Al-Ola Abdallah, MD: Welcome, everyone attending this CancerNetwork® [Around the Practice] discussion in Kansas City [Kansas]. I’m Dr Al-Ola Abdallah, the director of the plasma cell disorder clinic. Let me welcome my colleagues at the division of hematological malignancies and cellular therapeutics: Dr Nausheen Ahmed, an assistant professor; Dr Leyla Shune, an associate professor; and our PharmD, Jordan Snyder. Welcome, everybody. We’re going to discuss 3 major real-world cases. Let’s start with the first case.

[This is] a 45-year-old male patient who has a history of pulmonary embolism, DVT [deep vein thrombosis], and essential hypertension. Initially, he presents with weakness and atypical chest pain. He went to the ED [emergency department], and the work-up showed he had a hemoglobin of 13.8 g/dL; creatinine was elevated, up to 3.3 mg/dL, with a baseline of 1 mg/dL; albumin was 2.8 g/dL; and calcium was 14.5 mg/dL. It was decided that he needed to be admitted to the hospital.

During our evaluation, the total protein was elevated, up to 15 g/dL. He had a work-up for his chest pain that included an ECG [electrocardiogram] that was normal. His troponin level was also normal, but a CT scan of the chest showed multiple lytic legions. After the patient was admitted, he had a work-up for myeloma, including an SPEP [serum protein electrophoresis]. It showed an elevated serum and protein of 4.8 g/dL, an IgG level that was 6355, and a β-2 microglobulin of 6.6 mg/L. The LDH [lactate dehydrogenase] level was normal. The serum-free kappa light chain was elevated, up to 20 mg/dL with a ratio of 18.

To complete the work-up and confirm the diagnosis of myeloma, the patient had a bone marrow biopsy that showed 70% monoclonal plasma cells. Afterward, it takes time for the results to come, but the FISH [fluorescence in situ hybridization] showed deletion 13q and TP53 mutations. The results of the PET [positron emission tomography]–CT scan confirmed that the patient had lytic lesions of the spine, pelvis, proximal femurs, ribs, sternum, clavicles, and proximal humerus. In addition, there was extramedullary disease in the liver and lymph nodes with increased SUV [standardized uptake value] activity. The 24-hour UPEP [urine protein electrophoresis test] showed 150 mg in 24 hours, and he had an excellent performance status.

This patient had a PET-CT scan that showed many lytic legions, confirming the extramedullary disease with a diagnosis of myeloma. There was an urgency, of course, to start him on treatment for his hypercalcemia and acute renal failure with IV [intravenous] fluids, calcitonin from outside the facility, and bisphosphonate to lower his calcium. In addition, they started him with a bridging therapy with dexamethasone and started him immediately at an outside facility with induction therapy using quadruplet therapy of daratumumab, Revlimid [lenalidomide], Velcade [bortezomib], and dexamethasone for 4 cycles. The patient had a great response, and proceeded with melphalan 200 mg/m2 followed by stem cell transplant.

He was restaged at day 90 because had high-risk myeloma. The blood test showed that the serum M [monoclonal] protein has responded good after 4 cycles of daratumumab, Revlimid, Velcade, and dexamethasone. He proceeded with stem cell transplant and achieved stringent complete remission based on the bone marrow biopsy. MRD [minimal residual disease] testing was not done. The PET-CT scan showed complete remission for extramedullary and osseous lesions. The question with high-risk myeloma is, what’s next? Our institution decided about treatment for high-risk myeloma is Velcade-Revlimid. This is the reason we’re talking about it.

Transcript edited for clarity.