Initial Treatment of Nontransplant Patients With Multiple Myeloma

Hematologic malignancies of the liver: spectrum of disease

The incidence of hematologic malignancies and their extranodal manifestations is continuously increasing. Previously unsuspected hepatic involvement in hematologic malignancies such as Hodgkin disease and non-Hodgkin lymphoma, posttransplant lymphoproliferative disorder, myeloid sarcoma (chloroma), multiple myeloma, Castleman disease, and lymphohistiocytosis may be seen by radiologists. Although the imaging features of more common hepatic diseases such as hepatocellular carcinoma, metastases, and infection may overlap with those of hepatic hematologic malignancies, combining the imaging features with clinical manifestations and laboratory findings can facilitate correct diagnosis. Clinical features that suggest a hematologic neoplasm as the cause of liver lesions include a young patient (<40 years of age), no known history of cancer, abnormal bone marrow biopsy results, fever of unknown origin, and night sweats. Imaging features that suggest hematologic malignancy include hepatosplenomegaly or splenic lesions, vascular encasement by a tumor without occlusion or thrombosis, an infiltrating mass at the hepatic hilum with no biliary obstruction, and widespread adenopathy above and below the diaphragm. Familiarity with the imaging features of hepatic hematologic malignancies permits correct provisional diagnosis and may influence therapeutic management. For example, when biopsy is performed, core biopsy may be needed in addition to fine-needle aspiration so that the tissue architecture of the neoplasm can be discerned. The predominant treatment of hematologic malignancies is chemotherapy or radiation therapy rather than surgery. Online supplemental material is available for this article.

Imaging features of haematological malignancies of kidneys

Haematological malignancies are relatively uncommon neoplasms of kidneys. Nevertheless, the incidence of these neoplasms is increasing, partly due to more widespread use of computed tomography and magnetic resonance imaging. This article discusses the clinical and imaging features of renal lymphoma, leukaemia, extra-osseous multiple myeloma, and post-transplant lymphoproliferative disorder. Although there is overlap of imaging features with other more common malignancies, such as transitional and renal cell cancers, the combination of imaging findings and the appropriate clinical picture should allow the radiologist to raise a provisional diagnosis of a haematological neoplasm. This has management implications including the preference for image-guided core biopsies and a shift towards medical rather than surgical therapy.

Hematologic malignancies of the pancreas

Hematologic malignancies are relatively uncommon neoplasms of abdominal soft tissue. This article discusses the clinical and imaging features of pancreatic lymphoma, pancreatic extraosseous multiple myeloma, granulocytic sarcoma (chloroma), posttransplant lymphoproliferative disorder, and Castleman disease. The combination of imaging findings and the appropriate clinical presentation should allow the radiologist to raise a provisional diagnosis of hematologic malignancy.

Tretatment approach of nontransplant patients with multiple myeloma

Multiple myeloma is still an incurable disease with pattern of regression and remission followed by multiple relapses raising from the residual myeloma cells surviving even in the patients who achieve complete clinical response to treatment. In recent years there is a huge improvement in treatment of patients with multiple myeloma. The milestones of these improvement are: autologous transplantation and high-dose melphalan, imunomodulating drugs (thalidomide, lenalidomide), proteosom inhibitors (bortesomib, carfilzomib). The most significant improvement in overall survival has been achieved in the patients younger than 65 years. So, the major challenge for hematologist is to translate this improvement in the elderly patients with multiple myeloma. Today, physicians are able to offer wider variety of treatment options for elderly patients with multiple myeloma. Therapeutic options should be tailored and personalized according to patient's characteristics by balancing efficacy and toxicity of each drug which is especially important for elderly patients. In the mode of sequencing treatment for elderly patients with multiple myeloma, our goal is to achieve and maintain maximal response while limiting treatment -related toxicities as much as possible. Second-generation novel agent, such as carfilzomib, pomalidomide, elotuzumab, bendamustine are currently being evaluated as an option to improve treatment outcome in elderly patients.

Treatment of patients with multiple myeloma over 65 yr: more tolerability or better response?

OBJECTIVE

Two-thirds of newly diagnosed patients with multiple myeloma (MM) are over 65 yr and/or physically unfit. Such patients are not eligible for high-dose chemotherapy or stem cell transplantation. The treatment aims in these patients should be to prolong survival by obtaining the best possible response, while maintaining good tolerability. The aim of our study was to evaluate the response to treatment and treatment-related toxicities in patients treated with conventional and novel protocols.

METHODS

The records of 138 elderly (≥65 yr) patients with MM were retrospectively evaluated.

RESULTS

The median overall survival(OS) of the patients was 46 months. The median progression-free survival (PFS) was 18 months. The OS and PFS of the patients treated with the conventional protocols did not differ significantly from those treated with the novel protocols. The statistical analysis of the quality of the response to the treatment with the conventional and novel therapies showed that complete remission (CR), combined with a very good partial response (VGPR), was significantly higher in the latter. However, the toxicities were higher in the novel treatment group.

CONCLUSION

The novel drug protocols significantly increased the quality of the responses of elderly patients with MM to therapy, but they did not increase the patients' tolerability.

Therapeutic advancements in multiple myeloma

Multiple myeloma survival has significantly improved in the latest years due to a broad spectrum of novel agents available for treatment. The introduction of thalidomide, bortezomib, and lenalidomide together with autologous stem-cell transplantation has considerably increased complete remission rate and progression-free survival resulting ultimately in prolonged survival in myeloma patients. Moreover, novel strategies of treatment such as consolidation and maintenance are being used to further implement responses. Finally, a number of new drugs such as carfilzomib and pomalidomide are already in clinical practice, making the future of myeloma patients brighter.