Manni Mohyuddin: Ten important observations about myeloma
Manni Mohyuddin shared a thread on X: .
“Ten important observations about myeloma and its precursors that I often discuss with patients and teach to trainees in my clinic. An educational thread:
Most, but not all disease progressions at the time of relapse are biochemical (as in myeloma proteins increasing) and not clinical (as in new organ damage, anemia, bone lesions).
For those with high-risk disease, remissions appear to be very short without a transplant, and the role of transplant even more important, as shown in this excellent meta-analysis of high-risk disease patients across trials.
In a randomized trial (CASSIOPEIA), for those with high risk myeloma, outcomes were poor regardless of whether they achieved MRD negativity at 10-6 or not, indicating that single timepoint of MRD negativity may not truly overcome high-risk cytogenetics.
For those who experience MRD resurgence (no other signs of progression/lab abnormalities but recurrence of clonal marrow cells), it may be years before treatment needed, as 27% of people had still not clinically relapsed with 9 years of follow-up!
Light chain cast nephropathy does not happen below a level of 500mg/l or 50mg/dl, and almost always the light chain level is much higher than that.
Light chain cast nephropathy is a product of high-disease burden (its not a MGRS, but a MM event).
If you having to think about reducing the dose of melphalan to 140 (unless renal insufficiency), may as well not do an auto-transplant, as Mel-140 did not beat even len-dex in a randomized trial, let alone triplets or quadruplets.
If someones disease is refractory to daratumumab, isatuximab has zero clinical activity, with no responses seen in this trial. Combinations have worked in retrospective studies, but perhaps that was because of other agents and not the isa.
When evaluating someone with high-risk smoldering myeloma, get best imaging test. If someone already meets diagnostic criteria for myeloma, it may not matter, but for SMM, getting best test may change diagnosis. MRI detects lesions when PET normal.
If the myeloma FISH panel has no abnormalities, it is likely an unsorted specimen and you have missed some abnormalities. The vast majority of myeloma has some cytogenetic abnormality.
Hypercalcemia is rarely the isolated presenting feature of myeloma. If all you see is hypercalcemia and nothing else, its unlikely this is myeloma. Thanks for reading!”
Source: Manni Mohyuddin/X
Dr. Manni Mohyuddin is an Assistant Professor at the Huntsman Cancer Institute, University of Utah, specializing in oncology. He is mainly interested in myeloma, supportive care, end-of-life management, and implementing cost-effective, evidence-based treatment strategies.