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There are several types of plasma cell neoplasms. These diseases are all associated with a monoclonal (or myeloma) protein (M protein). They include monoclonal gammopathy of undetermined significance (MGUS), isolated plasmacytoma of the bone, extramedullary plasmacytoma, and multiple myeloma.
(Refer to the Lymphoplasmacytic Lymphoma (Waldenström Macroglobulinemia) section in the PDQ summary on Adult Non-Hodgkin Lymphoma Treatment for more information.)
Incidence and Mortality
Estimated new cases and deaths from multiple myeloma in the United States in 2015:
Clinical Presentation and Evaluation
Evaluation of patients with monoclonal (or myeloma) protein (M protein)
Idiotypic myeloma cells can be found in the blood of myeloma patients in all stages of the disease.[4,5] For this reason, when treatment is indicated, systemic treatment must be considered for all patients with symptomatic plasma cell neoplasms. Patients with MGUS or asymptomatic, smoldering myeloma do not require immediate treatment but must be followed carefully for signs of disease progression.
The major challenge is to separate the stable, asymptomatic group of patients who do not require treatment from patients with progressive, symptomatic myeloma who should be treated immediately.[6,7]
Patients with a monoclonal (or myeloma) protein (M protein) in the serum and/or urine are evaluated by some of the following criteria:
In most myeloma patients, the glomeruli function normally allows only the small molecular weight proteins, such as light chains, to filter into the urine. The concentration of protein in the tubules increases as water is reabsorbed. This leads to precipitation of proteins and the formation of tubular casts, which may injure the tubular cells. With tubular lesions, the typical electrophoresis pattern shows a small albumin peak and a larger light-chain peak in the globulin region; this tubular pattern is the usual pattern found in myeloma patients.
These initial studies should be compared with subsequent values at a later time, when it is necessary to decide whether the disease is stable or progressive, responding to treatment, or getting worse.
As mentioned before, the major challenge is to separate the stable, asymptomatic group of patients who do not require treatment from patients with progressive, symptomatic myeloma who should be treated immediately.[6,7,19]
Monoclonal Gammopathy of Undetermined Significance (MGUS)
Patients with MGUS have an M protein in the serum without findings of multiple myeloma, macroglobulinemia, amyloidosis, or lymphoma and have fewer than 10% of plasma cells in the bone marrow.[2,20,21,22] Patients with smoldering myeloma have similar characteristics but may have more than 10% of plasma cells in the bone marrow.
These types of patients are asymptomatic and should not be treated. Patients with MGUS and risk factors for disease progression, however, must be followed carefully because they are more likely to develop myeloma (most commonly), amyloidosis, lymphoplasmacytic lymphoma, or chronic lymphocytic leukemia and may then require therapy.[22,23,24]
Virtually all cases of multiple myeloma are preceded by a gradually rising level of MGUS.[25,26,27] The annual risk of progression of MGUS to a lymphoid or plasma cell malignancy ranges from 0.5% to 1.0% in population-based cohorts.[28,29] This risk ranges from 2 % to more than 20% in higher-risk patients.
Risk factors that predict disease progression include the following:
A Swedish cohort study confirmed the higher-risk factors of abnormal serum-FLC ratio and the high serum–monoclonal protein level. They described the additional risk factor of immunoparesis, which is defined as the reciprocal depression of the other Ig classes (if a patient has an IgG kappa M-protein, the IgM and IgA would be below normal levels with "immunoparesis"). Incorporation of gene-expression profiles to better assess risk is also under clinical evaluation.
Monoclonal gammopathies that cause organ damage, particularly to the kidney, heart, or peripheral nerves require immediate therapy with the same strategies applied for the conventional plasma-cell dyscrasias. A monoclonal gammopathy causing renal dysfunction—by direct antibody deposition or amyloidosis—is referred to as monoclonal gammopathy of renal significance. Rising serum creatinine, dropping glomerular filtration rates, and increasing urinary–albumin excretion are all parameters that may signify renal damage and are assessed prospectively for high-risk MGUS patients. Although the N-terminal pro-brain natriuretic peptide is a very sensitive marker for amyloid involvement in the heart, the low specificity must be noted. These extra tests are included with the M-protein level, FLC levels, and FLC ratio when following patients with MGUS.
Isolated Plasmacytoma of Bone
The patient has an isolated plasmacytoma of the bone if the following are found:
When clinically indicated, MRI may reveal unsuspected bony lesions that were undetected on standard radiographs. MRI scans of the total spine may identify other bony lesions.
A patient has extramedullary plasmacytoma if the following are found:
Multiple myeloma is a systemic malignancy of plasma cells that typically involves multiple sites within the bone marrow and secretes all or part of a monoclonal antibody.
Multiple myeloma is highly treatable but rarely curable. The median survival in the prechemotherapy era was about 7 months. After the introduction of chemotherapy, prognosis improved significantly with a median survival of 24 to 30 months and a 10-year survival rate of 3%. Even further improvements in prognosis have occurred because of the introduction of newer therapies such as pulse corticosteroids, thalidomide, lenalidomide, bortezomib, and autologous and allogeneic stem cell transplantation, with median survivals now exceeding 45 to 60 months.[39,40,41,42] Patients with plasma cell leukemia or with soft tissue plasmacytomas (often with plasmablastic morphology) in association with multiple myeloma have poor outcomes.[18,43]
Multiple myeloma is potentially curable when it presents as a solitary plasmacytoma of bone or as an extramedullary plasmacytoma. (Refer to the Isolated Plasmacytoma of Bone and Extramedullary Plasmacytoma sections of this summary for more information.)
Amyloidosis Associated With Plasma Cell Neoplasms
Multiple myeloma and other plasma cell neoplasms may cause a condition called amyloidosis. Primary amyloidosis can result in severe organ dysfunction especially in the kidney, heart, or peripheral nerves. Clinical symptoms and signs include the following:
Elevated serum levels of cardiac troponins, amino-terminal fragment brain-type natriuretic peptide, and serum-FLCs are poor prognostic factors.[44,45] A proposed staging system for primary systemic amyloidosis based on these serum levels requires independent and prospective confirmation.
No generally accepted staging system exists for monoclonal gammopathy of undetermined significance (MGUS), isolated plasmacytoma of bone, or extramedullary plasmacytoma. Of the plasma cell neoplasms, a staging system exists only for multiple myeloma.
Multiple myeloma is staged by estimating the myeloma tumor cell mass on the basis of the amount of monoclonal (or myeloma) protein (M protein) in the serum and/or urine, along with various clinical parameters, such as hemoglobin and serum calcium concentrations, the number of lytic bone lesions, and the presence or absence of renal failure. Impaired renal function worsens prognosis regardless of stage.
The stage of the disease at presentation is a strong determinant of survival, but it has little influence on the choice of therapy since almost all patients, except for rare patients with solitary bone tumors or extramedullary plasmacytomas, have generalized disease.
International staging system
The International Myeloma Working Group studied 11,171 patients, of whom 2,901 received high-dose therapy and 8,270 received only standard-dose therapy.
An International Staging System was derived and is shown below in Table 2.
Genetic factors and risk groups
Genetic aberrations detected by interphase fluorescence in situ hybridization (FISH) may define prognostic groups in retrospective and prospective analyses.[2,3] Short survival and shorter duration of response to therapy have been reported with t(4;14)(p16;q32), t(14; 16)(q32;q23), cytogenetic deletion of 13q-14, and deletion of 17p13 (p53 locus).[2,3,4,5,6] The question of whether the choice of therapy based on FISH analysis can influence outcome must await further study in prospective trials.
Newer clinical investigations are stratifying patients with multiple myeloma into so-called good-risk, intermediate-risk, and high-risk groups.[2,3,4,5,6,7,8] (See Table 3 below.) This stratification, based on cytogenetic findings, has been derived from retrospective analyses and requires prospective validation. Bone marrow samples are sent for cytogenetic and FISH analysis. Plasma cell leukemia has a particularly poor prognosis. The otherwise favorable prognosis of hyperploidy is trumped by coexistent adverse cytogenetics.
The major challenge in treating plasma cell neoplasms is to separate the stable, asymptomatic group of patients who do not require immediate treatment from patients with progressive, symptomatic myeloma who should be treated immediately.[1,2,3] Monoclonal gammopathy of undetermined significance or smoldering myeloma must be distinguished from progressive myeloma.
Asymptomatic Plasma Cell Neoplasms
Asymptomatic patients with multiple myeloma who have no lytic bone lesions and normal renal function may be initially observed safely outside the context of a clinical trial.[1,4,5] Increasing anemia is the most reliable indicator of progression. The following criteria represent the new definition for smoldering myeloma:
Symptomatic Plasma Cell Neoplasms
Treatment should be given to patients with symptomatic advanced disease .
Treatment should be directed at reducing the tumor cell burden and reversing any complications of disease, such as renal failure, infection, hyperviscosity, or hypercalcemia, with appropriate medical management. The International Myeloma Working Group (IMWG) has published new criteria for identifying patients with active myeloma who require therapy. These criteria include the following:
Response criteria have been developed for patients on clinical trials by the IMWG. A very good partial response (VGPR) is defined as a reduction of 90% or more in the serum monoclonal protein and a 24-hour urine monoclonal protein of less than 100 mg. Although not incorporated in the IMWG criteria, many trials report "near complete response (nCR)" when patients have less than 5% bone marrow plasma cells and unmeasurable serum monoclonal proteins but still have positive serum and/or urine immunofixation. Note that these nCR patients are incorporated into the VGPR group by the IMWG. Patients who achieve a CR by IMWG criteria (with a negative immunofixation along with the clear marrow and unmeasurable serum monoclonal proteins) are often said to have attained a "stringent CR" if they also normalize their free kappa/lambda light–chain levels and ratio. The clinical utility of these various categories must be validated in clinical trials. Whether these response definitions will translate into clinically meaningful endpoints, such as overall survival, remains to be seen.
Current therapy for patients with symptomatic myeloma can be divided into the following categories:
Treatment Options for Amyloidosis Associated With Plasma Cell Neoplasms
Treatment options for amyloidosis associated with plasma cell neoplasms include the following:
As is true for all plasma cell dyscrasias, responses have been reported for all the same regimens active in multiple myeloma.[1,2,3,4,5,6,7,8,9]
Two randomized trials showed prolonged overall survival (OS) with the use of oral chemotherapy with melphalan with or without colchicine versus colchicine alone.[10,11][Level of evidence: 1iiA]
Stem cell rescue
A randomized, prospective study of 100 patients with immunoglobulin light-chain amyloidosis compared melphalan plus high-dose dexamethasone with high-dose melphalan plus autologous stem cell rescue. After a median follow-up of 3 years, median OS favored the nontransplant arm (56.9 months vs. 22.2 months; P = .04).[Level of evidence: 1iiA] The 24% transplant-related mortality in this series and others reflects the difficulties involved with high-dose chemotherapy in older patients with organ dysfunction.[12,13,14,15,16,17] A randomized trial confirming the benefit of autologous transplantation is not anticipated.
An anecdotal series describes full-intensity and reduced-intensity allogeneic stem cell transplantation.
Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with primary systemic amyloidosis. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
Treatment Options for Monoclonal Gammopathy of Undetermined Significance (MGUS)
Treatment options for MGUS include the following:
Multiple myeloma, other plasma cell dyscrasia, or lymphoma will develop in 12% of patients by 10 years, 25% by 20 years, and 30% by 25 years.
All patients with MGUS should be kept under observation to detect increases in M protein levels and development of a plasma cell dyscrasia. Higher levels of initial M protein levels may correlate with increased risk of progression to multiple myeloma.[1,2] In a large retrospective report, the risk of progression at 20 years was 14% for an initial monoclonal protein level of 0.5 g/dL or less, 25% for a level of 1.5 g/dL, 41% for a level of 2.0 g/dL, 49% for a level of 2.5 g/dL, and 64% for a level of 3.0 g/dL.
Treatment is delayed until the disease progresses to the stage that symptoms or signs appear.
Patients with MGUS or smoldering myeloma do not respond more frequently, achieve longer remissions, or have improved survival if chemotherapy is started early while they are still asymptomatic as opposed to waiting for progression before treatment is initiated.[3,4,5,6] Newer therapies have not been proven to prevent or delay the progression of MGUS to a plasma cell dyscrasia.
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with monoclonal gammopathy of undetermined significance. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
Refer to the Lymphoplasmacytic Lymphoma (Waldenström Macroglobulinemia) section in the PDQ summary on Adult Non-Hodgkin Lymphoma Treatment for more information.
Treatment Options for Isolated Plasmacytoma of Bone
Treatment options for isolated plasmacytoma of bone include the following:
About 25% of patients have a serum and/or urine M protein; this should disappear following adequate radiation therapy to the lytic lesion.
The survival rate of patients with isolated plasmacytoma of bone treated with radiation therapy to the lesion is greater than 50% at 10 years, which is much better than the survival rate of patients with disseminated multiple myeloma.
Most patients will eventually develop disseminated disease and require chemotherapy; almost 50% of them will do so within 2 years of diagnosis.[2,3] However, patients with serum paraprotein or Bence Jones protein, who have complete disappearance of these proteins after radiation therapy, may be expected to remain free of disease for prolonged periods.[2,4] Patients who progress to multiple myeloma tend to have good responses to chemotherapy with a median survival of 63 months after progression.[2,4]
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with isolated plasmacytoma of bone. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
Treatment Options for Extramedullary Plasmacytoma
Treatment options for extramedullary plasmacytoma include the following:
Patients with isolated plasma cell tumors of soft tissues, most commonly occurring in the tonsils, nasopharynx, or paranasal sinuses, should have skeletal x-rays and bone marrow biopsy (both of which should be negative) and evaluation for M protein in serum and urine.[1,2,3,4]
About 25% of patients have serum and/or urine M protein; this should disappear following adequate radiation.
Extramedullary plasmacytoma is a highly curable disease with progression-free survival ranging from 70% to 87% at 10 to 14 years after treatment with radiation therapy (with or without previous resection).[1,2,5]
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with extramedullary plasmacytoma. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
The initial approach to the patient is to evaluate the following parameters:
Treatment selection is influenced by the age and general health of the patient, prior therapy, and the presence of complications of the disease.
Despite the introduction of many new therapeutic agents over the past two decades, there is still no confirmed curative approach. Major controversies have resulted regarding the framework for both future trials and current therapeutic recommendations. Unresolved questions in multiple myeloma include the following:
Several questions are raised when therapy is chosen for a patient with symptomatic myeloma at first presentation:
In summary, clinicians utilize a clinical trial or one of the following strategies for a newly diagnosed patient with multiple myeloma:
There are regional geographic variations to the approaches listed. Clinical trials and future discoveries should help to explicate the best therapeutic strategy.
Induction therapy agents
Multiple therapeutic agents are available for induction therapy, either alone or in combinations. These include the following:
Clinical trials are needed to establish the regimens with the best efficacy and least long-term toxicity. (Refer to the Combination therapy section of this summary for a list of current clinical trials.)
Guidelines for choosing induction therapy
Until results become available, outside the context of a clinical trial, clinicians may choose induction therapy based on the following guidelines:
These guidelines require validation by ongoing clinical trials; participation in clinical trials is the preferred choice, when possible.
Since the mid-1980s, dexamethasone has been administered at a dose of 40 mg orally for 4 consecutive days, which is the same schedule used with the vincristine plus doxorubicin plus dexamethasone (VAD) regimen. Response rates of 60% to 70% in previously untreated patients appeared to be as high as those in patients treated with VAD.[18,19][Level of evidence: 3iiiDiv]
A prospective trial randomly assigned 488 patients older than 65 years to receive dexamethasone alone, melphalan plus dexamethasone, dexamethasone plus interferon-alpha, and melphalan plus prednisone (MP).
There has never been a randomized trial comparing single-agent oral dexamethasone at a traditional high dose (40 mg a day for 4 days, repeated after 4 days off) with a lower dose (≤40 mg weekly). This issue of dexamethasone dose has been evaluated in two of the following prospective, randomized trials:
On the basis of these trials, almost all ongoing clinical trials in the United States and Europe have implemented the low-dose dexamethasone schedule with or without other therapeutic agents: 40 mg dexamethasone (oral [PO] or intravenous [IV]) weekly in younger patients or fit older patients or 20 mg dexamethasone (PO or IV) in less-fit older patients.
IMiDs (immunomodulatory drugs)
Lenalidomide has substantially greater myelosuppression but less neuropathy than seen with thalidomide; however, both have the same tendency for DVT.[11,22,23,25] A randomized, prospective trial of 342 previously untreated patients receiving lenalidomide-containing regimens compared aspirin (100 mg/day) with enoxaparin (40 mg/day); the 2% incidence of venous thromboembolic events was similar for both interventions. Empirically, the greater the number of risk factors for DVT, the more intense the recommendation for prophylactic anticoagulation. (Refer to the Thalidomide section of this summary for more information about risk factors.)
A retrospective review of almost 4,000 relapsed or refractory patients who received lenalidomide in 11 clinical trials suggested an increased incidence of nonmelanoma skin cancers. As a result of predominant renal clearance, lenalidomide doses need to be reduced in the setting of impaired renal function (creatinine clearance, 30–50: 10 mg per day; creatinine clearance, <30: 15 mg every other day; dialysis, 15 mg on day after dialysis). Uncontrolled trials, including NCT00151203, have added clarithromycin (500 mg twice a day) to lenalidomide and dexamethasone with a claim of increased response rates; controlled studies are required to establish the value of this approach.
Pomalidomide was approved for patients who relapse after two previous regimens, which must have included bortezomib and lenalidomide. Although some myelosuppression and increased risk of thromboembolic events are noted as with lenalidomide and thalidomide, very little peripheral neuropathy is noted in comparison with the other agents.
Eleven randomized prospective studies involving more than 4,600 patients have examined the introduction of thalidomide as induction therapy for previously untreated symptomatic patients with multiple myeloma.[35,36,37,38,39,40,41,42,43,44]
As previously described in the section on corticosteroids, high-dose dexamethasone can complicate interpretation of clinical trials by worsening cardiopulmonary toxicity and deaths, especially in the context of thalidomide or lenalidomide, both of which are thrombogenic agents.
Factors that have been implicated to worsen the risk of DVT include the use of high-dose dexamethasone, concomitant erythropoietic growth factors, and concomitant doxorubicin, liposomal doxorubicin, or alkylating agents.[46,47]
Personal cardiovascular risk factors can also influence the rate of DVT. Various clinical trials have included different DVT prophylaxis measures, including aspirin (81 mg–100 mg a day), warfarin, or low molecular-weight heparin.[39,47,48] In a randomized, prospective trial, 667 previously untreated patients who received thalidomide-containing regimens were randomly assigned to aspirin (100 mg/day), warfarin (1.25 mg/day) or enoxaparin (40 mg/day). The rate of serious thromboembolic events, acute cardiovascular events, or sudden death was 6.5% and similar for all three interventions.
Prospective electrophysiologic monitoring provides no clear benefit over clinical evaluation for the development of clinically significant neuropathy while on thalidomide.
Late in the disease course, when all other options have failed, thalidomide can be employed, sometimes with durable responses. By utilizing a low dose (50 mg PO daily), significant sedation, constipation, and neuropathy may be avoided. Prophylaxis to avoid thrombosis with aspirin, warfarin, or low molecular–weight heparin is required; the choice of therapy depends on pre-existing risk factors.
Because bortezomib is metabolized and cleared by the liver, it appears active and well tolerated in patients with renal impairment.[15,59] In several retrospective, nonrandomized comparisons, bortezomib administered once weekly had significantly less grade 3 to 4 peripheral neuropathy (2%–8% vs. 13%–28%) with no loss of efficacy compared with standard biweekly administration.[60,61]
In a randomized, prospective trial, subcutaneous injections of bortezomib were compared with intravenous infusions in the usual schedule (days 1, 4, 8, 11). After a median follow-up of 1 year, grade 3 to 4 neurologic toxicity was reduced from 16% to 6% (P = .026) using the subcutaneous route, with no perceived loss of efficacy in terms of response. However, this study was not powered for noninferiority of response. New clinical trials are employing these changes of weekly treatment and subcutaneous route to improve the safety profile of bortezomib-containing regimens. In this trial, the bisphosphonates were continued until the time of relapse.
More than 6 months after completion of bortezomib induction therapy, bortezomib can be applied again with a 40% overall response rate, according to one anecdotal phase II trial.[Level of evidence: 3iiiDiv]
Evidence (conventional-dose chemotherapy):
The VAD regimen has shown activity in previously treated and in untreated patients with response rates ranging from 60% to 80%.[68,69,70,71][Level of evidence: 3iiiDiv]
Evidence is not strong that any alkylating agent is superior to any other. All standard doses and schedules produce equivalent results. The two most common regimens historically have been oral MP and oral cyclophosphamide plus prednisone.[74,75,76]
Combinations, such as those used in EST-2479, of alkylating agents and prednisone, administered simultaneously or alternately, have not proven to be superior to therapy with MP.[77,78,79,80][Level of evidence: 1iiA]
A meta-analysis of studies comparing MP with drug combinations concluded that both forms of treatment were equally effective.[Level of evidence: 1iiA] Patients who relapsed after initial therapy with cyclophosphamide and prednisone had no difference in OS (median OS, 17 months) when randomly assigned to receive vincristine plus carmustine plus melphalan plus cyclophosphamide plus prednisone or VAD.[Level of evidence: 1iiA]
Evidence (combination therapy):
Several national and international trials have been implemented to define the optimal combination regimens. Participation in these trials should be the preferred approach, when feasible. The combination regimens in these trials represent the most successful from numerous phase II reports during the last several years.
Options for combination regimens:
High-dose chemotherapy: Autologous bone marrow or peripheral stem cell transplantation
Evidence (high-dose chemotherapy: autologous bone marrow or peripheral stem cell transplantation):
The failure of conventional therapy to cure the disease has led investigators to test the effectiveness of much higher doses of drugs such as melphalan. The development of techniques for harvesting hemopoietic stem cells, from marrow aspirates or the peripheral blood of the patient, and infusing these cells to promote hemopoietic recovery made it possible for investigators to test very large doses of chemotherapy.
Based on the experience of treating thousands of patients in this way, it is possible to draw a few conclusions, including the following:
Single autologous bone marrow or peripheral stem cell transplantation
Evidence (single autologous bone marrow or peripheral stem cell transplantation):
While some prospective randomized trials showed improved survival for patients who received autologous peripheral stem cell or bone marrow transplantation after induction chemotherapy versus chemotherapy alone,[5,96,97,98][Level of evidence: 1iiA] other trials have not shown any survival advantage.[99,100,101,102][Level of evidence: 1iiA]
Two meta-analyses of almost 3,000 patients showed no survival advantage.[103,104][Level of evidence: 1iiA]
Even the trials suggesting improved survival showed no signs of a slowing in the relapse rate or a plateau to suggest that any of these patients had been cured.[5,96,97,98,105] The role of ASCT has also been questioned with the advent of novel induction therapies with high complete-remission rates.[106,107]
Tandem autologous bone marrow or peripheral stem cell transplantation
Another approach to high-dose therapy has been the use of two sequential episodes of high-dose therapy with stem cell support (tandem transplants).[108,109,110,111,112]
Evidence (tandem autologous bone marrow or peripheral stem cell transplantation):
A Cochrane review of 14 controlled studies found none of the trials helpful for contemporary treatment decisions regarding single versus tandem transplants. None of the trials employed bortezomib or lenalidomide, and the sharp decrease in compliance with a second transplant complicated sample-size calculations for sufficient statistical power.
High-dose chemotherapy: Allogeneic bone marrow or peripheral stem cell transplantation
Evidence (high-dose chemotherapy: allogeneic bone marrow or peripheral stem cell transplantation):
Many patients are not young enough or healthy enough to undergo these intensive approaches. A definite graft-versus-myeloma effect has been demonstrated, including regression of myeloma relapses following the infusion of donor lymphocytes.
Favorable prognostic features included the following:
Myeloablative allogeneic stem cell transplantation has significant toxic effects (15%–40% mortality), but the possibility of a potent and possibly curative graft-versus-myeloma effect in a minority of patients may offset the high transplant-related mortality.[123,124,125] In one anecdotal series of 60 patients who underwent ASCT, six of the patients relapsed between 6 and 12 years, suggesting that late relapses still occur with this type of consolidation.
The lower transplant-related mortality from nonmyeloablative approaches has been accompanied by a greater risk of relapse. Since the introduction of lenalidomide and bortezomib, a trial exploring donor versus no donor comparison of ASCT) versus autologous SCT and nonmyeloablative allogeneic SCT in 260 untreated patients showed no difference in PFS or OS.[Level of evidence: 3iiiA] This result contrasted with two older trials (before introduction of lenalidomide and bortezomib), which suggested improvement of PFS and OS with a sibling donor.[116,128][Level of evidence: 3iiiA] Given the lack of evidence so far that the high-risk patients benefit from allogeneic stem cell transplantation in this era of novel new agents, it remains debatable whether ASCT should be offered in the first-line setting outside the context of a clinical trial.[125,129]
Six clinical trials compared the outcomes of patients receiving tandem autologous transplant to those of patients receiving a reduced-intensity allogeneic SCT after autologous transplant. Patients were assigned to the latter treatments based on the availability of an HLA-matched donor. Two meta-analyses of these data showed that although the complete remission rate was higher in patients undergoing reduced-intensity allogeneic SCT, OS was comparable because of an increased incidence of nonrelapse mortality with allogeneic transplant.[120,121][Level of evidence: 1iiA]
Myeloma patients who respond to treatment show a progressive fall in the M protein until a plateau is reached; subsequent treatment with conventional doses does not result in any further improvement. This has led investigators to question how long treatment should be continued. No clinical trial has directly compared a consolidation approach with a maintenance approach to assess which is better in prolonging remission and, ultimately, survival. Most clinical trials employ one or both. Maintenance trials with glucocorticosteroids [21,131] and with interferon  showed very minor improvements in remission duration and survival but with toxicities that outweighed the benefits. The efficacy and tolerability of thalidomide, lenalidomide, and bortezomib in the induction and relapse settings has made these agents attractive options in maintenance trials.
Thalidomide maintenance therapy
After ASCT, six randomized, prospective trials showed benefit in PFS for maintenance thalidomide (30–36 months vs. 20–26 months), but only three showed benefit in OS (11–19 months in median OS).[36,43,133,134,135,136] No survival benefit could be consistently seen for thalidomide maintenance after induction chemotherapy alone; interpretation of some trials was confounded by thalidomide use during induction.[37,135,137,138,139,140,141] Several trials suggested particularly poor outcomes using thalidomide for patients with poor-risk cytogenetics.[43,135] The lowest active dose for thalidomide is 50 mg daily with a duration of at least 1 year.
Lenalidomide maintenance therapy
After ASCT, three randomized, prospective trials showed benefit in median EFS or PFS (40–43 months vs. 21–27 months),[3,4,5] one with OS benefit (at a median follow-up of 34 months, 85% vs. 77%; P = .03).[Level of evidence: 1iiA] For elderly patients not eligible for transplantation, a randomized, prospective trial of lenalidomide maintenance after induction with melphalan and prednisone or melphalan, prednisone, and lenalidomide showed a 66% reduction in the rate of progression (HR, 0.34; P < .001), which translated to an EFS of 31 months versus 14 months in favor of maintenance lenalidomide.[Level of evidence: 1iiDi] All three trials showed an increase in myelodysplasia or acute leukemia from 3% to 7%, consistent with other studies of lenalidomide. Doses of 5 mg to 15 mg a day have been utilized either continuously or with 1 week off every month.
Bortezomib maintenance therapy
For 178 elderly, untreated patients with an induction combination regimen including bortezomib, maintenance using bortezomib plus thalidomide versus bortezomib plus prednisone was not significantly different in PFS or OS, but both resulted in median PFS of 32 to 39 months and a 5-year OS over 50%.[Level of evidence: 1iiDiv]
In 511 previously untreated patients not eligible for transplant and aged 65 years or older, a randomized comparison of bortezomib plus melphalan plus prednisone plus thalidomide plus subsequent maintenance using bortezomib plus thalidomide versus bortezomib plus melphalan plus prednisone (with no maintenance) showed superiority of the arm with thalidomide and bortezomib during induction and maintenance.
With a median follow-up of 47 months, 3-year PFS was 55% versus 33% (P < .01) and 5-year OS was 59% versus 46% (P = .04).[Level of evidence: 1iiA] Because of trial design, it is unclear whether the improved results were caused by the addition of thalidomide during the induction or by the use of maintenance therapy with bortezomib and thalidomide.
Management of lytic bone lesions with bisphosphonates
Evidence (bisphosphonate therapy):
Radiation therapy for bone lesions
Lytic lesions of the spine should be radiated if any of the following are true:
Back pain caused by osteoporosis and small compression fractures of the vertebrae responds best to chemotherapy. (Refer to the PDQ summary on Pain for more information on back pain.)
Extensive radiation of the spine or long bones for diffuse osteoporosis may lead to prolonged suppression of hemopoiesis and is rarely indicated.
Bisphosphonates are useful for slowing or reversing the osteopenia that is common in myeloma patients.
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with multiple myeloma. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
There are two main types of refractory myeloma patients:
A subgroup of patients who do not achieve a response to induction chemotherapy have stable disease and enjoy a survival prognosis that is as good as that for responding patients.[1,2] When the stable nature of the disease becomes established, these types of patients can discontinue therapy until the myeloma begins to progress again. Others with primary refractory myeloma and progressive disease require a change in therapy. (Refer to the Treatment for Multiple Myeloma section of this summary for more information.)
The myeloma growth rate, as measured by the monoclonal (or myeloma) protein-doubling time, for patients who respond to their initial therapy increases progressively with each subsequent relapse, and remission durations become shorter and shorter. Marrow function becomes increasingly compromised as patients develop pancytopenia and enter a refractory phase; occasionally, the myeloma cells dedifferentiate and extramedullary plasmacytomas develop. The myeloma cells may still be sensitive to chemotherapy, but the regrowth rate during relapse is so rapid that progressive improvement is not observed.
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with refractory multiple myeloma. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.
General Information About Plasma Cell Neoplasms
Updated statistics with estimated new cases and deaths for 2015 (cited American Cancer Society as reference 1).
Added text to the list of patient evaluation criteria to state that bone marrow is also usually sent for cytogenetics and fluorescence in situ hybridization testing for genetics markers of high-risk disease; the free light chain (FLC) ratio of over 100 can predict a greater than 70% progression within 2 years in patients with smoldering myeloma (cited Larsen et al. as reference 10); if clinically warranted, taking needle aspirates of a solitary lytic bone lesion, extramedullary tumor(s), or enlarged lymph node(s) to determine whether these are plasmacytomas; and obtain a spinal magnetic resonance imaging scan (or spinal computed tomography [CT] or positron emission tomography-CT scan depending on availability) if the skeletal survey is negative (cited Horger et al. as reference 11, Walker et al. as reference 12, and Kyle et al. as reference 13); also revised text to state that the presence of circulating myeloma cells is considered a poor prognostic factor.
Cited 2014 Rajkumar et al. as reference 19.
Added text to state that patients with monoclonal gammopathy of undetermined significance (MGUS) and risk factors for disease progression must be followed carefully because they are more likely to develop myeloma, amyloidosis, lymphoplasmacytic lymphoma, or chronic lymphocytic leukemia and may then require therapy.
Added text to state that the annual risk of progression of MGUS to a lymphoid or plasma cell malignancy ranges from 0.5% to 1.0% in population-based cohorts (cited 2005 Turesson et al. as reference 29). Also added that this risk ranges from 2% to more than 20% in higher-risk patients.
Added text to state that a Swedish cohort study confirmed the higher-risk factors of abnormal serum-FLC ratio and the high serum–monoclonal protein level; they described the additional risk factor of immunoparesis. Added that the incorporation of gene-expression profiles to better assess risk is also under clinical evaluation (cited Dhodapkar et al. as reference 30).
Added text to state that monoclonal gammopathies that cause organ damage require immediate therapy with the same strategies applied for the conventional plasma cell dyscrasias. Also added that monoclonal gammopathy causing renal dysfunction is referred to as monoclonal gammopathy of renal significance. Added that although the N-terminal pro-brain natriuretic peptide is a very sensitive marker for amyloid involvement in the heart, the low specificity must be noted; these extra tests are included with the M-protein level, FLC levels, and FLC ratio when following patients with MGUS (cited Merlini as reference 31).
Stage Information About Plasma Cell Neoplasms
Added text to state that the otherwise favorable prognosis of hyperploidy is trumped by coexistent adverse cytogenetics (cited Pawlyn et al. as reference 10); revised the Risk Groups for Multiple Myeloma table to show this change in the Cytogenetic Findings column.
Treatment Option Overview for Plasma Cell Neoplasms
This section was extensively revised.
Treatment for Amyloidosis Associated With Plasma Cell Neoplasms
Cited Reece et al. as reference 6.
Treatment for Multiple Myeloma
Added text to the list parameters of initial approaches used to evaluate the patient to include presence of hypercalcemia and detection of renal dysfunction attributable to the plasma cell dyscrasia.
Added Therapeutic Overview as a new subsection.
Added text to the list of multiple therapeutic agents that are available for induction therapy, either alone or in combinations, to include histone deacetylase inhibitors and ponatinib.
Revised text to state that bortezomib is given subcutaneously and can cause neuropathic toxicities.
Revised text to state that on the basis of these trials, almost all ongoing clinical trials in the United States and Europe have implemented the low-dose dexamethasone schedule with or without other therapeutic agents: 40 mg dexamethasone weekly in younger or fit older patients or 20 mg dexamethasone in less-fit older patients.
Added text to state that a prospective randomized study of 1,623 transplant-ineligible, untreated patients compared lenalidomide and low-dose dexamethasone when given until progression with a 72-week induction regimen versus melphalan plus prednisone plus thalidomide for 72 weeks (cited Benboubker et al. as reference 24); with a median follow-up of 37 months, this trial showed improved overall survival (OS) for patients on the continuous lenalidomide plus dexamethasone (added level of evidence 1iiA); also added that although median progression-free survival (PFS) was 5 months longer for continuous lenalidomide plus dexamethasone versus 72 weeks of the same regimen, there was no difference in OS (added level of evidence 1iiDiii).
Added text to state that for 302 patients with relapsed or refractory disease, a pomalidomide and low-dose dexamethasone regimen was compared with high-dose dexamethasone in a randomized prospective trial; after a median follow-up of 10.0 months, the PFS favored the pomalidomide arm by 4.0 to 1.9 months (cited San Miguel et al. as reference 33 and level of evidence 1iiDiii).
Added text to state that pomalidomide was approved for patients who relapse after two previous regimens, which included bortezomib and lenalidomide; also added that although some myelosuppression and increased risk of thromboembolic events have been noted as with lenalidomide and thalidomide, very little peripheral neuropathy has been noted in comparison with the other agents (cited Lacy et al. as reference 34).
Added text to state that late in the disease course, when all other options have failed, thalidomide can be employed, sometimes with durable responses (cited 2008 Palumbo et al. as reference 46).
Revised text to state that with a median follow-up of 54 months, 3-year PFS was 35% versus 25%, and 5-year OS was 61% versus 51% (cited Palumbo et al. [J Clin Oncol 2014] as reference 57 and level of evidence 1iiA).
Added text to state that more than 6 months after completion of bortezomib induction therapy, bortezomib can be applied again with a 40% overall response rate according to one anecdotal phase II trial (cited Petrucci et al. as reference 63 and level of evidence 3iiiDiv).
Added text with evidence about carfilzomib as a new subsection.
Added text to include three additional options for combination regimens: carfilzomib, cyclophosphamide, and dexamethasone (cited Bringhen et al. as reference 65); carfilzomib, lenalidomide, and dexamethasone (cited Jakubowiak et al. as reference 66); and bortezomib, bendamustine, and dexamethasone (cited Ludwig et al. as reference 89).
Added Palumbo et al. N Engl J 2014 as reference 5.
Added text to state that in one anecdotal series of 60 patients who underwent allogeneic stem cell transplantation (ASCT), six of the patients relapsed between 6 and 12 years, suggesting that late relapses still occur with this type of consolidation (cited Sahebi et al. as reference 126).
Revised text to state that after ASCT, three randomized, prospective trials showed benefit in median event-free survival or PFS, one with OS benefit.
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Purpose of This Summary
This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about treatment of plasma cell neoplasms (including multiple myeloma). It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.
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Levels of Evidence
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National Cancer Institute: PDQ® Plasma Cell Neoplasms (Including Multiple Myeloma) Treatment. Bethesda, MD: National Cancer Institute. Date last modified <MM/DD/YYYY>. Available at: http://www.cancer.gov/types/myeloma/hp/myeloma-treatment-pdq. Accessed <MM/DD/YYYY>.
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Last Revised: 2015-05-22
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