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Is chemotherapy the right treatment for multiple myeloma?

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Posted on Mon, 30 May 2016
Question: Hi,

My mother is diagnosed with Multiple Myeloma IgG Kappa. The initial plasma cell count was 15%, Mprotein 2.54, Kappa 122.0, Lambda 5.4 and k/l ratio 22.593

We underwent 4 cycles of chemotherapy with VTD + Lipodox + Zolendronic acid. Thalix 100mg daily was also prescribed. Post 4 cycles plasma cell count was 7% Mprotein 0.53, Kappa 33.8, Lambda 0.53 and k/l ratio 67.600.

Late 2 more cycles chemotherapy with RVD + Zolendronic acid was administered. Lenalidomide 10mg daily (3 weeks ON and 1 week OFF) was also prescribed. Current test results are plasma cell (not tested), Mprotein 0.24, Kappa 30, Lambda 9.9 and k/l ratio 3.03.

Proposed regime is to continue with 2 more cycles of chemotherapy with RVD + Zolendronic acid
Lenalidomide 25mg daily (3 weeks ON and 1 week OFF).

I am looking for a 2nd opinion on this chemo regime. Is this chemotherapy required? or should we look for oral administration of Lenalidomide, Dexona & Bortezomib as maintenance.
What is the complete response/remission that we should be looking at with respect to Mprotein, Kappa, Lambda and k/l ratio values?

Regards
XXXX XXXXXXX
doctor
Answered by Dr. Indranil Ghosh (38 minutes later)
Brief Answer:
can continue with lenalidomide and dexamethasone only

Detailed Answer:
Hi
Thanks for your query.

At present your mom has achieved very good response. There is no fixed target for response, the more the better. If bone marrow plasma cells less than 5% with no m band and Kappa lambda normal, that is best but few patients can achieve that.

First we need to see if she is a stem cell transplant candidate. If possible, that is best. Otherwise, we can continue with lenalidomide plus dexamethasone, omitting bortezomib. And zoledronate can continue. In this regime, Lenalidomide can be escalated to 25 if tolerated. But with bortezomib I don't recommend increasing lenalidomide to more than 10 mg.

There are various approaches to treatment of myeloma. Continuing full treatment with RVD is also an option.

Hope this helps.
Regards
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Indranil Ghosh (4 hours later)
Hi,

Thanks for the response

Question
What is the Kappa lambda normal values.
And I am assuming its ideal to have no M band, but what would be nominal value.

How long should we ideally continue lenalidomide and dexamethasone before a reassessment.

My mother is not willing for stem cell transplant, so that option is waved off

Also recently she is having tooth ache and tiredness. Will this be a side affect of any medicine or after effect of myeloma. As per the dentist I consulted, faulty tooth can be removed only after 6 months of stopping chemo. Is this information correct. Thanks

Regards
XXXX XXXXXXX
doctor
Answered by Dr. Indranil Ghosh (51 minutes later)
Brief Answer:
please refer below

Detailed Answer:
Normal levels of serum free light chains are:
Kappa: 3.3–19.4 mg/L
Lambda: 5.71–26.3 mg/L
Kappa/lambda ratio: 0.26–1.65 (all can vary with lab)

Ideal would be normal M band in both electrophoresis and immunofixation methods and normal kappa/lambda.

If we continue len-dex, test M band and kappa/lambda every 3 months and continue treatment as long as disease under control.

Tooth extraction can be done while or lenalidomide or dexa or bortezomib but avoided if on zoledronate. Can be done preferably 3 months after stopping it.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Indranil Ghosh (55 minutes later)
Sorry belive you missed on one question

Is tooth degradation side affect of any medicine or because of myeloma. Or is it unrelated issue

Thanks
doctor
Answered by Dr. Indranil Ghosh (11 hours later)
Brief Answer:
probably unrelated

Detailed Answer:
unlikely to be because of myeloma or treatment. Most probably it is unrelated tooth problem only
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
Answered by
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Dr. Indranil Ghosh

Oncologist

Practicing since :2004

Answered : 1656 Questions

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Is chemotherapy the right treatment for multiple myeloma?

Brief Answer: can continue with lenalidomide and dexamethasone only Detailed Answer: Hi Thanks for your query. At present your mom has achieved very good response. There is no fixed target for response, the more the better. If bone marrow plasma cells less than 5% with no m band and Kappa lambda normal, that is best but few patients can achieve that. First we need to see if she is a stem cell transplant candidate. If possible, that is best. Otherwise, we can continue with lenalidomide plus dexamethasone, omitting bortezomib. And zoledronate can continue. In this regime, Lenalidomide can be escalated to 25 if tolerated. But with bortezomib I don't recommend increasing lenalidomide to more than 10 mg. There are various approaches to treatment of myeloma. Continuing full treatment with RVD is also an option. Hope this helps. Regards