Management of multiple myeloma

Salvage therapy for multiple myeloma: the University of Arkansas experience

OBJECTIVE

To summarize a spectrum of salvage regimens for multiple myeloma (MM) developed during the past decade.

DESIGN

We reviewed the experience at the University of Arkansas in the management of patients with MM who failed to achieve remission ("primary unresponsive") or had a relapse despite myelosuppressive doses of chemotherapy ("resistant relapse").

MATERIAL AND METHODS

Results with use of the various chemotherapeutic protocols are presented, and multivariate regression analysis was applied to determine the independent contributions of certain factors toward event-free and overall survival.

RESULTS

The VAD regimen (vincristine sulfate, Adriamycin [doxorubicin hydrochloride], and dexamethasone) yielded responses in 29% of previously unresponsive and 46% of relapsed cases of MM, in comparison with 25% and 21%, respectively, with use of dexamethasone only. Responses occurred more frequently when tumor cell RNA content was high, tumor burden was low, and duration of drug resistance was less than 1 year. The duration of survival in patients who received high doses of melphalan was decreased in those with increased serum levels of lactate dehydrogenase. EDAP (etoposide, dexamethasone, ara-C, and cisplatin) produced 75% or more tumor cytoreduction in 8 of 20 patients. Overall in patients with an increasing number of adverse factors, response rates and survival decreased progressively with less intensive therapy but were unaffected when more intensive therapy was used. In the multivariate analysis, the most important features for extended survival were a low beta 2-microglobulin level before transplantation and application of two bone marrow transplants within 6 months.

CONCLUSION

Variables relative to the patient's overall medical condition, prior treatment, characteristics of MM at diagnosis, and response history should be carefully assessed to determine a plan for salvage therapy that will maximize the opportunity for sustained remission and survival.

Vascular signals from pleura-based lung lesions studied with pulsed Doppler ultrasonography

Vascular signals arising from pleura-based lung lesions were studied in 50 patients using pulsed Doppler ultrasonography. Twenty-seven had malignant lesions and 23 benign lesions. In 24/27 of the malignant masses, we observed no Doppler signals: in 2 cases, a low-velocity, turbulent, pulsatile flow was demonstrated; in 1 case pulsed Doppler ultrasonography showed only a low-velocity, continuous flow. In 20/23 of the benign lesions, we found 2 types of Doppler signal waveforms: an irregularly pulsatile, venous-like signal, and a regularly pulsatile, arterial-like waveform. The last 8 patients of our series underwent color Doppler ultrasound examination, which demonstrated the presence of arterial and venous vessels in 4 benign lesions and the absence of blood flow in 4 malignant masses. To our knowledge, we report for the first time the ability of obtaining Doppler signals from a variety of lung lesions. The actual clinical relevance of this application requires further studies.

A plea to overcome the concept of "staging" and related inadequacy in multiple myeloma

From a retrospective multivariate study on 107 multiple myeloma (MM) patients, serum beta 2-microglobulin (beta 2M) proved to be the best prognostic discriminator, better than each of the currently used staging systems (Durie and Salmon's [DS], Merlini, Waldenström and Jayakar's [MWJ] and the British Medical Research Council's [BMRC]). The predictive ability of each staging system is better improved by combining consideration of beta 2 M as a continuous rather than a binary variable (even at its best prognostic cut-off). The combination of BMRC with beta 2 M demonstrated the highest prognostic value, followed by those involving DS or MWJ. Ease and measurability of clinical parameters at diagnosis, parametric type of statistical model assumed for description of survival, and supply of direct estimate of expected survival are the characteristics of the MWJ system that suggest it is best able to integrate beta 2 M correctly in a prognostic index. The basic concepts and the clinical use of the available staging systems for MM are criticized along the following lines: a) the need to include new and homogeneously weighted parameters in future prognostic systems -b) the lack of direct correspondence between treatment requirements (according to stage) and available therapeutic resources -c) evidence of the rough stratification of the actual survival expectancy, as permitted by the current staging systems. A direct, and as accurate as possible estimate of prognosis--based on easy and measurable parameters evaluable at diagnosis--should replace the current classification of patients according to stages. This estimate should mark the clinical evaluation at diagnosis, should flexibly indicate treatment even according to different protocols or centers, and should allow very accurate statistical corrections for different survival expectancy at diagnosis when evaluating different treatments in clinical trials.