By Jack Aiello
San Francisco/Greater Bay Area, CA
@JackMAiello
[email protected]

Today’s first meeting started at 7:30 am with a session titled Myeloma (MM): Controversies in Therapy. Dr. Philippe Moreau (University Hospital of Nantes, France) took the Pro position and Dr. Paul Richardson (Dana-Farber Cancer Institute) took the Con position to the question about always using an autologous stem cell transplant (SCT) as part of initial therapy for transplant-eligible MM patients. So if two brilliant MM specialists can argue each side of this question, it’s no wonder that patients might have a difficulty deciding.

Some comments I thought I’d share:

Moreau – “Velcade must be part of induction treatment in preparation for an SCT.” “For transplant-eligible patients, feasibility of an early SCT is 90% but <70% for a delayed SCT.”

Richardson – “We have to be cognizant of long-term malignancies from high-dose therapies [SCT].” “At some point the biology of a patient’s MM will dictate whether or not SCT is the best treatment.”

You should know that both these doctors are jointly working together as primary investigators for the large 1300 patient accrual hoping to answer this very question (but it may be 2016-17 before we have initial results).

Dr. Joseph Mikhael (Mayo Clinic) presented a practical approach to treating relapsed/refractory patients. He began by reminding the several thousand attendees that the definition of MM has recently changed which previously required one of the CRAB symptoms. However, ultra high-risk smoldering MM, defined as having one of: plasma % > 60, free light chain ratio >100, or >1 focal lesion, is now classified as MM… which he abbreviated as SLiM CRAB. He said doctors should always ask 5 questions: 1) Do I treat the patient now? 2) Should I retreat with previous therapy? 3) Have I employed the Big 5 (Thalomid, Velcade, Revlimid, Kyprolis, & Pomalyst)? 4) Have I considered an “add-on” agent (e.g. cytoxin, doxil)? 5) Have I considered an individualized risk-stratified approach?

Later this morning I attended oral presentations on ibrutinib (BTK inhibitor) and oprozomib (oral proteasome inhibitor) but being early in phase II trials, I think the results, while promising, are too early to get excited. I also listened to results from two trials with panobinostat (HDAC inhibitor), one with Kyprolis for R/R patients and one with Revlimid-Velcade-dexamethasone (RVd) for newly diagnosed patients. These were trials generally trying to determine MTD (maximum tolerated dose) of panobinostat (20 and 10 mg respectively).

This afternoon I spent time reviewing posters (selected paper presentations) as well as visiting some of the exhibits, such as Sequentia where I learned more about minimal residual disease (MRD) testing. One of the posters I found intriguing investigated treatment outcomes for patients who have more than one monoclonal immunoglobulin (M-protein), such as IgG kappa + IgA lambda rather than only IgG kappa. I didn’t even know this was possible but in fact about 2% of MM patients have multiple M-proteins. How ‘bout that? It turns out that this occurrence is NOT associated with adverse treatment or survival outcomes.

This evening I attended the IMF’s annual grants award reception. After listening to some wonderful patient stories, I was encouraged to see young researchers presented with monetary awards to continue their research in areas such as MRD and the myeloma microenvironment.

That’s it for a long day. Wishing you best of health. -Jack

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