Changes to This Summary (05/17/2013)
The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.
Updated statistics with estimated new cases and deaths for 2013 (cited American Cancer Society as reference 1).
Added text to state that primary plasma cell leukemia has a particularly poor prognosis (cited 2011 Pagano et al. as reference 16).
Revised text to state that further improvements in prognosis have occurred because of the introduction of newer therapies such as pulse corticosteroids, thalidomide, lenalidomide, bortezomib, and autologous and allogeneic stem cell transplantation (ASCT), with median survivals now exceeding 45 to 60 months (cited 2011 Palumbo et al. as reference 36). Also added text to state that patients with plasma cell leukemia or with soft tissue plasmacytomas in association with multiple myeloma have poor outcomes (cited 2011 Bladé et al. as reference 37).
Revised text to state that elevated serum levels of cardiac troponins, brain natriuretic peptide, and serum-free light chains are poor prognostic factors (cited Kumar et al. [Journal of Clinical Oncology 2012] and Pinney et al. as references 38 and 39, respectively).
Added text to state that as is true for all plasma cell dyscrasias, responses have been reported for all the same regimens active in multiple myeloma (cited Reece et al. as reference 8).
Revised text to state that the choice of induction therapy is unclear at the present time; however, the current basic categories include the use of steroids, thalidomide, lenalidomide, bortezomib, and alkylating agents, often in combination.
Added text to state that in a randomized, prospective trial, 667 previously untreated patients who received thalidomide-containing regimens were randomly assigned to aspirin, warfarin, or enoxaparin. The rate of serious thromboembolic events, acute cardiovascular events, or sudden death was 6.5% and similar for all three interventions (cited 2011 Palumbo et al. as reference 31).
Cited Delforge et al. as reference 32.
Added text to state that a randomized, prospective trial of 342 previously untreated patients receiving lenalidomide-containing regimens compared aspirin with enoxaparin; the 2% incidence of venous thromboembolic events was similar for both interventions (cited Larocca et al. as reference 36).
Cited 2011 Dimopoulos et al. as reference 39.
Cited 2010 Dimopoulos et al. as reference 41. Also revised text to state that in several retrospective, nonrandomized comparisons, bortezomib administered once weekly had significantly less grade 3 to 4 peripheral neuropathy with no loss of efficacy compared with standard biweekly administration (cited Mateos et al. as reference 43).
Added text to state that in a randomized, prospective trial, subcutaneous injections of bortezomib were compared with intravenous infusions in the usual schedule (cited 2011 Moreau et al. as reference 44).
Cited Khan et al. as reference 64.
Cited Kumar et al. (American Journal of Hematology 2011) as reference 65.
Added text to state that new monoclonal gammopathies of an isotype distinct from the original clone can emerge in long-term follow-up (cited Wadhera et al. as reference 72).
Cited 2008 Moreau et al. as reference 91 and level of evidence 3iiiA.
Revised text to state that two studies showed a survival advantage for the autologous transplant followed by an allogeneic transplant (cited Bruno et al. and Björkstrand et al. as references 92 and 93, respectively, and level of evidence 3iiiA).
Revised text to state that two studies showed no difference in overall survival (OS) (cited Krishnan et al. as reference 95).
Added text to state that no clinical trial has directly compared a consolidation approach with a maintenance approach to assess which is better in prolonging remission and, ultimately, survival (cited Ludwig et al. as reference 109); most clinical trials employ one or both. Also added that maintenance trials with glucocorticosteroids (cited Berenson et al. as reference 110) and with interferon (cited The Myeloma Trialists' Collaborative Group as reference 111) showed very minor improvements in remission duration and survival but with toxicities that outweighed the benefits.
Added text to state that after ASCT, six randomized, prospective trials showed benefit in progression-free survival for maintenance thalidomide, but only three showed benefit in OS (cited [Blood 2006] Barlogie et al. as reference 18, Lokhorst et al. as reference 25, Spencer et al. as reference 112, 2006 Attal et al. as reference 113, 2012 Morgan et al. as reference 114, Barlogie et al. as reference 115). Also added that no survival benefit could be consistently seen for thalidomide maintenance after induction chemotherapy alone; interpretation of some trials was confounded by thalidomide use during induction (cited [Blood 2008] Palumbo et al. as reference 19, 2006 Palumbo et al. as reference 116, Wijermans et al. as reference 117, Waage et al. as reference 118, Beksac et al. as reference 119). Several trials suggested particularly poor outcomes using thalidomide for patients with poor-risk cytogenetics. The lowest active dose for thalidomide is 50 mg daily with a duration of at least 1 year.
Added text to state that after ASCT, two randomized, prospective trials showed benefit in median event-free survival (EFS) (cited McCarthy et al. and 2012 Attal et al. as references 120 and 121, respectively, and level of evidence 1iiA), one with OS benefit. For elderly patients not eligible for transplantation, a randomized, prospective trial of lenalidomide maintenance after induction with melphalan and prednisone or melphalan, prednisone, and lenalidomide showed a 66% reduction in the rate of progression, which translated to an EFS of 31 months versus 14 months in favor of maintenance lenalidomide (cited 2012 Palumbo et al. as reference 122 and level of evidence 1iiDi).
Added text to state that a randomized, prospective trial of 1,970 patients compared intravenous zoledronate with oral clodronate in newly diagnosed patients receiving induction chemotherapy with or without consolidation (cited 2010 Morgan et al. as reference 126 and level of evidence 1iiA). Added that as expected, skeletal-related events were also reduced in the zoledronate group (cited 2011 Morgan et al. as reference 127 and [Blood 2012] Morgan et al. as reference 128).
This summary is written and maintained by the PDQ Adult Treatment Editorial Board, which is editorially independent of NCI. The summary reflects an independent review of the literature and does not represent a policy statement of NCI or NIH. More information about summary policies and the role of the PDQ Editorial Boards in maintaining the PDQ summaries can be found on the About This PDQ Summary and PDQ NCI's Comprehensive Cancer Database pages.