ResourcesOncoLogue: Cases in Follicular Lymphoma, Chronic Lymphocytic Leukemia, and Multiple Myeloma
Earn up to 1.5 AMA PRA Category 1 Credits™
OncoLogue is a dialogue among a multidisciplinary panel of experts that reflects real-world clinical discussions. It allows participants to hear and see thought leaders discuss patient management and treatment issues, experience case-based learning, and digest evidence-based commentary regarding treatment decisions.
The activity will include three clinical scenarios with which participants may engage: one patient diagnosed with follicular lymphoma (FL), one with chronic lymphocytic leukemia (CLL), and one with multiple myeloma (MM).
PER Pulse™ Recap
Two PER Pulse™ Recaps highlighting key decision points from case presentations on multiple myeloma, follicular lymphoma and chronic lymphocytic leukemia.
PER Pulse™ Recap
Medical Writer: David Lee, PhD
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PER Pulse™ Recap:
Management of a Patient with Transplant-Ineligible Multiple Myeloma
The online CME activity OncoLogue: Cases in Follicular Lymphoma, Chronic Lymphocytic Leukemia, and Multiple Myeloma featured experts in hematologic malignancies addressing best practices for the management of patients with follicular lymphoma (FL), chronic lymphocytic leukemia (CLL), and multiple myeloma (MM), as well as emerging therapeutic paradigms. This first of 2 PER Pulse™ Recaps examines a patient with transplant-ineligible MM addressed by Dr. Sagar Lonial.
The patient was a newly diagnosed, 76-year-old male. He had a past history of coronary artery disease, myocardial infarction, and hypertension, and had led a sedentary lifestyle for the past 5 years. He also had borderline diabetes and was taking medication for angina. He underwent laboratory and immunologic workup; a bone marrow biopsy showed a cellularity of 60% with over 60% clonal plasma cells detected by flow cytometry. A CD138-selected fluorescence in situ hybridization (FISH) panel showed del(13) and hyperdiploidy, but no t(4;14), t(14:16), or del(17p) abnormalities. One important test that had not been done prior to his referral to Dr. Lonial was an assessment of b2-microglobulin levels; the results of this test established the patient as having International Staging System (ISS) stage II symptomatic MM. Due to his medical history, the patient’s cardiologist considered him to be at increased cardiac risk from stem-cell transplant and so should avoid this procedure.
Several treatment options were mentioned, including both melphalan-based and melphalan-free regimens. Dr. Lonial mentioned that while melphalan-based triplets have long been a standard of care for patients with transplant-ineligible MM, recent trials such as the phase III FIRST study have challenged this paradigm. The FIRST trial compared lenalidomide/dexamethasone (Ld), for a fixed or continuous schedule to melphalan/prednisone/thalidomide (MPT), and showed improved progression-free survival (25.5 months vs 21.2 months; P = .00006) and 4-year overall survival (59% vs 51%; hazard ratio = 0.78; P = .0168) for continuous Ld versus MPT.
These results provide the rationale for a melphalan-free regimen for patients with transplant-ineligible MM. Bortezomib plus dexamethasone was studied in elderly patients in the UPFRONT trial and is another reasonable treatment option. The combination of MP plus bortezomib (MPV) using weekly bortezomib dosing was mentioned by Dr. Lonial as another option based on trials such as VISTA. The combination of MP plus lenalidomide (MPR) has been studied, and Dr. Lonial mentioned that the benefit associated with MPR appears to be the use of lenalidomide maintenance, which can potentially be used without a melphalan-based induction regimen. Finally, variations on the combination of lenalidomide, bortezomib, and dexamethasone (RVD) are being explored for use in elderly patients.
2 of 2
PER Pulse™ Recap:
Management of Patients with Follicular Lymphoma and Chronic Lymphocytic Leukemia
The online CME activity OncoLogue: Cases in Follicular Lymphoma, Chronic Lymphocytic Leukemia, and Multiple Myeloma featured experts in hematologic malignancies addressing best practices for the management of patients with follicular lymphoma (FL), chronic lymphocytic leukemia (CLL), and multiple myeloma (MM), as well as emerging therapeutic paradigms. This second of 2 PER PulseTM Recaps examines a patient with asymptomatic FL, addressed by Dr. Christopher Maisel, and a patient with relapsed/refractory CLL, addressed by Dr. William Wierda.
Dr. Maisel described the case of a 71-year-old patient with FL who did not have any fever, weight loss, or other B symptoms. Although re-staging computed tomography scans showed increasing adenopathy, Dr. Maisel pointed out that this patient was still asymptomatic and still met the GELF (Groupe d'Etude des Lymphomes Folliculaires) criteria for low tumor burden. Clinical trials have investigated active treatment in this population of patients, most notably a trial conducted in the United Kingdom of observation versus rituximab. This trial demonstrated a significantly prolonged time to initiation of new therapy with rituximab given weekly for 4 weeks followed by maintenance compared with observation; however, 3-year overall survival (OS) was not significantly different. Thus, in patients with asymptomatic, low-tumor-burden FL, observation remains the standard of care.
The patient with CLL reviewed by Dr. Wierda was a 55-year-old male initially noted to have lymphocytosis and a subsequent diagnosis of Rai stage II (Binet A) CLL with del(11q) and unmutated IgVH genes. He did not have any B symptoms or other criteria for treatment, and therefore underwent observation, although Dr. Wierda stated that the del(11q) feature suggests a shorter time to requiring therapy, often within 3 years of diagnosis. After 2 years of monitoring, the patient presented with fatigue and dyspnea on exertion, as well as a decreasing platelet count (ie, below 100,000/mm3). At this point, the patient had high-risk, Rai stage IV disease and was treated with fludarabine/cyclophosphamide/rituximab (FCR) for 5 cycles, achieving a complete response.
The patient’s first remission lasted only 18 months, at which point he had symptomatic, progressive disease. At this point, for this patient with pretreated CLL, del(11q), and a short first remission, the Bruton’s tyrosine kinase inhibitor ibrutinib, approved in this setting, would be considered a standard option. This recommendation is based on a phase III trial in relapsed/refractory CLL demonstrating superior progression-free survival (PFS) with ibrutinib compared with ofatumumab (not reached vs 8.1 months; P < .0001); OS was also significantly improved with ibrutinib (P = .0049; median not reached for either arm). If this option was not available, Dr. Wierda mentioned that one could consider bendamustine/rituximab (BR), an alkylating agent-based regimen followed by allogeneic stem cell transplant, or lenalidomide plus rituximab. Treatment with FR or retreatment with FCR would not be optimal given the short remission duration.
For additional commentary about these topics and others, visit www.gotoper.com to access archived video of OncoLogue: Cases in Follicular Lymphoma, Chronic Lymphocytic Leukemia, and Multiple Myeloma.
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This activity is not approved for AMA PRA Category 1 Credit™.
This activity is supported by an educational grant from Celgene Corporation.