosed setting and choice of bisphosphonate versus denosumab. IMWG guidelines do recommend resuming zo...
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 - minimum number of months of therapy, driving distance to clinic, at least a CR with or without MRD negativity?
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...
Please assume that IVIG is fine (as it is for many Jehovah's Witness patients, since IgG is often not considered a blood product per se).
Specifically, do you offer closer follow-up for certain patients after local radiation?
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?
Would you do a 24-hour urine and echocardiogram in all of these patients? Cardiac biomarkers, PT/PTT, or any other such blood tests?
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?
This question seems quite specific but happens quite often. Multi-drug chemotherapy runs the risk of profound cytopenias and infections, while bispeci...
How frequently and what type of testing/sample are you performing MRD assessment?
Does your approach differ between transplant-eligible and transplan...
I.e. dosing regimen frequency, side effect profile, duration of follow up, etc.
Modified HyperCVAD? V(R)D-PACE? DCEP? Are there any data to favor one over the other?
Do you utilize rituximab or any other specific management strategies?
Would you prefer CAR-T or bi-specific or neither? If CAR-T, how do you approach lymphodepletion?
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
i.e., 60+% bone marrow plasmacytosis, light chain ratio >100, and/or >1 MRI lesion
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 your choice of agent differ, or are you more or less likely to offer maintenance than if the patient had multiple myeloma alone?
Does it assist in prognosis in any way?
In addition to reversing hypercalcemia, initiating myeloma therapy, etc.
Ide-cel? Cilta-cel? Teclistamab?
For example, would you use a tool like the Hydrashift assay? Would this change your management?
If tolerated through Cycle #1, how aggressively do you try to titrate the selinexor dose up toward 100mg weekly or 80mg twice-weekly?
And does your a...
Do you have a certain immunoglobulin level which you would use to determine this?
If so, when do you think this might occur?
How much weight do you give to a hgb/hct threshold versus symptoms?
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?
In this case, the patient had received daratumumab/lenalidomide/dexamethasone as part of a cooperative group trial. Would you say that the patient had...
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.
Would you consider Dara-CyBorD or a MM triplet/quadruplet such as VRd or Dara-VRd?
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...
What factors (i.e. timing from transplant, dose, prior therapy) impact your decision?
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...
Do the results change your clinical practice?
Does measuring serum free-light chains make a 24-hour UPEP unnecessary?
Does a progressing kappa/lambda ratio > 100 at any point in time warrant treatment, or does one wait to treat patients in the setting of a slowly i...
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
Frailty Index per Palumbo et al. PMID 25628469Is it practical to apply in clinics? Have you made decision changes based on it?
Venetoclax has demonstrated efficacy in patients harboring t(11;14) mutations but is not FDA approved for MM. Can you expand on what situations you ma...
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...
For example: shorten IMiD duration each cycle, add scheduled G-CSF, add antibacterial prophylaxis, etc.
How do you decide how long to continue?
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?
What about multiple anaplastic plasmacytoma without bone marrow involvement?
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.
Would you use MRD status to guide your decision making?
If so, venetoclax/dexamethasone by itself or do you include a PI?
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)?
When would you consider utilizing autologous SCT in those with a PR or SD?
Is there a potential role for BCMA-directed CAR-T or bispecific therapy in...
How do you distinguish this entity from other plasma cell disorders (eg. MGUS, MM, etc.)?
Review of literature suggests that most of these pa...
What regimens would you consider combining it with?
Any specific combinations to avoid or special considerations?
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.
Does your management change based on the type of end-organ involvement at the time of diagnosis?
Are there any reports of CNS involvement with non-se...
Is there concern for impaired healing? Do you pause therapy and for how long?
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...
Given the recent reclassification of gain(1q21) as a high risk cytogenetic abnormality, has this changed your practice in managing newly diagnosed pat...
Is there evidence for daratumumab-based doublet regimens?
Would your choice differ based on the patient's transplant eligibility?
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...
Do you worry about the ability to collect stem cells (at the time of progression to MM) if someone with SMM has been on prolonged lenalidomide?
What features are used to distinguish anaplastic multiple myeloma (AMM), and what other conditions should be considered in a differential diagnosis (e...
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 recommend surgical resection if feasible? Or just monitor every 3-6 months as NCCN guidelines suggest?
Would your management differ based o...
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...
Are there specific patient groups where you would choose one over the other?
Are the cost differences significant enough to dissuade you from choosin...
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?
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Papers discussed in this category
JAMA, 2013-04-03
Haematologica, 2016-12-01
Clin Pharmacokinet, 2012-12-01
Blood, 2016-12-22
The New England journal of medicine, 2015-08-13
The Lancet. Oncology, 2010-01
The New England journal of medicine, 2014-09-04
The New England journal of medicine, 2019-05-30
Lancet (London, England), 2017-02-04
The New England journal of medicine, 2018-02-08
Blood, 2018-01-18
N Engl J Med,
Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 1993-05
British journal of haematology, 2018-10
Blood Adv,
Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2017-10-10
The New England journal of medicine, 2017-04-06
Haematologica, 2011 Nov 04
Clin. Cancer Res., 2011 Feb 16
J. Clin. Oncol., 2013 Oct 21
Bone marrow transplantation, 2018-07
Blood, 2016 Mar 21
Lancet Oncol, 2020 Aug 28
N. Engl. J. Med.,
Leukemia, 2014-03
The Lancet. Oncology, 2014-03
The New England journal of medicine, 2012-05-10
Leukemia, 2019-01
BMC Cancer, 2006 May 05
International journal of radiation oncology, biology, physics, 2001-05-01
International journal of radiation oncology, biology, physics, 1998-07-15
Blood cancer journal, 2018-06-12
Leukemia, 2013-08
J. Clin. Oncol., 2019 Oct 25
Clinical lymphoma, myeloma & leukemia, 2016-09
Leuk. Lymphoma, 2011 Feb 08
Cancer,
Leukemia, 2009-10
Ann. Allergy Asthma Immunol., 2019 Aug 07
Clin Lymphoma Myeloma Leuk,
Blood, 2012-01-05
Lancet (London, England), 2019-01-19
The Lancet. Oncology, 2019-01
Lancet Haematol, 2020 Apr 30
Leukemia, 2017 Jul 04
Clin Lymphoma Myeloma Leuk, 2020 Mar 06
J Hematol Oncol, 2018 Jan 16
Blood, 2017-07-06
The Lancet. Oncology, 2019-06
Lancet, 2019 Jun 03
Blood,
Leuk Lymphoma, 2011 Dec 13
Haematologica, 2019 Oct 03
Ann Hematol, 2020 Apr 19
Lancet Oncol, 2019 Dec 16
N Engl J Med,
Lancet,
Blood, 2007-01-15
Blood,
Blood, 2017 Jan 27
Blood, 2013-10-24
The Lancet. Oncology, 2011-08
The Lancet. Oncology, 2018-03
Leukemia, 2018 Apr 25
Blood Cancer J, 2021 May 12
Leuk Lymphoma, 2019 Nov 18
Blood, 2013-10-03
Leukemia, 2019-09
J Clin Oncol, 2012 Jul 16
Lancet (London, England), 2016-04-09
The Lancet. Oncology, 2019-06
Lancet Oncol,
Strahlenther Onkol, 2017 Jun 01
Nature communications, 2019-04-23
Blood, 2012 Aug 13
J Clin Oncol, 2020 Apr 16
Blood,
Blood,
N Engl J Med,
The New England journal of medicine, 2018-11-08
Eur J Haematol, 2021 Aug 11
Lancet Oncol, 2020 Oct 29
Blood Adv, 2021 Sep 01
Cell,
Am J Hematol, 2021 Jul 05
The Lancet. Oncology, 2018-07
Blood Cancer J, 2020 Mar 09
JAMA Oncol,
JAMA, 2016-11-15
N Engl J Med,
J Clin Oncol, 2019 Apr 10
J Clin Oncol, 2020 Feb 21
J Clin Oncol, 2020 Oct 06
The Lancet. Oncology, 2021 Oct 13
The Lancet. Haematology, 2023 Sep 11
JCO Oncol Pract, 2020 Aug 21
Mayo Clin Proc,
Neurol Sci, 2021 Sep 16
Journal of clinical pathology, 2017-09
Leukemia, 2018-06
American journal of kidney diseases : the official journal of the National Kidney Foundation, 2017-05
Transplant Proc,
Clin Lymphoma Myeloma Leuk, 2020 Mar 07
Clin Lymphoma Myeloma Leuk, 2021 Jul 18
Blood Cancer J, 2021 Jan 11
JAMA Oncol,
Blood Cancer J, 2020 May 11
Lancet Oncol, 2019 Oct 23
Blood, 2011-09-15
Haematologica, 2011 Dec 01
Cancer Chemother Pharmacol, 2016 Jun 10
Clin Cancer Res, 2020 Aug 17
American journal of hematology, 2019-11
J Clin Oncol, 2011 Jan 31
J Natl Compr Canc Netw,
J Clin Oncol, 2021 Aug 13
Blood, 2015-03-26
Clin Lymphoma Myeloma Leuk, 2019 Oct 09
JCO Oncol Pract, 2019 Nov 25
Lancet Haematol,
Leukemia, 2020 Jul 21
Clin Lymphoma Myeloma Leuk, 2020 Jul 29
Lancet Oncol, 2014 Oct 26
Blood cancer journal, 2016-07-29
Leukemia, 2022 Apr 11
N Engl J Med, 2022 Jun 05
N Engl J Med,
American journal of hematology, 2019-05
Amyloid, 2017 Apr 23
Leukemia, 2015 Oct 07
British journal of haematology, 2017-10
Blood Adv,
Blood Cancer J, 2018 May 24
Amyloid, 2019 Jan 20
J Clin Oncol, 2022 Aug 12
Proc Natl Acad Sci U S A, 2019 Apr 15
N Engl J Med,
Blood Cancer J, 2022 Sep 14
Blood, 2018-01-11
Blood,
N Engl J Med,
Clin Cancer Res, 2022 May 02
Lancet, 2021 Jun 24
Blood, 2022 Jan 27
Br J Haematol, 2021 Aug 15
Blood, 2022 Dec 08
Transpl Infect Dis, 2015 Sep 26
Clin Lymphoma Myeloma Leuk, 2021 Feb 07
Lancet, 1994 Apr 30
N Engl J Med, 2022 Jun 05
J Clin Oncol, 2022 Jun 04
J Clin Oncol, 2022 Oct 21
Leukemia, 2019-03
Journal of the American Society of Nephrology : JASN, 2007-03
Lancet Haematol, 2019 Mar 11
Blood Cancer J, 2022 Sep 02
Cancer, 2021 Jun 28
Leukemia, 2022 Feb 21
Lancet Haematol, 2019 Jul 18
Lancet Haematol, 2019 Jul 18
Br J Haematol, 2021 Jun 10
N Engl J Med, 2023 Jun 05
N Engl J Med, 2023 Feb 10
Lancet Oncol, 2021 Dec 03
Lancet, 2021 Jun 04
Blood, 2022 Oct 20
Lancet Oncol, 2021 Nov 11
N Engl J Med, 2023 Jun 05
Br J Haematol, 2023 Jun 07
J Clin Oncol, 2022 May 23
Blood Cancer J, 2022 Jan 31
Experimental hematology & oncology, 2022 Feb 28
Blood advances, 2020 Dec 08
Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2021 Dec 13
Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2022 Apr 04
The Lancet. Haematology, 2023 Sep 27
Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2023 Sep 27
American journal of hematology, 2022 Jul 05
Blood advances, 2023 Oct 24
Blood, 2018 Aug 14
Leukemia, 2024 Apr 09
Haematologica, 2013-01
The Lancet. Haematology, 2015 May 06
European respiratory review : an official journal of the European Respiratory Society, 2017 Sep 06
Mayo Clinic proceedings, 2017-06
Blood advances, 2017 Dec 21
British journal of clinical pharmacology, 2010 May
Blood, 2023 Nov 30
Cancer, 2011-10-01
International journal of radiation oncology, biology, physics, 2006-01-01
Blood, 2014 May 29
Blood, 2014 Jun 17
International journal of radiation oncology, biology, physics, 2011 Jan 27
Leukemia & lymphoma, 2021 Feb 03
Dominion law reports, 1990 Mar 30
Transplantation and cellular therapy, 2022 Dec 06
American journal of hematology, 2019-04
Blood advances, 2023 Mar 28
American journal of hematology, 2023 Jul 08
Blood cancer journal, 2024 Apr 15
Blood cancer journal, 2019 Nov 25
British journal of haematology, 2019 Dec 09
The New England journal of medicine, 2023 Dec 12
Blood cancer journal, 2024 Apr 22
Biology of blood and marrow transplantation : journal of the American Society for Blood and Marrow Transplantation, 2015-05
Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2012-03-20
Blood, 2010-12-09
Clinical chemistry, 2005-05
Clinical chemistry and laboratory medicine, 2016 Jun 01
ESC heart failure, 2021 May 07
Lancet (London, England), 2019 Dec 10
The New England journal of medicine, 2024 Jun 03
Nature medicine, 2024 Jun 03
Blood, 2023 Jan 19
The New England journal of medicine, 2024 Jun 01
The New England journal of medicine, 2024 Jun 02
Clinical pharmacokinetics, 2017 Feb
Cancer chemotherapy and pharmacology, 2016 Dec 30
Blood cancer journal, 2018-11-19
Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2022 Jun 06
Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2022 Oct 31
Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2022 Jun 06
Transplant Cell Ther, 2023 Mar 17
Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2023 Oct 24
Blood advances, 2023 Aug 22
Kidney international, 2018-07
BMC nephrology, 2019-02-14
Leukemia & lymphoma, 2024 Apr 16
International journal of radiation oncology, biology, physics, 2024 Oct 27
The Lancet. Oncology, 2022 Feb 10
Blood cancer journal, 2023 May 09
Platelets, 2023 Oct 11
Blood, 2011 Aug 11
Blood, 2024 Aug 08
Nature medicine, 2023 Aug 15
The New England journal of medicine, 2024 Dec 09
Blood cancer journal, 2020 Oct 16
Blood advances, 2023 Nov 14