Multiple Myeloma: A Review in Single Center Experience View PDF

Multiple myeloma (MM) is a clonal plasma cell disease characterized by malignant bone marrow plasmacytosis, which secrete monoclonal protein, and the presence of target organ damage including bone lytic lesion, anemia, hypercalcemia, and renal derangement [1]. Males are predominantly affected by a median age of 70 years in Western countries, however, in some countries, onset is recorded in younger age groups [2,3]. Multiple myeloma is reported to be the second most common hematological malignancies after non-Hodgkin lymphoma. It accounts for approximately 1.8% of all new cancers and 10% of all hematological malignancies [4]. Multiple myeloma is known to be a treatable but unfortunately not curable disease, and thus prolong observation and follow- up are highly recommended recommended [5]. International staging system is commonly used, has recently been updated [6]. Skeletal survey in form of whole body MRI, low dose CT, and PET/CT is a nowadays practiced as the initial workup of myeloma patients [7] unfortunately a plain X-rays, can only showed lesion when at least 20% to 30% bone is lost. So, with advanced imaging modalities, even subtle bone marrow infiltration can be checked without any bone loss. Full workup should include complete blood count, biochemistry panel LDH, calcium, protein electrophoresis, bone marrow study and cytogenetics. Anemia, high calcium, Azotemia, and bony lesions are known to be a myeloma defining events. The appearance of any of these events is an indication to start treatment. The type of treatment depends on age, stage o transplant eligibility, performance status [8]. Still high dose chemotherapy and autologous stem cells transplant (HDT/ASCT) and novel agents, such as immune modulatory drugs (thalidomide, lenalidomide, and pomalidomide), and proteasome inhibitors (bortezomib, carfilzomib) are the standard of care for transplant eligible; patients [9]. The present study aimed at determining the characteristics and outcomes of multiple myeloma patients treated in our center. We analyzed demographic features, progression- free survival, and overall survival of patients with MM treated with different available chemotherapeutic regimens.

In total, 77 MM patients were enrolled from March 2016 to December 2019 in Thiqar hematology center among patients enrolled 75 patients had symptomatic MM based on International Myeloma Working Group (IMWG) diagnostic criteria were selected. Thus, two patients were excluded because they were diagnosed with smouldeing myeloma. VGPR was defined as serum para protein reduction of >90% and/or a 24?h urine M?protein excretion lower than 100 mg. PR was defined as a reduction of M protein by at least 50% in serum and 90% in urine and/or to <200 mg/24 hr, as well as a reduction in 50% or more of the cross?sectional areas of extraosseous plasmacytomas. 

The median patient age was 65 years (range, 37–88 years) and 56% of patients were male (Table 1). Fourty five patients (60 %) had lytic bone lesions. Four patients (5.3%) had extramedullary plasmacytoma and 10 (13%) ad >60% of plasma cells in bone marrow. Eighty-three patients (50.6%) had hemoglobin concentrations 3. Hypercalcemia (serum calcium concentration >11 mg/dl) and renal function impairment (serum creatinine concentration >2 mg/dl) were present in 12 (16%) and 6 (8%) patients, respectively (Table 1). The main presenting features were bone pain (88%). Median serum creatinine concentration was 0.8 mg/dl (range, 0.5-10 mg/dl). Median serum M-protein concentration was 6.6 g/dl (range 0.0-17 g/dl). Urine M-protein concentration was not done. Sixty one patients (81.5%) were treated with VCD (Velcade, Endoxan, and dexamethasone); while the other 14 patients (18.5%) were treated with VRD (Velcade, Revlimid, Dexamethasone) as a chemo free regimen chosen by patients who refused chemotherapy based. The response had an assessed by SPE/IF. Both group did not showed any statistically significant survival differences with P value of 0.170, of these 75 patients, 28 (37.3%)  relapsed, 15 (20% ) transplanted and 22 (30%) died, of these 61 patients, 47 (75%) achieved VGPR while 14 (33%) attained less than PR. In compare to 14 patients were treated by VRD, 13 (92%) patients achieved VGPR and one patient only failed to attained PR again with failed to achieved any statically difference between two protocols, the median duration of survival was 25 months (Tables 2 and 3).

Table 1: Patient characteristics and laboratory findings.

Table 2: Response comparison between two chemotherapy protocols.

Table 3: Chemo survival cross tabulation.

This study evaluated characteristics and outcomes of 75 MM patients, globally, quite 114,000 new MM cases were diagnosed worldwide in 2012 (0.8% of total cancer cases [10]. According to this study, MM accounts for 1.66% of total cancer cases, with an age-standardized incidence of 1% in males and 0.7% in females which is above global figures highlighted a neighborhood of high incidence might be explained due to war pollutions [11]. Our study showed that the median age at the onset of the disease was 65 years, with 50.6% of patients being younger than 65 years of age) which is far younger compared to the Western data. Similar age of onset has been noticed in Saudi Arabia [12]. Prevalence of MM was more in males needless to say which is in line with other studies. The bulk of the patients during this study were within the advanced stage of the disease (Durie salmon, II/III). One reason might be due to lack of awareness among other medical specialties (orthopedist and rheumatologist), which is in comparable a study conducted in Abu Dhabi/UAE [13-15]. In this study, nearly 60% of patients suffered from skeletal complications. Till date, conventional bone survey remains the quality modality for the assessing of myeloma skeletal disease in our center and this correlates with published evidence. This number may go up if whole body MRI or PET/CT are used at initial workup [7-16], which isn't available in our center at time of the study. Unavailability of whole body MRI in many centers, many patients will be undertreated. The goal of induction treatment before autologous stem cell transplant (ASCT) is to achieve the very best possible response rate while avoiding significant toxicity in transplant eligible VCD and VRD are the 2 most ordinarily used induction therapy for newly diagnosed, transplant eligible MM patients. Our results indicate that both VCD and VRD are efficacious and well tolerated induction regimens with comparable statistical figures. Although our patients consisted of mostly transplant eligible patients, only 15 (20%) patients underwent HDT/ASCT. there have been different reasons for delaying transplant including the shortage of transplant services in Iraq, cost of the procedure for those patients who were paying for his or her treatment. some patients refuse transplant due to complications including deaths which will occur during HDT/ASCT. Limitations of the study there have been some limitations during this study. This was a retrospective analysis, single center experience). Iraq is that the large country within the area, with a population of quite 38 million [14]. Despite healthcare being liberal to Iraqi citizens, still variety of massive barriers controlling healthcare access, While MM may be a relatively uncommon cancer in Iraq, it's been recorded that the characteristics of Iraqi patients with MM differ from those of western MM patients, highlighting the necessity for a national study of the trends and outcomes of MM in Iraq. However, published literature on MM patient characteristics, treatment patterns, and outcomes in Iraq is scant.

Based on our results, onset of myeloma occurs during a relatively younger age bracket and the majority present with advanced stage.

Cost and availability of novel agents and transplant access are major challenges in providing high standard care to patients with myeloma in Iraq.

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