Thursday, May 1, 2014

Notes on Myeloma, lesson learned (II)

*If del 17 present -give RVD (revlimid, velcade, Decadron)
*After first transplant, your options are:
1.Tandem Therapy  Vs  Revlimid
2.Maintenance therapy with Revlimid +/- Velcade based on Cytogenetics
whatever drug you choose give until progression of disease.

*In younger patients 3 drug therapy is better
-to increase efficacy, which turn out to be better,
-Maintenance therapy is standard
for high risk patients, think RVD
*for all transplant candidate
Give "triple therapy" for induction
but again for high risk Myeloma, think RVD

*some argue that Myeloma is a curable disease, indeed when you look at survival curb, a plateau exists...meaning aggressive treatment when feasible should be offered to our patients!

*Some start questioning that adding alkylating agent (Cytoxan) to the mix in myeloma may be pouring  flame to the Mutations already present, CRBCM agrees! But may be important when del 17 present!

*Obtaining MRD appears important to reduce proportion of non responders to treatment.
and VTD appears beter than TD.  the proportion of VGPR  62  Vs 20
*and VTD anihilate the risk of t(4,14) translocation, choose this combination in people with this translocation

*Velcade should no longer be given Intravenously, always give Sub-cutaneously to decrease significantly Neuropathy!

*carfilzomid has definitely entered the frey, combination therapy CRD being offered, see results in the literature!

*One may consider deferring transplant in patient who are reluctant to proceed:(up to 25% of patients who qualify for transplant actually delay therapy believe it or not!)
3 criteria
A-Standard 3 medications used, and no complicated Cytogenetics in play
B-good response to therapy (high VGPR)
C-Good tolerance of treatment!

*CR 1X 10 (power 8)
but can consider by Molecular or flow 1x10(power4)

*Maintenance therapy is definitely standard since it has shown longer progression free and overall survival (HOVON65/GMMG-HD4)  Use of Velcade IV vs SC discussed earlier

*Ixazomid best for maintenance therapy since PO, and once a week dose considered, with decreased Neuropathy!

*for maintenance therapy, particularly in bad Cytogenetics, add Velcade to Rev. (please try to avoid Decadron in this setting if possible for side effects!)

*Major development
Velcade is safe in renal failure
and guess what is added to the list Carfilzomib, also safe!
renal failure bad for Pomalidomide!!! do not use!!!

*Most if not all Oncologists will treat laboratory signs of progression of disease
ptions would include
1.RVD
2.Resume Velcade
3.Carfilzomib
4.Pomidomide
5.DOXORUBICIN (+/- Melphalan?)

(All info to be used cautiously after check of literature)
Note I still to come!
CRBCM, tracking the news!lesson learned in LAS VEGAS!CRBCM does not fabricate and does not own this information....but this may help someone somewhere!

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