MULTIPLE MYELOMA (incidence:3-5/100,000 people) Diagnostic triad:
plasmacytosis(> 10%) + M-spike/Bence Jones protein + osteolytic lesion

Clinical triad: bone pain + anemia + renal insufficiency 98-99% of
patients will have a monoclonal protein in serum/urine lgG=60%, lgA=20%,
Bence Jones (only)= 10%, lgD=1%, lgE=0.01% Prognosis: stage dependent
(e.g., IA=~62 months;IIIB~15 months)

start chemotherapy if stage IB-IIIB

(asymptomatic, early stages and patient with smoldering MM should not be
treated see Fig 37-1 for follow-up scheme)

Melphalan (0.25 mg/kg or 9 mg/m2 for 4 days or 0.15 mg/kg for 7 days)
Prednisone 50 mg bid for 4 days or 20 mg tid for 7 days

take melphalan in fasting state (food J- absorption > 1/3)

q 5-6 weeks (encourage patient to walk and drink at least 2-3 L of
fluids/day) avoid diuretics analgesic on fixed schedule

Continue treatment as long as M-protein continues to decline

yes(4-6 months)


BMT (allogenic if donor available) or autologous BMT

no in patient < 55 and/or poor prognostic factors

Obtain CBC q 2-3 weeks after 1 cycle (to monitor melphalan

if some degree of leukopenia and thrombocytopenia is observed continue
with same dose; if CBC unchanged increase dose of melphalan 2-4 mg/day
cycle until leukopenia/thrombocytopenia is observed;

withold treatment if WBC <2,500/ccu (ANC<1,800/ccu) or

Maintenance treatment:

interferon -2b 3 MU/m2 3 times a week SC (see CML chapter for side

stable disease but not full response

Response to treatment:

Serum M-protein decreases to < 50% of the pretreatment value on 2
separate measurements (taken at 4 week intervals)

Urine M-protein decreases to < 10% of pretreatment value (changes not
considered significant if there is renal failure)




(progression on

initial treatment or failure

to acheive initial response)

Check CBC before each chemotherapy cycle

Treatment monitoringdetermine

CBC before each treatment cycle (see Fig. 38-2)

Calcium, creatinine q 1-2 months

SPE and IPE to follow M-spike concentration

q 2 months (SPE more reliable than IPE

if M-peak visible) 24 h urine collection for total protein and light

chain analysis (q 2-3 months) /?2-microglobulin in q 2 months Skeletal
x-ray survey (q 6-12 m) Marrow aspirate if pancytopenia develops

(to distinguish between multiple myeloma


chance for response

VAD + verapamil

and treatment effect)

VAD regimen:

(40% response)

Vincristine 0.4 mg and doxorubicine 9 mg/m2 for 4 days in continuous

Dexamethasone 40 mg for 4 days starting on days 1, 9 and 17 q 28 days

Antacids/H2 blockers and trimethoprim-sulfamethoxazole for prophylaxis
(1 DS bid)

Anti-emetics before treatment


Dexamethasone 40 mg for 4 days starting on days 1, 9 and 17 q 28 days;
or prednisone 100 mg qod (decrease dose to 50% qod if response is noted)

Antacids/H2 blockers and

trimethoprim-sulfamethoxazole for prophylaxis (1 DS bid)

| 2 cycles

yes (-20-40%)

Continue as long as response is achieved;

after maximal response, give 4 additional cycles before treatment is




Third line treatment:

EDAP or cr-interferon 3 MU/m2 3 times a week or sequential hemibody

Determine glycoprotein P-170 (multidrug resistance protein)

cannot be assayed

or negative