Multiple Myeloma and Plasma Cell Dyscrasias

Fast Facts Fast Facts: Multiple Myeloma and Plasma Cell Dyscrasias Karthik Ramasamy and Sagar Lonial A comprehensive yet accessible handbook, pitched at a good level for primary care practitioners, junior doctors and allied healthcare professionals. Maggie Lai, Scientific and Medical Education Specialist, Myeloma UK

Fast Facts Fast Facts: Multiple Myeloma and Plasma Cell Dyscrasias Karthik Ramasamy PhD FRCP FRCPath Consultant Haematologist NIHR Thames Valley and South Midlands LCRN: Cancer Research Lead Churchill Hospital, Oxford University Hospitals NHS Trust Oxford, UK Sagar Lonial MD FACP Professor and Executive Vice Chair Department of Hematology and Medical Oncology Chief Medical Officer, Winship Cancer Institute Emory University Atlanta, GA, USA Declaration of Independence This book is as balanced and as practical as we can make it. Ideas for improvement are always welcome: feedback@fastfacts.com

Fast Facts: Multiple Myeloma and Plasma Cell Dyscrasias First published August 2015 Text 2015 Karthik Ramasamy, Sagar Lonial 2015 in this edition Health Press Limited Health Press Limited, Elizabeth House, Queen Street, Abingdon, Oxford OX14 3LN, UK Tel: +44 (0)1235 523233 Book orders can be placed by telephone or via the website. For regional distributors or to order via the website, please go to: www.fastfacts.com For telephone orders, please call +44 (0)1752 202301 (UK, Europe and Asia Pacific), 1 800 247 6553 (USA, toll free) or +1 419 281 1802 (Americas). Fast Facts is a trademark of Health Press Limited. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the express permission of the publisher. The rights of Karthik Ramasamy and Sagar Lonial to be identified as the authors of this work have been asserted in accordance with the Copyright, Designs & Patents Act 1988 Sections 77 and 78. The publisher and the authors have made every effort to ensure the accuracy of this book, but cannot accept responsibility for any errors or omissions. For all drugs, please consult the product labeling approved in your country for prescribing information. Registered names, trademarks, etc. used in this book, even when not marked as such, are not to be considered unprotected by law. A CIP record for this title is available from the British Library. ISBN 978-1-910797-01-3 Ramasamy K (Karthik) Fast Facts: Multiple Myeloma and Plasma Cell Dyscrasias/ Karthik Ramasamy, Sagar Lonial Medical illustrations by Annamaria Dutto, Withernsea, UK. Printed in Europe with Xpedient Print.

List of abbreviations 5 Introduction 7 Epidemiology and etiology 9 Predisposing conditions associated with myeloma 16 Pathophysiology of myeloma and MGUS 29 Diagnosis, staging and monitoring of myeloma 36 Genetics and myeloma 51 Induction therapy for newly diagnosed multiple myeloma 58 Transplantation and myeloma 70 Relapsed and refractory myeloma 78 Bone disease and renal complications in myeloma 96 AL amyloidosis 105 Rare plasma cell dyscrasis 119 Supportive care 134 Useful resources 147 Index 149

List of abbreviations ABMT: autologous bone marrow transplantation ADCC: antibody-dependent cellmediated cytotoxicity ADCP: antibody-dependent cellular phagocytosis AIDS: autoimmune deficiency syndrome AL amyloidosis: amyloid light chain amyloidosis Allo-SCT: allogeneic stem cell transplantation ASCT: autologous stem cell transplantation ATTR: transthyretin amyloidosis CDC: complement-dependent cytotoxicity CKD: chronic kidney disease CR: complete response CRP: C-reactive protein DEXA: dual-energy X-ray absorptiometry DSS: Durie and Salmon Staging (system) FISH: fluorescence in situ hybridization FLC: free light chain GEP: gene expression profiling HDAC: histone deacetylase (inhibitor) HDT: high-dose therapy HIV: human immunodeficiency virus Ig: immunoglobulin IL: interleukin IMiD: immune-modifying drug IMWG: International Myeloma Working Group ISS: International Staging System LDH: lactate dehydrogenase MGRS: monocloncal gammopathy of renal signifiance MGSS: monoclonal gammopathy of skeletal significance MGUS: monoclonal gammopathy of undetermined significance MIDD: monoclonal immunoglobulin deposition disease MM: multiple myeloma NT-proBNP: N-terminal pro-brain natriuretic peptide OPG: osteoprogerin PET-CT: positron emission tomography-computed tomography POEMS: polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy and skin changes (syndrome) PR: partial response RANKL: receptor activator of nuclear factor (NF)-kB ligand RRMM: relapsed and refractory multiple myeloma SAP: serum amyloid P sflc: serum free light chain SMM: smoldering multiple myeloma VGPR: very good partial response VTE: venous thromboembolism WM: Waldenström s macroglobulinemia 5

Introduction Myeloma is a clonal plasma cell disorder, characterized by the secretion of antibodies and a complex array of clinical manifestations including anemia, bone lesions, hypercalcemia and renal dysfunction. Although myeloma is incurable, survival has almost tripled over the past 10 years and it is now projected that a third of patients will survive more than 10 years after diagnosis. Here, we aim to provide the non-specialist with a comprehensive overview of myeloma and other plasma cell dyscrasias, from bench to bedside, putting the pathogenesis, diagnosis and treatment of these disorders in the context of daily clinical practice. Patients with myeloma almost universally have a premalignant stage. The precancerous condition monoclonal gammopathy of undetermined significance and an inactive form called smoldering myeloma carry differing risks of progression to active myeloma (see Chapter 2). Early diagnosis is critical for a favorable outcome, and we discuss the latest advances in diagnostic tests and imaging in Chapter 4. However, diagnosis is often delayed, enabling life-threatening comorbidities such as renal impairment requiring dialysis, or fracture leading to spinal cord compression, to develop (see Chapter 9). Gene expression profiling and mutational analysis using genome sequencing are likely to help develop personalized therapy. As different subsets of myeloma patients are identified, treatment approaches will be tailored to the individual, with the goal of achieving cure rather than similar progression-free or overall survival rates between groups. Chapter 5 summarizes the latest approaches to genetic assessment. Rapid progress is being made in the development of new treatments for myeloma. As a result, it is now incumbent upon clinicians to treat to maximal response and to consider long-term therapeutic strategies. In Chapter 6 we examine all aspects of induction therapy for newly diagnosed patients. Triple-drug regimens (an immunomodulatory drug, proteasome inhibitor and steroid) are now standard practice for most transplant-eligible patients. Meanwhile, lenalidomide- and bortezomibbased induction regimens have replaced melphalan with prednisone for transplant-ineligible patients. 7

Fast Facts: Multiple Myeloma and Plasma Cell Dyscrasias While the myeloma community debates whether stem cell transplantation is still necessary for patients with myeloma, randomized clinical trials of high-dose therapy and autologous stem cell transplantation as part of the initial treatment strategy continue to show significant benefits in terms of duration of remission and overall survival for suitable patients. Chapter 7 looks at these regimens in detail. The management of patients with relapsed or refractory myeloma presents a special therapeutic challenge, with the choice of salvage treatment representing a balance between the efficacy and toxicity of the regimen. In Chapter 8 we examine the clinical trial evidence for established treatment regimens (immunomodulatory drugs and proteasome inhibitors) alongside the latest information on a number of emerging therapies, including second-generation proteasome inhibitors, histone deacetylase inhibitors and new kids on the block, the monoclonal antibodies. Supportive care that addresses both the consequences of disease activity and the complications of anti-myeloma treatment is essential to enhance long-term outcomes and improve quality of life. In Chapter 12, we address the management of anemia, fatigue, bone pain, neuropathy, infection, venous thromboembolism and coagulopathy, as well as the need for palliative care for patients with rapidly progressing refractory disease. Together with chapters on other rarer plasma cell dyscrasias, namely AL amyloidosis, plasmacytoma, Waldenström s macroglobulinemia and POEMS syndrome, this highly accessible handbook on multiple myeloma is the ideal resource for primary care providers, specialist nurses, junior doctors and allied healthcare professionals wanting to get up to speed quickly on this fast-moving field. 8 Acknowledgments. We thank Ms Charise Gleason, Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, USA, for her coauthorship of Chapter 1. Also, from the Department of Clinical Haematology, Oxford University Hospitals NHS Trust, UK, Dr Jaimal Kothari and Dr Faye Sharpley for critical reading of the book, and Dr Debbie Hay for image contribution. We also thank Dr Dale Powner, Binding Site (UK), for providing images.

1 Epidemiology and etiology Epidemiology Multiple myeloma accounts for about 0.8% of all cancers worldwide, with about 114 000 new cases each year. In the USA, it is the 14th most common cancer and the second most common hematologic disorder. In Europe, it is the 20th most common cancer and the third most common hematologic malignancy. Incidence and prevalence. The incidence of multiple myeloma varies markedly between countries; the highest rates are observed in North America, parts of Europe, Australia and New Zealand, while the lowest rates are seen in Asia. In the USA, the annual incidence of multiple myeloma has increased by an average of 0.8% per year in the past decade, while death rates have been stable between 2002 and 2012. In 2012, there were an estimated 89 658 people living with myeloma and approximately 26 850 new cases were diagnosed in 2015. The estimated survival rate at 5 years is 46.6%. In Europe in 2012, up to 39 000 new cases of myeloma were diagnosed (1% of total cancer cases) and the estimated age-standardized incidence rate (ASR) of new myeloma cases was 4.5 per 100 000. Cancer Research UK reported 4792 new myeloma patients, diagnosed in 2011, with an ASR of 5.4 per 100 000. In 2012, 24 000 myeloma patient deaths were reported in Europe. The age-standardized mortality rate is 2.7 per 100 000 for men and 1.8 per 100 000 for women. In 2012, the 5-year myeloma prevalence in Europe was estimated at 89 191 cases. Etiology The exact etiology of myeloma is unknown, although a number of risk factors have been identified (Table 1.1). Age. Myeloma most commonly affects older adults. In the USA, the median age at diagnosis is 69 years. UK data also show increasing incidence of myeloma cases with age (Figure 1.1). In the USA, the 9

Fast Facts: Multiple Myeloma and Plasma Cell Dyscrasias TABLE 1.1 Known risk factors for multiple myeloma Older age Male sex Personal history of monoclonal gammopathy of undetermined significance (MGUS) African or African-American ethnicity (a) 30 New cases (%) 25 20 15 10 10 5 0 (b) 500 Average number of cases per year (bar) 400 300 0 34 35 44 45 54 55 64 65 74 75 84 85+ Age at diagnosis (years) Male rates Female rates Male cases Female cases 200 30 100 0 0 4 5 9 10 14 15 19 20 24 25 29 30 34 35 39 40 44 Age at diagnosis (years) 45 49 50 54 55 59 60 64 65 69 70 74 75 79 80 84 85+ Figure 1.1 Incidence of multiple myeloma in (a) the USA and (b) the UK, in relation to age. Sources: (a) National Cancer Institute 2015, www.seer. cancer.gov/statfacts/html/mulmy.html; (b) Cancer Research UK 2015, www.cancerresearchuk.org/health-professional/cancer-statistics/statisticsby-cancer-type/myeloma/incidence, last accessed 21 June 2015. 75 60 45 15 0 Rate per 100 000 (line)

5 Genetics and myeloma Importantly, not all patients who receive a pathological diagnosis of multiple myeloma have the same natural history or response to therapy. While simple blood markers such as C-reactive protein (CRP) or lactate dehydrogenase (LDH) have been used to separate patients according to their level of risk, current strategies use routine karyotyping and fluorescence in situ hybridization (FISH), while gene expression profiling (GEP) and mutational analysis using genome sequencing are attracting increasing attention. As different subsets of myeloma patients are identified, it will become increasingly important that treatment approaches are tailored to the individual patient: the ultimate goal is to treat patients with individualized therapies to achieve cure, rather than achieving similar progression-free or overall survival rates between groups. Risk assessment in myeloma A number of strategies have been used in attempts to stratify patients with myeloma according to their likely prognosis. Initially, morphological assessments were used to identify patients who had a more proliferative form of myeloma, but this was subsequently replaced with the use of blood markers such as CRP, which has been shown to be an independent prognostic factor in patients with newly diagnosed myeloma. It was subsequently shown that CRP is a surrogate marker for serum interleukin (IL)-6, which is known to induce plasma cell proliferation and drug resistance. As described in Chapter 4, biochemical markers such as CRP were incorporated into the Durie and Salmon staging (DSS) system, which distinguished between DSS stage I disease (smoldering myeloma) and DSS stage III disease (patients requiring therapy because of a high tumor burden) (see Table 4.3); all other patients were characterized as DSS stage II. Subsequently, serum creatinine was incorporated into the DSS system as a measure of renal dysfunction, such that each stage was subdivided into A and B classes, depending on the creatinine level at presentation (< 2.0 mg/dl is A, > 2.0 mg/dl is B). 51

Fast Facts: Multiple Myeloma and Other Plasma Cell Dyscrasias The DSS system has been widely used since 1975 to stratify patients in clinical trials according to their level of risk. More recently, however, it has been shown that β 2 -microglobulin is a better predictor of survival than CRP, and hence this marker, together with serum albumin, has been incorporated into the International Staging System (ISS) (see Table 4.2). This system proved to be more informative than the DSS system in the prognostic assessment of risk, and was also found to be useful in older transplant-ineligible patients as well as with younger transplant-eligible patients. It differs from the DSS system in a number of ways. There is no need to include a specific marker of renal function because β 2 -microglobulin levels increase in patients with renal impairment. Patients with ISS stage I myeloma are not considered to have smoldering myeloma, because the ISS can only be applied to patients who are defined as symptomatic according to the CRAB criteria (see page 18). Newly diagnosed patients with ISS stage III myeloma are considered to be at high risk of adverse outcomes. Genetic assessment Approaches to genetic assessment in patients with multiple myeloma are include: routine karyotyping (Figure 5.1) fluorescence in situ hybridization (FISH) (see Figure 5.1) gene expression profiling sequencing and mutational analysis. 52 Routine cytogenetics. Studies of routine karyotyping in patients with multiple myeloma have shown that changes in chromosome 13, particularly deletion of 13q (del 13) (see Figure 5.1b), are associated with poor outcomes, probably as a result of the higher proliferation rates seen in affected patients. It has subsequently been shown that the presence of any cytogenetic abnormality on routine karyotyping is associated with high-risk disease, because of increased proliferation. Such abnormalities occur in 15 20% of patients with newly diagnosed myeloma. The increased proliferation associated with chromosomal

Genetics and myeloma (a) (b) (c) (d) Figure 5.1 (a) Normal male XY karyotype. (b) Complex male XY karyotype of a myeloma patient, showing 5 copies of 1q (shown at 1 and 21), del(13) (q14), and hyperdiploidy with mostly odd numbered chromosomes (gains at 1, 3, 9, 11, 18 and 21). (c) FISH analysis showing gain of 3 copies (1q21CKS1B), (1p32.3CDKN2C). (d) FISH analysis showing deletion 13 (13q14 D13S25), (13q34 LAMP). The deletion of both FISH markers makes it look like a monosomy 13; however, karyotype (b) shows that part of 13 is retained just below the centromere. 53