Multiple Myeloma with Central Nervous System Relapse Early after Autologous Stem Cell Transplantation: A Case Report and Literature Review

Relapsed refractory multiple myeloma with CNS involvement successfully treated with Elranatamab: first reported case

Central nervous system (CNS) involvement in multiple myeloma (MM) is a rare and challenging complication associated with poor prognosis and limited treatment options. Emerging T-cell directing therapies, such as bispecific antibodies (bsAbs) and chimeric antigen receptor T cells (CAR-T), have shown remarkable success in treating MM, but their efficacy in CNS involvement remains unclear. Elranatamab, a humanized bispecific antibody targeting B-cell maturation antigen (BCMA) and CD3-expressing T cells, has demonstrated promising results in relapsed refractory MM. However, its efficacy in treating CNS-MM has not been reported. We present a case of a 37-year-old male MM patient with CNS involvement who has been successfully treated with Elranatamab.

Elkourahy Omar S. Treatment of Multiple Myeloma in the First Relapse

The treatment scope for relapsed myeloma has been expanded considerably in the last few years, by virtue of the advent of numerous novel agents with new mechanisms of actions. This has resulted in increasing responses and prolonging survival even in advanced diseases. The wealth of novel regimens comes with the challenges of balancing toxicities and aligning a regimen with the biology of myeloma and the nature of relapse in conjunction with the patient’s treatment history, comorbidities, and personal preference. The second-line treatment in myeloma includes new generation of proteasome inhibitors and immunomodulators, CD38 monoclonal antibodies, Panobinostat, and Elotuzumab. Recent randomized trials have shown that triplet combinations incorporating CD38 monoclonal antibodies, dexamethasone along with either proteasome inhibitor or immunomodulator were superior to doublet combinations in terms of response rate and progression-free survival. The choice of the second-line therapy is determined by lenalidomide/bortezomib exposure and resistance and access to new agents. Furthermore, autologous transplantation should be considered in selected cases. Here, we will be discussing the optimal management of multiple myeloma in the first relapse.