Patient Handbook for the Newly

February 2023 Edition | Prepared by Brian G.M. Durie, MD

Founded in 1990, the International Myeloma Foundation (IMF) is the first and largest organization focusing specifically on myeloma. The IMF’s reach extends to more than 525,000 members in 140 countries. The IMF is dedicated to improving the quality of life of myeloma patients while working toward prevention and a cure through our four founding principles: Research, Education, Support, and Advocacy.

RESEARCH

The IMF is dedicated to finding a cure for myeloma, and we have a range of initiatives to make this happen. The International Myeloma Working Group, which emerged from the IMF’s Scientific Advisory Board established in 1995, is the most prestigious organization with nearly 300 myeloma researchers conducting collaborative research to improve outcomes for patients while providing critically appraised consensus guidelines that are followed around the world. Our Black Swan Research Initiative® is bridging the gap from long-term remission to cure. Our annual Brian D. Novis Research Grant Program is supporting the most promising projects by junior and senior investigators. Our Nurse Leadership Board, comprised of nurses from leading myeloma treatment centers, develops recommendations for the nursing care of myeloma patients.

EDUCATION

The IMF’s webinars, seminars, and workshops provide up-to-date information presented by leading myeloma scientists and clinicians directly to patients and their families. We have a library of more than 100 publications for patients, care partners, and healthcare professionals. IMF publications are always free-of-charge, and available in English and select other languages.

SUPPORT The IMF InfoLine responds to your myeloma-related questions and concerns via phone and email, providing the most accurate information in a caring and compassionate manner. We also sustain a network of myeloma support groups, training hundreds of dedicated patients, care partners, and nurses who volunteer to lead these groups in their communities.

ADVOCACY

We empower thousands of individuals who make a positive impact each year on issues critical to the myeloma community. In the U.S., we lead coalitions to represent the interests of the myeloma community at both federal and state levels. Outside the U.S., the IMF’s Global Myeloma Action Network works to help patients gain access to treatment.

Learn more about the ways the IMF is helping to improve the quality of life of myeloma patients while working toward prevention and a cure. Call us at 1.818.487.7455 or 1.800.452.CURE, or visit myeloma.org .

You are not alone

The International Myeloma Foundation is here to help you. The IMF is committed to providing information and support for patients with multiple myeloma (which we refer to simply as “myeloma”) and their care partners, friends, and family. We achieve this through a broad range of resources available on our website myeloma.org, the IMF InfoLine, seminars, webinars, workshops, and other programs and services.

Myeloma is a cancer that is not known to most patients at the time of diagnosis. It is important and helpful to learn as much as possible about myeloma and its treatment options in order to play an active role in your own medical care and to make good decisions about your care with your doctor. The information in this booklet will help you in discussions with your healthcare team.

What you will learn from this booklet

The IMF’s Patient Handbook for the Newly Diagnosed will help you to better understand myeloma. Words in bold+blue type are explained in the “Terms and definitions” section at the end of this booklet. The IMF’s Glossary of Myeloma Terms and Definitions, a more complete myeloma-related compilation, is located at glossary.myeloma.org.

If you are reading this booklet in electronic format, the light blue hyperlinks will take you to the corresponding resources. All IMF publications are free-of-charge and can be downloaded or requested in printed form at publications.myeloma.org.

Myeloma is a highly treatable disease

Healthy plasma cells are an important part of the immune system. Plasma cells are a type of white blood cell (WBC) in the bone marrow responsible for making antibodies, also called immunoglobulins (Ig).

Myeloma cells are malignant plasma cells that do not make functioning antibodies, but instead produce an abnormal monoclonal protein (myeloma protein, M-protein).

Myeloma is called “multiple” because it frequently involves multiple areas in the body. The only time that myeloma is not “multiple” is in the rare case of a solitary plasmacytoma.

Myeloma most often grows in the marrow within the bones of the spine, skull, pelvis, rib cage, shoulders, and hips. Usually, the bones of the hands, feet, and lower parts of the arms and legs are not affected. Myeloma can appear as a tumor and/or as an area of bone loss. In either case, this is called a lesion. The presence of myeloma cells within the bone marrow can

lead to other medical problems within and outside the bone marrow microenvironment.

Many highly effective therapies are approved for treatment of myeloma by the United States Food and Drug Administration (FDA), the European Medicines Agency (EMA), and by other regulatory agencies. Numerous clinical trials are currently taking place around the world, adding more promising therapies to the growing list of treatment options.

Many myeloma patients lead full and productive lives for years, even decades, after diagnosis. Survival and quality of life of myeloma patients are improving steadily. Learning about myeloma and understanding how it is treated can help patients and their loved ones reduce their anxiety, gain a sense of control, and make it easier to come to terms with the diagnosis.

Precursors to myeloma

The earliest stage of myeloma is a benign condition called monoclonal gammopathy of undetermined significance (MGUS). People with MGUS must be monitored carefully for a possible change in their status. If the level of M-protein remains stable and there are no other health changes, the time between visits to your hematologist and/or oncologist can be extended.

All myeloma patients have MGUS before they progress to myeloma, but only 20% of people diagnosed with MGUS eventually develop myeloma. The risk of progression from MGUS to myeloma is 1% per year.

The stage between MGUS and active myeloma is called smoldering multiple myeloma (SMM). It is characterized by a higher level of M-protein than MGUS but with no indicators of active myeloma. In patients with standard-risk SMM, the risk of progression to active myeloma is 10% per year for the first five years, 3% per year for the next five years, and 1%–2% per year for the next 10 years. For more information, read the IMF publication

Understanding MGUS and Smoldering Multiple Myeloma.

Some myeloma statistics

In the United States, according to data from the National Cancer Institute's SEER (Surveillance, Epidemiology, and End Results) program, there were approximately 34,470 new cases of myeloma in 2022, representing 1.8% of

Figure 1. Myeloma cells in the bone marrow

all new cancer cases. Also according to the latest available SEER data, there were an estimated 159,787 people living with myeloma in the U.S. in 2019.

As published in the journal Oncologist in 2020, the global incidence of myeloma shows significant disparities, indicating under-recognition and suboptimal treatment in many parts of the world. The article highlights the importance of economic resources, access to and quality of healthcare, and patient education for improving diagnosis and survival of patients with myeloma worldwide.

Myeloma is most frequently diagnosed in individuals who are 65–74 years old, but it is also being diagnosed in people younger than 50. Only 5%–10% of myeloma patients are under the age of 40. Myeloma in children is extremely rare.

Men are more likely than women to develop myeloma. The disease is twice as common in people of African descent. It appears that the incidence of myeloma is increasing in several parts of the world, especially in Asia.

Approximately 5%–7% of myeloma diagnoses occur in individuals with a close relative diagnosed with MGUS, SMM, or myeloma. If you have a close relative with such a diagnosis, tell your primary care doctor to include this information in your medical record. Conversely, tell your relatives to inform their doctors to include your diagnosis in their medical history if you have MGUS, SMM, or myeloma.

Causes or triggers of myeloma

Exposure to anything that interferes with or suppresses the immune system, or infection with cancer-causing viruses, have all been implicated as causes or triggers of myeloma. Toxic chemicals that have been identified include:

¡ Benzene.

¡ Dioxins (such as those found in Agent Orange).

¡ Agricultural chemicals (such as defoliants and pesticides).

¡ Solvents.

¡ Fuels.

¡ Engine exhausts.

¡ Cleaning products.

Viruses that have been implicated as possible triggers for myeloma include HIV (the AIDS virus), hepatitis, some herpes viruses, and simian virus 40 (SV40, a contaminant in Sabin polio vaccine preparations that were used between 1955 and 1963).

Get the correct diagnosis

Myeloma is a highly individual disease. Often, it is slow-moving. Sometimes, it can be very aggressive. A skilled hematologist-oncologist who specializes in myeloma and other diseases of the plasma cells can make the correct diagnosis and tailor a treatment approach best suited to your individual situation.

A local oncologist might see a few myeloma patients or none at all. Myeloma specialists at large “high-volume” treatment centers and large academic institutions see hundreds of myeloma patients, conduct clinical trials with new drugs and new combination therapies, and develop the expertise needed to make appropriate decisions. Experienced myeloma specialists can anticipate treatment-related problems, and prevent or mitigate them.

Table 1.

DISORDER DEFINITION

MGUS All criteria must be met

Diagnostic Criteria

1. Presence of M-protein in the serum < 3 g/dL,

2. Presence of monoclonal plasma cells in the bone marrow < 10%, and

3. Absence of CRAB criteria – elevated Calcium, Renal (kidney) damage, Anemia, or Bone disease.

Light chain MGUS All criteria must be met

1. Abnormal FLC ratio < 0.26 or > 1.65,

2. Level of the appropriate involved light chain (increased kappa FLC in patients with ratio > 1.65 and increased lambda FLC in patients with ratio < 0.26),

3. No Ig heavy chain expression on immunofixation,

4. Absence of CRAB criteria,

5. Presence of monoclonal plasma cells in the bone marrow < 10%, and

6. Presence of M-protein in the urine based on a 24-hour collection < 500 mg.

SMM Both criteria must be met

1. Presence of M-protein in the serum (IgG or IgA) ≥ 3 g/dL, or urinary M-protein ≥ 500 mg per 24-hour collection, and/or presence of monoclonal plasma cells in the bone marrow 10%–60%, and

2. Absence of myeloma-defining events (MDE) or amyloidosis.

Myeloma Both criteria must be met

1. Presence of monoclonal plasma cells in the bone marrow ≥ 10%, or biopsy-proven bony or extramedullary plasmacytoma, and

2. Any one or more of the following myeloma-defining events (MDE):

¡ Presence of CRAB criteria,

¡ Presence of monoclonal plasma cells in the bone marrow ≥ 60%,

¡ Ratio of involved-to-uninvolved serum FLC ≥ 100 (involved FLC level must be ≥ 100 mg/L and urine M-protein level must be at least 200 mg per 24-hour collection on UPEP),

¡ One or more focal lesions on MRI studies (at least 5mm in size),

¡ One or more osteolytic lesions on skeletal radiography, CT, or PET-CT

Modified from Rajkumar SV, Dimopoulos MA, Palumbo A, et al . International Myeloma Working Group updated criteria for the diagnosis of multiple myeloma. Lancet Oncology 2014.

IMWG

Table 2. Medical problems related to myeloma

E FFECTS OF INCREASED MYELOMA CELLS IN BONE MARROW CRAB criteria

CAUSE IMPACT ON PATIENT

C – Increase in blood Calcium Release of calcium from damaged bone into bloodstream.

• Mental confusion

• Dehydration

• Constipation

• Fatigue

• Weakness

• Renal (kidney) damage

R – Renal problems –kidney damage

Abnormal M-proteins produced by the myeloma cells are released into the bloodstream and can pass into the urine, causing kidney damage. High blood calcium, infections, and other factors can also cause or increase the severity of kidney damage.

A – Anemia Decrease in number and activity of red blood cell-producing cells in the bone marrow.

B – Bone Damage

• Thinning (osteoporosis) or

• Areas of more severe damage (called lytic lesions), fracture, or collapse of a vertebra

Additional types of organ dysfunction

The myeloma cells activate osteoclast cells, which destroy bone and block osteoblast cells, which normally repair damaged bone.

• Sluggish circulation

• Fatigue

• Mental confusion

Abnormal immune function

Local or systemic effects of myeloma, other than CRAB features.

• Fatigue

• Weakness

• Bone pain

• Fracture or collapse of a bone

• Bone swelling

• Nerve or spinal cord damage

The myeloma cells reduce the number and activity of normal plasma cells capable of producing antibodies against infection.

• Neuropathy

• Recurrent infections

• Bleeding problems

• Other individual problems

• Susceptibility to infection

• Delayed recovery from infection

Even if there is no myeloma specialist near you, we encourage you to get a second opinion from a specialist, either in person or remotely. Also, your local doctor can schedule a consultation with a myeloma specialist to discuss your case, then work collaboratively with the specialist in administering your care.

A large study published in 2016 shows that overall survival (OS) rates are higher for patients who receive care at “high-volume” centers than in smaller medical practices. This is why we urge you to consult with a myeloma specialist.

Criteria for diagnosing myeloma

"CRAB criteria" are the most common medical problems caused by myeloma:

¡ An elevated level of Calcium in the blood.

¡ Kidney damage (or in medical terms, Renal damage).

¡ Low blood counts (especially low red blood cell (RBC) count, or Anemia).

¡ Bone damage.

For many years, the CRAB criteria were the sole basis for a diagnosis of active myeloma. Without one of these signs that myeloma had already caused “end-organ damage,” patients were monitored by their doctor but not treated.

Within the last few years, more effective treatments for myeloma as well as better methods of assessing early disease have led to significant changes in the treatment paradigm.

Members of the IMF’s research arm, the International Myeloma Working Group (IMWG), studied patients with asymptomatic SMM to find biological markers

- + Myeloma cells Lytic lesion

HEALTHY BONE

MULTIPLE MYELOMA

Figure 2. Healthy bone compared to myeloma bone

STAGE I (low cell mass)

Myeloma-de ning events (MDE)

 Bone marrow plasma cells ≥ 60%

 Ratio of monoclonal to normal light chains ≥100

 >1 focal lesion on MRI

Spanish Criteria

MM Multiple Myeloma

Early Active Myeloma Ultra-High-Risk Smoldering Myeloma

HR SMM High-Risk Smoldering Multiple Myeloma

LR SMM Low-Risk Smoldering Multiple Myeloma

MGUS Monoclonal Gammopathy of Undetermined Signi cance

All of the following:

• Hemoglobin value > 10 g/dL

• Serum calcium value normal or < 10.5 mg/dL

• Bone X-ray, normal bone structure (scale 0), or solitary bone plasmacytoma only

• Low M-protein production rates IgG value < 5 g/dL; IgA value < 3 g/dL

• Urine light chain M-protein on electrophoresis < 4 g/24h

STAGE II (intermediate cell mass) Fitting neither Stage I nor Stage III

STAGE III (high cell mass) One or more of the following:

• Hemoglobin value < 8.5 g/dL

• Serum calcium value > 12 mg/dL

• Advanced lytic bone lesions (scale 3)

• High M-protein production rates IgG value > 7 g/dL; IgA value > 5 g/dL

• Urine light chain M-protein >12 g/24h

600 billion/m2

600 to 1,200 billion/m2

> 1,200 billion/m2

SUBCLASSIFICATION (either A or B)

• A: relatively normal renal function (serum creatinine value) <2.0 mg/dL

• B: abnormal renal function (serum creatinine value) >2.0 mg/dL

Table 3. The Durie-Salmon Staging System (DSS)

cells in whole

that could predict that end-organ damage would occur within 18 months to two years. After this research was completed and published, the IMWG wrote new guidelines for the diagnosis of myeloma to include three myeloma-defining events (MDE). The following MDEs independently indicate the need for treatment:

1. Presence of ≥ 60% plasma cells in the bone marrow.

2. A ratio of involved free light chains to uninvolved free light chains ≥ 100. (Uninvolved light chains are those that are not made by myeloma cells.)

3. The presence of more than one focal lesion seen on a magnetic resonance imaging (MRI) scan.

These three MDEs can be identified using tests that should be a part of a newly diagnosed patient’s myeloma work-up:

¡ Bone marrow biopsy.

¡ Freelite® test (serum free light chain assay).

¡ MRI scan.

Staging of myeloma

When myeloma is diagnosed, the stage of the disease varies from patient to patient.

In 1975, the Durie-Salmon Staging System (DSS) was introduced to classify patients with myeloma. The DSS demonstrated the correlation between the amount of myeloma and the damage caused by it. In some patients who produce a lot of M-protein, the number of myeloma cells can be quite low. Conversely, in patients with low M-protein production, the number of myeloma cells can be high.

In 2005, the IMWG developed the International Staging System (ISS), which is based on prognostic factors and expected survival. The ISS assesses disease behavior that is most predictive of aggressive myeloma. The ISS is based on four highly predictive markers of aggressive disease:

1. Serum beta-2 microglobulin (S β2M),

2. Serum albumin (S ALB),

3. C-reactive protein (CRP), and

4. Serum lactate dehydrogenase (LDH).

In 2015, the IMWG published the Revised International Staging System (R-ISS), combining ISS with two tests for chromosomal abnormalities. We strongly recommend that these two chromosomal studies are performed on bone marrow samples taken at the time of diagnosis:

¡ Cytogenetics (karyotyping),

¡ Fluorescence in situ hybridization (FISH).

Figure 5. Fluorescence in situ hybridization (FISH) of a myeloma cell

Figure 4. Karyotype analysis of human chromosomes

Figure 6. Chromosomal abnormalities in high-risk myeloma Deletion Translocation

Tests you really need

A laboratory blood test can assess the blood-borne proteins S β2M, S ALB, CRP, and LDH.

Cytogenetics is the laboratory assessment of chromosomes in dividing myeloma cells. The active growth rate of myeloma cells is usually very low. Fewer than 3% and often fewer than 1% of the cells are proliferating. This provides an incomplete assessment of any chromosomal changes present. Nonetheless, if abnormalities are noted, they are important because they appear on the few cells that are actually growing.

FISH is the assessment of the chromosomes of all myeloma cells in a bone marrow sample. FISH testing can detect the presence of translocations, missing pieces, extra pieces, and loss of chromosomes. FISH can detect changes regardless of whether myeloma cells are growing or not. Special gene probes that fluoresce (glow) are added to the bone marrow sample. These probes track genetic material after cell division and signal the presence or absence of chromosomal abnormalities that are known to occur in myeloma.

Each chromosome is given probes of a different color. For example, if genetic material from chromosome 4 is wrongly connected to chromosome 14, then the differently colored dots of genetic material from these chromosomes appear together, indicating the high-risk abnormality t(4;14), which stands for “translocation of genetic material between chromosomes 4 and 14.” Other abnormalities that are considered high-risk are t(14;16) and Table 4. Risk factors for myeloma and the R-ISS PROGNOSTIC FACTOR CRITERIA

ISS Stage I

Serum β2-microglobulin < 3.5 mg/L, serum albumin ≥ 3.5 g/dL II Not ISS stage I or III III

Serum β2-microglobulin ≥ 5.5 mg/L

CA by FISH High Risk Presence of one or more of the following: del(17p), t(4;14), t(14;16)

Standard Risk No high-risk CA

LDH Normal Serum LDH < the upper limit of normal High Serum LDH > the upper limit of normal

A new model for risk stratification for multiple myeloma

R-ISS Stage I

ISS stage I and standard-risk CA by FISH and normal LDH II

III

Not R-ISS stage I or III

ISS stage III and either high-risk CA by FISH or high LDH

CA, chromosomal abnormalities; FISH, fluorescence in situ hybridization; ISS, International Staging System; LDH, lactate dehydrogenase; R-ISS, Revised International Staging System.

t(14;20), del(17p) which stands for “deletion of the short arm (upper part) of chromosome 17,” and +1q which stands for “a gain in the long arm (lower part) of chromosome 1.”

The presence of abnormal chromosomes generally suggests poor prognosis, but this is a trend and not a guaranteed outcome. Approximately one third of patients with any of the high-risk features can do well and have normal outcomes with current standard treatment options, including induction therapy followed by autologous stem cell transplant (ASCT).

Baseline testing

Bone marrow biopsy:

This is the single most critical test to determine both the presence and the percentage of myeloma cells in the bone marrow, and to assess prognosis. In stage I myeloma or for a solitary plasmacytoma, direct biopsy of the tumor mass may be necessary. Cytogenetic analysis can reveal good or poor chromosomal features, but a fresh bone marrow sample is needed for this type of testing.

Blood tests:

¡ Complete blood count (CBC) is used to assess presence and severity of anemia, low white cell count, and low blood platelet count.

¡ Chemistry panel is used to assess kidney function (creatinine and BUN), liver functions, albumin, calcium level, and LDH.

Serum β2 microglobulin (S β2M)

Serum albumin (S ALB)

C-reactive protein (CRP)

Serum lactate dehydrogenase (LDH)

Abnormal chromosomes on bone marrow cytogenetics and fluorescence in situ hybridization (FISH)

The higher the level, the more advanced the stage.

The lower the level, the more advanced the stage.

Increased with active disease.

Increased with active disease.

Several chromosome deletions or translocations are considered high-risk; can be associated with shorter duration of remission.

Figure 6. Bone marrow biopsy

Table 5. Prognostic factors TEST SIGNIFICANCE

¡ Serum protein electrophoresis (SPEP) assesses amount of the myeloma heavy chain protein, and shows the presence of the M-spike.

¡ Immunofixation electrophoresis (IFE) shows the heavy chain (G, A, D, E, and M) and light chain (kappa [κ], lambda [λ]) types of the myeloma protein.

¡ Freelite assay measures the amount of free kappa or lambda light chains, and the kappa-tolambda ratio, if no SPEP or UPEP abnormality is discovered.

¡ Hevylite® assay measures normal and abnormal levels of intact immunoglobulins.

Urine tests:

Urine protein electrophoresis (UPEP) shows the amount of M-protein in the urine. Immunofixation shows the type of M-protein.

Bone testing:

The presence, severity, and location of bone damage can be assessed using the following:

Abnormal result with myeloma cells producing the M-protein, creating an M-spike in the beta-2 zone

Abnormal result with myeloma cells producing the M-protein, creating an M-spike in the gamma region

¡ X-rays show characteristic myeloma bone disease in the majority of patients, but X-rays can be negative in approximately 25% of patients with active myeloma. Further imaging with whole-body MRI, whole-body low-dose computed axial tomography (CAT or CT), or positron emission tomography (PET) -CT is needed to rule out possible bone involvement. A full skeletal survey for myeloma using a series of X-rays is needed to show loss (osteoporosis) or thinning (osteopenia) of bone caused by myeloma bone destruction, lytic lesions, or any fracture or collapse of bone.

¡ MRI can reveal the presence and distribution of disease in the bone marrow when X-rays show no bone damage. MRI shows more detail

Figure 7. SPEP test results

of particular areas, such as spine and brain. MRI can also reveal extramedullary disease, which may be pressing on nerves and/or on the spinal cord.

¡ CT scanning creates three-dimensional images of structures inside the body. In myeloma, CT scanning is used when X-rays are negative or for more detailed imaging of specific areas. CT scanning is especially useful for detection or detailed evaluation of small areas of bone damage or nerve pressure.

¡ PET scanning is a much more sensitive whole-body scanning technique. Using fluorodeoxyglucose (FDG)-PET or PET-CT is helpful for monitoring myeloma, especially for non-secretory myeloma. CT is used to assess sites of PET-positive disease.

¡ Bone density testing is helpful in myeloma to assess the severity of diffuse bone loss and to measure the serial improvement with bisphosphonate therapy.

¡ Nuclear medicine scans are not useful in myeloma and should not be performed unless ruling out other diagnoses.

For more information about tests used in myeloma, read the IMF’s publication Understanding Your Test Results.

Possible urgent problems at diagnosis

Because the vertebrae are often affected by myeloma, and because the spinal cord runs through the vertebrae, painful vertebral fractures that in turn cause nerve compression are not uncommon. Loss of motor nerves can cause paralysis. Myeloma tumors growing in the vertebrae can also press on spinal nerves. Breakdown of calcium from bones can result in hypercalcemia, a high level of calcium in the blood. Both hypercalcemia and high levels of M-protein in the blood can seriously affect the kidneys, causing kidney failure.

Vertebral compression fractures, damage to the nerves of the spinal cord, infections, and kidney failure are all emergency medical problems that require attention before beginning systemic therapy for myeloma.

We encourage prompt consultation with a myeloma specialist to ensure that any treatment of urgent problems leaves all therapeutic options open for the future. For example, radiation therapy to shrink a plasmacytoma that is pressing on nerve tissue must be weighed carefully against a surgical option, because radiation may damage the bone marrow and limit choices for later treatment.

Types of myeloma

There are different types and subtypes of myeloma, which are based on the type of immunoglobulin protein produced by the myeloma cells. The five types of normal heavy chain immunoglobulins that perform different functions in the body are IgG, IgA, IgD, IgE, and IgM. Each patient’s myeloma cells produce only one of these five types of immunoglobulins.

Each immunoglobulin is made up of two heavy chains bound to two light chains. The two types of light chains are kappa (κ) and lambda (λ). The typing of myeloma is done with immunofixation electrophoresis (IFE).

Approximately 65% of myeloma patients have IgG myeloma with either kappa or lambda light chains. The second-most common type is IgA myeloma, also with either kappa or lambda light chains. IgD, IgE, and IgM myelomas are quite rare.

Approximately one third of myeloma patients produce free light chains in addition to the complete molecule combination of light chains bound to heavy chains. In approximately 15%–20% of patients, the myeloma cells produce only light chains and no heavy chains. This is Bence-Jones myeloma, named for the English doctor who first detected and identified light chains, and published his findings in 1848. Light chain monoclonal proteins are smaller and weigh less than heavy chains, making it possible for them to fit through the tiny capillaries that send blood to the kidneys. The light chains that arrive by blood to the kidneys may build up to the point of blocking the kidney’s tubules, causing reduced kidney function.

In rare instances, only in about 1%–2% of patients, the myeloma cells produce very little or no monoclonal protein of any type. This is called non-secretory myeloma. The Freelite test can detect minute amounts of light chains in the blood of about 70% of these very low-secreting patients. In 2015, Mayo Clinic published a study of 124 patients with non-secretory myeloma, concluding that the survival of patients with non-secretory myeloma appears superior to that of patients with secretory disease.

Figure 9. Structures of immunoglobulins

IgE, IgD

Table 6. Types of myeloma and related diseases

DISEASE TYPE

Myeloma:

IgG κ or λ IgA κ or λ Rarer subtypes:

IgD, E, or M

Light Chain only or Bence-Jones myeloma: κ or λ types

Non-secretory myeloma: κ or λ types

IgM myeloma: κ or λ subtypes

Amyloidosis: AL or immunoglobulin

light chain type κ or λ subtypes

Light Chain Deposition Disease (LCDD): κ or λ subtypes

DESCRIPTION

• Typical myeloma – majority of patients

Monitored by tracking monoclonal protein in serum using SPEP (IgG) and/or quantitative immunoglobulin (QIG) measurement (IgA/IgD/IgE). For IgA myeloma, QIG measurement is often more reliable.

• Bence-Jones myeloma – approximately 15%–20% of patients

Monitored by tracking monoclonal light chains in the urine using UPEP and/or with serum free light chain measurements (Freelite) in the serum.

• Less common myeloma – 1%–2% of patients

Monitored by using the serum free light chain assay (Freelite) or with bone marrow biopsy and/or PET-CT scan.

• IgM myeloma – a very rare subtype

Typically, IgM production occurs in Waldenström macroglobulinemia, a disease that is more like a lymphoma versus myeloma, which is a bone marrow cancer.

• Amyloidosis

The light chains are deposited in a linear fashion (β-pleated) in tissues rather than being broken down and/or excreted in the urine. There are many varieties of amyloidosis involving deposits of different types of protein. For example, Alzheimer’s disease involves deposits of proteins in the brain.

• Myeloma-related amyloid

Light chains can be deposited in many tissues, including skin, tongue, heart, kidneys, nerves, lungs, liver, and intestines. Tissues stain positive with a “congo red” dye test, which is diagnostic. More detailed testing with mass spectroscopy and/or electron microscopy may be appropriate and necessary.

• LCDD

The light chains are deposited in a disorganized crosslinked fashion. Tissues stain positively with direct κ or λ immunostaining. Congo red staining is usually negative. There are different patterns of tissue deposits often involving the kidneys, the lining of the lungs (pleura) or peritoneum (around intestines) or within the eyes.

POEMS syndrome: Usually IgG or IgA λ (rarely κ subtype)

• POEMS syndrome

A complex disorder involving polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes. Diagnosed and treated differently from myeloma.

The importance of knowing your myeloma type

Knowing your type of myeloma will help you to understand and follow your test results over the course of your treatment. The Freelite test, along with SPEP, are used to monitor the levels of light chain and heavy chain M-protein produced by the myeloma cells. Measuring the output of myeloma cells is an indirect but effective way to assess the amount and activity of the cancer. The only way to observe myeloma cells directly is through a bone marrow biopsy.

Tests to monitor your level of M-protein, and many other tests, will be performed regularly to assess your response to treatment and keep track of your status during periods of remission. We strongly advise you to keep an ongoing record of your test results and to familiarize yourself with tests used in myeloma. Once again, we recommend that you read the IMF’s publication Understanding Your Test Results.

Behavior of the different types of myeloma

¡ IgG myeloma is the most common type, and its behavior conforms to the usual CRAB features.

¡ IgA myeloma is sometimes characterized by tumors outside of the bone.

¡ IgD myeloma can be accompanied by plasma cell leukemia (PCL), characterized by high levels of myeloma cells circulating in the blood. IgD myeloma is also known to cause kidney damage.

¡ Light chain myeloma is the most likely type to cause kidney damage and/or lead to deposits of light chains in the kidneys and/or on nerves or other organs. Depending upon the characteristics of the light chain deposits, this condition is called either amyloid light-chain amyloidosis (AL amyloidosis) or light chain deposition disease (LCDD).

Other related diseases of the plasma cells are Waldenström macroglobulinemia (WM), which is associated with IgM, and POEMS syndrome, a rare disease associated with neuropathy, enlarged organs, endocrine disorders, monoclonal protein, and skin changes.

Myeloma’s effects in the bone marrow

Myeloma cells release many proteins and other chemicals into the local bone marrow microenvironment and directly into the bloodstream. All the blood cells – white blood cells, red blood cells, and platelets – are made in the bone marrow. When myeloma grows in the bone marrow, the effects include a reduction in blood cell production. Anemia, a low level of red blood cells or hemoglobin, is an early and common sign of myeloma.

Cells in healthy bone marrow maintain our skeletons in a dynamic, balanced process of bone breakdown and bone buildup. The presence of myeloma cells in the bone marrow stimulates the cells that break downbone (osteoclasts) and suppresses cells that build new bone (osteoblasts). This upsets their balance, resulting in bone pain, fractures, and the release of calcium into the blood.

Myeloma’s effects outside the bone marrow

As myeloma cells reproduce and build up in the bone marrow, M-protein is released into the circulating blood. M-protein can cause tissue damage at distant sites. For example, kidney damage is quite common. M-protein can also interfere with blood clotting and/or circulation, potentially causing other organ or tissue damage, such as damage to nerve tissue (peripheral neuropathy, PN).

Treatment for newly diagnosed myeloma

Prompt and effective treatment is essential for any myeloma patient, especially for those with features of high-risk myeloma. Baseline testing, staging, and prognostic classification are essential. The most important initial decision is when to begin treatment for your myeloma.

Treatment for myeloma controls bone breakdown and tumor growth, as well as the diverse effects caused by M-proteins and the cytokines they stimulate.

Treatment is recommended for symptomatic active myeloma and for asymptomatic SMM with MDEs. The urgency of treatment depends upon the exact problems faced by an individual patient. This is why the experience and expertise of a myeloma specialist is of such importance.

A number of important clinical trials in recent years have led to significant advances in the treatment of newly diagnosed myeloma, and have greatly expanded the options that are available for patients. Drug-specific Understanding-series publications, available free-of-charge from the IMF, discuss drugs used to treat myeloma in greater detail.

Osteoblast (builds new bone)

Osteoc yte

Osteoclast (breaks down bone)

Spongy bone containing red marrow

Compac t bone Yellow marrow

Figure 10. Bone-building anatomy

© 2017 Slaybaugh Studios

potential newly diagnosed SMM or myeloma

SMM (absence of

intermediate-risk or low-risk SMM

observation

clinical trials

high-risk SMM

myeloma (presence of MDE):

• One or more CRAB features,

• ≥ 60% plasma cells,

• FLC ratio ≥ 100,

• MRI >1 focal lesion.

early therapy with Revlimid or Rd for 2 years

treat as myeloma

standard-risk myeloma

VRd or DRd for 3–4 cycles

early ASCT

maintenance with Revlimid

stem cell collection and cryopreservation

VRd induction: continue VRd for 6 cycles, then maintenance with Revlimid or

DRd induction: continue DRd, with delayed ASCT at relapse

high-risk myeloma

D-VRd for 3–4 cycles

early ASCT

maintenance with VR

standard-risk myeloma

VRd for 8–9 cycles

maintenance with Revlimid

DRd until progression

high-risk myeloma

VRd for 8–9 cycles

maintenance with VR

DRd until progression

Figure 11. When to begin treatment for SMM or newly diagnosed myeloma

MDE)

©2022, SV Rajkumar

©2022, SV Rajkumar

Figure 12. Frontline treatment algorithm for patients eligible for ASCT

©2022, SV Rajkumar

©2022, SV Rajkumar

Figure 13. Frontline treatment algorithm for patients ineligible for ASCT

©2022, SV Rajkumar

©2022, SV Rajkumar

As of January 2023, these are the drugs approved by the FDA for newly diagnosed myeloma, listed here in alphabetical order:

¡ Darzalex®(daratumumab), a monoclonal antibody administered by intravenous infusion and approved in the following combinations:

• With Velcade® (bortezomib) + thalidomide + dexamethasone (D-VTd) for patients who are eligible for ASCT,

• With Revlimid® (lenalidomide) + dexamethasone (DRd) for patients ineligible for ASCT,

• With Velcade + melphalan + prednisone (D-VMP) for patients ineligible for ASCT, and

• With Velcade + Revlimid + dexamethasone (D-VRd) – see note below about the VRd regimen.

¡ Darzalex Faspro® (daratumumab and hyaluronidase-fihj), a monoclonal antibody administered by subcutaneous (under the skin) injection and approved in the following combinations:

• D-VTd for patients who are eligible for ASCT,

• DRd for patients who are ineligible for ASCT, and

• D-VMP for patients who are ineligible for ASCT.

¡ Dexamethasone and other steroids are typically given in combination with one or more other agents and can be administered orally or intravenously.

¡ Revlimid® (lenalidomide), an oral immunomodulatory agent , is a component of several combination therapies approved in the frontline setting, including VRd (see below).

¡ Thalidomide, approved for myeloma in 2006, is the first immunomodulatory agent to receive such approval by the FDA.

¡ Velcade® (bortezomib), a proteasome inhibitor, is a component of several combination therapies approved in the frontline setting, including VRd (see below).

¡ VRd combination therapy of Velcade + Revlimid + dexamethasone is currently considered the standard of care for patients with newly diagnosed myeloma.

• The combination therapy of Darzalex + VRd (D-VRd) is not formally approved by the FDA, but it is included by the National Comprehensive Cancer Network (NCCN) in its guidelines for the management of myeloma. In December 2021, at the annual meeting of the American Society of Hematology (ASH), an updated analysis presented from the GRIFFIN clinical trial demonstrated that D-VRd

was safe and more effective than VRd alone in patients with newly diagnosed myeloma eligible for ASCT, with no additional safety concerns or negative effects on stem cell mobilization.

Other major classes of drugs that are FDA-approved for frontline treatment include alkylating agents (e.g., melphalan, cyclophosphamide) and anthracyclines (e.g., doxorubicin, liposomal doxorubicin), but these drugs are used infrequently because more active agents are available.

If a particular induction therapy is not working, there are numerous treatment options available beyond the scope of this introductory handbook. However, it is not advisable to rapidly skip from one treatment regimen to another without exhausting available options.

Autologous stem cell transplant

ASCT has been used as a treatment for myeloma for more than two decades. Transplant doctors attempt to reduce the tumor burden (kill as many myeloma cells as possible) before collecting stem cells and administering high-dose therapy (HDT). Patients, therefore, receive induction therapy before they begin the process of HDT with stem cell rescue. Even if there isn’t a significant response to frontline therapy, patients can proceed to harvest, HDT, and ASCT and still have an excellent result. Response after HDT is far more important than response before, as long as the disease is not still progressing.

In March 2021, the NCCN updated its guidelines for the management of myeloma. The NCCN states that ASCT remains a key part of frontline treatment for eligible patients with newly diagnosed myeloma. Updated findings from the follow-up data of the IFM 2009 clinical trial confirmed the benefit of ASCT in newly diagnosed myeloma. At a median followup of 93 months, the median progression-free survival (PFS) was 47.3 months with ASCT after induction with the VRd combination vs 35.0 months with VRd alone.

In the U.S., Medicare insurance will cover a single ASCT for eligible patients of any age if they have Durie-Salmon stage II or III myeloma and are either newly diagnosed or still responsive to treatment. Patients must also have adequate heart, liver, lung, and kidney function. Medicare will not cover “tandem” (two back-to-back) autologous transplants, but if a patient has one transplant that is covered by Medicare and then relapses after a remission of two years or longer, Medicare may cover another transplant at that time.

For more information, read the IMF’s publication Understanding Stem Cell Transplant in Myeloma.

Selecting a treatment regimen

Several important issues must be considered.

¡ Day-to-day functioning: Will treatment affect the ability to perform daily activities?

¡ Work : Will any changes or interruptions be required?

¡ Age: Is this a factor in treatment selection and expected outcomes?

¡ Treatment side effects: How significant will these be?

¡ Other medical issues: Will they affect treatment choices and tolerance of treatment?

¡ Transplant: Is high-dose chemotherapy with ASCT recommended?

¡ Speed of response: How rapidly will the treatment work? How will response be assessed?

¡ Initial and later decisions: How much needs to be decided right away?

¡ Financial considerations: Which part of my treatment is covered by my insurance? What will be my financial responsibility? Are there resources to help pay for my treatment?

Table 7. Treatment goals and timely decision-making

TYPE OF TREATMENT Stabilizing Palliative OBJECTIVE

Countering the life-threatening disruptions to body chemistry and the immune system

Relieving discomfort and increasing the patient’s ability to function

EXAMPLES

• Plasmapheresis to thin the blood and avoid stroke

• Hemodialysis when kidney function is impaired

• Drugs to reduce hypercalcemia (may include chemotherapy)

• Radiation to stop bone destruction

• Red cell transfusion to relieve anemia

• Orthopedic surgery to repair and/or strengthen bone

TIME TO DECIDE Hours to Days Days to Months

TYPE OF TREATMENT

OBJECTIVE

EXAMPLES

Improving symptoms, slowing or arresting the course of the disease

• Therapy to kill malignant cells throughout the body

• Radiation to kill malignant cells at a tumor site

TIME TO DECIDE Weeks to Months

• Stem cell transplants as a means of delivering high-dose chemotherapy

Weeks to Months

*Cure means permanent eradication of disease. “Functional cure” is a term that has been used to describe an excellent response to treatment, when the patient is stable and in remission for many years from diagnosis, but the myeloma is not completely eradicated.

Maintenance therapy or not

After maximum response to treatment has been achieved, your doctor may recommend a maintenance regimen. The benefit of continuous therapy until disease progression has been amply demonstrated to improve survival, but it is not necessary or appropriate for every patient. The financial, physical, and emotional implications of continuous therapy must be taken into consideration along with the characteristics of each patient’s myeloma.

Clinical trials

Clinical trials for induction therapy can be an excellent way to receive a new combination therapy or new treatment that is not otherwise available. Even in a randomized clinical trial, where patients have an equal chance of receiving the standard of care or a new therapy, a clinical trial provides rigorously documented treatment and monitoring. If you choose to participate in a clinical trial, it is vital for you to understand the full scope of the treatment protocol. For a comprehensive discussion of clinical trials, read the IMF publication Understanding Clinical Trials.

Supportive care

Just as important as initiating induction therapy is the early use of supportive care measures to alleviate the physical and emotional impact of myeloma.

The IMF’s booklet Understanding Treatment of Myeloma Bone Disease discusses bone-modifying agents such as the bisphosphonates Aredia® (pamidronate) and Zometa® (zoledronic acid), and the monoclonal antibody Xgeva® (denosumab).

Figure 14. What to consider when selecting a treatment regimen

Table 8. Supportive care

SYMPTOM TREATMENT

Fatigue and weakness due to anemia

Bone pain

• Blood transfusion (packed red blood cells: leukoreduced, virus screened) if anemia severe

• Erythropoietin if anemia mild to moderate and induced by therapy

• Bisphosphonate Aredia (90 mg IV over 2–4 hrs monthly), Zometa (4 mg IV over 15–45 min monthly).

• Monoclonal antibody Xgeva® (denosumab) is given as a subcutaneous (under the skin) injection.

• Pain medication

As needed, ask your doctor about prescription or over-the-counter (OTC) medication.

Fever and/or evidence of infection

• Appropriate antibiotics

• Neupogen® if necessary to boost low white blood cell count

• Intravenous immunoglobulin (IVIG) for severe infections

• Tests as needed to diagnose the exact type of infection should be performed (except for dangerous biopsies/cultures)

Gastrointestinal side effects

• Appropriate medications to treat nausea, vomiting, constipation, or diarrhea

• Maintain adequate fluid intake and nutrition

Blood clots and thromboembolic events

• Clotting events are medical emergencies; treatment based on event and patient risk factors

• Aspirin or anti-clotting medications may be prescribed

Peripheral neuropathy

• Pain medications

• Adjustment of dose, schedule, and/or route of administration

• Physical therapy, vitamin and other supplements

Steroid side effects

• Take as directed by your doctor

• Be aware of signs and symptoms of infection, changes in blood sugar

• Medications to prevent shingles and yeast infections

COMMENTS

The treatments are simple, usually highly beneficial, and improve feelings of well-being.

• Relief of bone pain is important in itself and improves physical activity, which in turn promotes bone strength and healing and improves emotional well-being.

• Potential damage to kidneys and jaws, though rare, can result from chronic bisphosphonate therapy.

• Awareness is the key to prevention.

• Although antibiotics should be selected and used with care, it is extremely important that infections be brought under control promptly.

• Having an antibiotic on hand for emergency use (especially if traveling) is recommended.

Discuss symptoms with healthcare providers; severe symptoms may require hospitalization.

Risk may be reduced by exercise, weight loss, and not smoking.

• Discuss symptoms with healthcare providers.

• Early intervention can prevent permanent damage and allow continued treatment.

• Do not adjust doses on your own.

• Do not take supplements without discussing with doctor.

• Report side effects and symptoms to healthcare providers.

• Do not stop or adjust doses on your own.

The IMF’s booklet Understanding Fatigue discusses fatigue that is related to cancer and its treatments, which has been defined by the NCCN as “a distressing, persistent, subjective sense of tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning.”

The IMF’s booklet Understanding Peripheral Neuropathy in Myeloma is designed both to help myeloma patients who already have PN and to help patients avoid developing this problem. It’s always best to prevent problems before they occur and to treat them early when they do occur. This is especially true for PN.

Beyond the management of specific symptoms, other supportive measures are critically important:

¡ Physical activity: Check with your doctor to clarify if full physical activity is feasible or if adjustments must be made due to bone disease or bone damage. Usually, some physical activity can be planned, such as walking or swimming, flexibility and strength exercises, and/or a personalized yoga program.

¡ Diet: No specific diet has been developed for myeloma patients, although research has clearly demonstrated the link between obesity and myeloma. We recommend a healthy, Mediterranean diet emphasizing fruits, vegetables, fish, other lean animal proteins, whole grains, and unprocessed “real” foods. Avoid foods that include processed sugars and artificial trans fats. Caution should be used in two areas:

 Herbal and vitamin supplements: Check with your doctor or pharmacist BEFORE taking supplements while receiving treatment for myeloma. Some interactions between drugs and/or supplements can prevent myeloma treatments from working effectively and some interactions can create serious medical problems. Pharmacies have reference resources to help identify potential interactions.

 Vitamin C: Doses greater than 1000 mg per day may be counterproductive in myeloma and can increase the risk of kidney damage.

¡ Mental health: Your mental health is critical as you move forward with planned treatment. Make sure you’re comfortable with the treatment plan. Schedule an appointment with a mental health professional if you believe that you might be anxious or depressed or if others are concerned that you might be depressed. This is a

normal response to a cancer diagnosis and most cancer patients will need some help at one time or another. Support among peers is vital at this time, and a myeloma support group can be helpful in this context. For a referral to a myeloma support group, visit support.myeloma.org and contact the IMF InfoLine at InfoLine@myeloma.org or 1.818.487.7455.

¡ Regular sleep: This is very important for your immune system.

¡ Make adjustments: If possible, reduce stress in job, family, or social situations, and avoid crowds and close contact with school-age children. Wash your hands frequently. Your immune system is compromised both by the disease and the treatments. Management of your myeloma is the top priority until remission or a stable situation has been reached.

Your healthcare team

While hematologist-oncologists plan and administer treatments, your healthcare team may also include the following important members:

¡ Primary care physician or family doctor,

¡ Nurse or nurse practitioner,

¡ Orthopedic surgeon (bone specialist),

¡ Pharmacist,

¡ Nephrologist (kidney specialist),

¡ Dentist and/or oral surgeon.

Optimal care occurs when there is effective communication among the members of your healthcare team and you or your designated care partner.

Myeloma patients and COVID-19

Visit the COVID-19 page on the IMF website covid19.myeloma.org for the latest information for myeloma patients. New variants of COVID-19 continue to emerge and cautions are recommended for patients with myeloma, such as use of masks indoors and in situations of increased risk of exposure.

The IMF recommends that patients with myeloma, SMM, or MGUS get vaccinated either with the Pfizer-BioNTech COVID-19 vaccine or the Moderna COVID-19 vaccine, whichever is available to you. These vaccines offer excellent benefits and, currently, their efficacy far outweighs any toxicity concerns. Before planning for your COVID-19 vaccination, talk with the doctor treating your myeloma to address any questions or concerns you may have. If you are already vaccinated, ask your doctor if you need an an additional booster.

In closing

This booklet is not meant to replace the advice of your doctors and nurses who are best able to answer questions about your specific healthcare management plan. The IMF intends only to provide you with information that will guide you in discussions with your healthcare team. To help ensure effective treatment with good quality of life, you must play an active role in your own medical care.

We encourage you to visit myeloma.org for more information about myeloma and to contact the IMF InfoLine with your myeloma-related questions and concerns. The IMF InfoLine consistently provides the most up-to-date and accurate information about myeloma in a caring and compassionate manner. Contact the IMF InfoLine at 1.818.487.7455 or InfoLine@myeloma.org.

Terms and definitions

The following selected terms are used in this booklet, while a more complete compendium of myeloma-related vocabulary can be found in the IMF’s Glossary of Myeloma Terms and Definitions located at glossary.myeloma.org.

Albumin (ALB): Simple water-soluble protein found in blood serum. Production of albumin is inhibited by interleukin-6 when myeloma is very active.

Amyloid light chain amyloidosis (AL amyloidosis): A plasma cell disorder in which light chain proteins are not excreted by the kidneys. Instead, the proteins become crosslinked with each other, and these amyloid fibrils are then deposited in tissues and organs, most commonly the kidneys, heart, gastrointestinal (GI) tract, peripheral nerves, skin, and soft tissue. AL amyloidosis is also called primary amyloidosis. See “Amyloidosis.”

Anemia: Red blood cells contain hemoglobin, a protein that carries oxygen to the body’s tissues and organs. Anemia is usually defined as a decrease in hemoglobin < 10 g/dL or as a decrease of ≥ 2 g/dL from the normal level for an individual. More than 13–14 g/dL is considered normal. Low levels of oxygen in the body may cause shortness of breath and feelings of exhaustion. Many newly diagnosed myeloma patients have anemia.

Antibody: A protein produced by plasma cells in response to an antigen that enters the body. See “Antigen” and “Immunoglobulin (Ig).”

Antigen: Any foreign substance that causes the immune system to produce natural antibodies. Examples of antigens include bacteria, viruses, parasites, fungi, and toxins.

Asymptomatic: Producing no signs or symptoms.

Bence-Jones myeloma: Myeloma characterized by the presence of Bence-Jones protein, an abnormal protein in urine made up of free kappa or lambda light chains. See “ Bence-Jones protein.”

Bence-Jones protein: A myeloma monoclonal protein. The protein is composed of either free kappa or free lambda light chains. Because of their small size, Bence-Jones light chains can be filtered through the kidneys and pass into the urine. The amount of Bence-Jones protein in the urine is expressed in terms of grams per 24 hours. Normally, a very small amount of protein (< 0.1 g/24 h) can be present in the urine, but this is albumin rather than Bence-Jones protein. The presence of any BenceJones protein in the urine is abnormal. Myeloma protein heavy chains are too large to be filtered through the kidneys. See “ Bence-Jones myeloma.”

Benign: Not cancerous; does not invade nearby tissue or spread to other parts of the body.

Beta-2 microglobulin (β2-microglobulin, β2M, or β2M): A small protein found in the blood. High levels occur in patients with active myeloma. Low or normal levels occur in patients with early myeloma and/or inactive disease. Approximately 10% of patients have myeloma that does not produce β2M. At the time of relapse, β2M can increase before there is any change in the myeloma protein level. Factors such as viral infection can sometimes produce elevated serum β2M levels.

Biopsy: The removal of a sample of tissue for microscopic examination to aid in diagnosis.

Bisphosphonate: A type of drug that protects against osteoclast activity (bone breakdown) and binds to the surface of bone where it is being resorbed or destroyed.

Bone marrow: The soft, spongy tissue in the center of bones that produces white blood cells, red blood cells, and platelets. When myeloma is growing, abnormal plasma cells build up in the bone marrow.

Bone marrow aspiration: The removal, by a needle, of a sample of fluid and cells from the bone marrow for examination under a microscope.

C-reactive protein (CRP): A protein made in the liver that increases in amount when there is inflammation throughout the body.

Calcium: A mineral found mainly in the hard part of bone matrix (hydroxyapatite). If produced or released in excess, it can build up in the bloodstream. See “ Hypercalcemia.”

Cancer: A term for diseases in which malignant cells divide without control. Cancer cells can invade nearby tissues and spread through the bloodstream and lymphatic system to other parts of the body.

Chromosome: A strand of DNA and proteins in the nucleus of a cell. Chromosomes contain genes and function in the transmission of genetic information. Normally, human cells contain 46 chromosomes (23 pairs).

• Chromosomal deletion – Genetic mutation in which part or all of a chromosome become lost during DNA replication. Chromosomal deletions that occur in myeloma include loss of the long arm of chromosome 13 (written as 13q-) or loss of the short arm of chromosome 17 (written as 17p-).

• Chromosomal translocation – Genetic mutation in which parts of different chromosomes are rearranged. Written with a lowercase “t” followed by the numbers of the chromosomes with translocated genetic material. Translocations that occur in myeloma include t(4;14), t(11;14), and t(14;16), and t(14;20).

Clinical trial: A research study of new treatment that involves patients. Each study is designed to find better ways to prevent, detect, diagnose, or treat cancer and to answer scientific questions.

• Accrual – The process of enrolling patients in a clinical trial, or the number of patients already enrolled or anticipated to be enrolled in a clinical trial.

• Arm – A treatment group in a randomized study, in which there are two or more arms.

• Cohort – A group of patients in the same study receiving the same treatment or placebo (no treatment).

• Control group – The arm of a randomized clinical trial that receives the standard treatment or placebo.

• Double blind – When neither the patient nor the investigator knows the arm of the trial to which the patient is randomized. The purpose is to eliminate any bias in the reporting of results.

• Endpoint – The goal of the study. A clinical trial endpoint may aim to measure toxicity, response rate, or survival.

• Experimental group – The arm of a randomized trial that gets the new treatment.

• Randomized clinical trial – A study in which patients are randomly assigned to receive a particular treatment.

• Phase I clinical trial – A study to determine the maximum-tolerated dose (MTD) and safety profile of a new drug or a new combination of

drugs. It may be the first testing of a new treatment in humans. Please note that in combination therapies, the individual elements may already have been well tested in humans.

• Phase II clinical trial – A study designed to determine the efficacy and safety of a new therapy that has been tested in a phase I trial. Patients are usually required to have measurable disease that is refractory to any standard treatment. If the results of a phase II study are clearly much better than the standard treatment, then the treatment may be approved without being tested in a phase III study. If results from a phase II study are promising, the treatment may then be tested in a phase III study.

• Phase III clinical trial – A study that compares two or more treatments. The endpoint of a phase III study may be survival or progression-free survival (PFS). Phase III studies are usually randomized, so patients don’t choose which treatment they receive. Some phase III trials compare a new treatment that had good results in phase II study with a standardof-care treatment; other phase III studies compare treatments that are already in common use.

• Phase IV clinical trial – Even after a drug has been approved by the U.S. Food and Drug Administration (FDA) for use in a particular indication, there may be need for additional studies. For example, safety surveillance is designed to detect any rare or long-term side effects over a larger patient population and longer time period than was possible during the phase I-III clinical trials.

Computed axial tomography (CAT or CT): Creates three-dimensional images of structures inside the body. In myeloma, used when X-rays are negative or for more detailed scanning of specific areas. Especially useful for detection or detailed evaluation of small areas of bone damage or nerve pressure.

CRAB criteria: An elevated level of Calcium in the blood, Renal (kidney) damage, Anemia or low red blood cell count, and Bone damage are criteria used to diagnose myeloma along with “Myeloma-defining event (MDE).”

Cytokine: A cytokine is a protein that circulates in the bloodstream, usually in response to infection. Cytokines can stimulate or inhibit the growth or activity in other cells.

Electrophoresis: A laboratory test used both for diagnosis and for monitoring, in which a patient’s serum (blood) or urine proteins are subjected to separation according to their size and electrical charge. Serum or urine electrophoresis (SPEP or UPEP) enables both the calculation of the amount of myeloma protein and the identification of the type of M-spike for each patient.

Extramedullary plasmacytoma: A tumor of monoclonal plasma cells that is found in soft tissue outside of the bone marrow and separate from bone.

Fluorescence in situ hybridization (FISH): A procedure that allows myeloma specialists to locate the positions of specific DNA sequences on chromosomes.

Free light chain (FLC): An immunoglobulin light chain is the smaller of two units that make up an antibody. There are two types of light chain: kappa and lambda. A light chain may be bound to a heavy chain or it may be unbound (free). Free light chains circulate in the blood and are small enough to pass into the kidneys, where they may be filtered out into the urine or may stick together and block the kidney’s tubules.

Frontline therapy: A general term for the initial treatment used in an effort to achieve response in a newly diagnosed myeloma patient. See “ Induction therapy ” and “ Response.”

Hematologist: A doctor who specializes in the problems of blood and bone marrow.

High-risk myeloma: Myeloma that is more likely to relapse quickly after treatment or to be refractory to treatment, as defined by the cytogenetic (chromosomal) abnormalities t(4;14), t(14;16), t(14;20), del 17p, and 1q gain, along with Revised International Staging System (R-ISS) Stage III disease, and/or a high-risk gene expression profile (GEP) signature.

Hypercalcemia: A higher than normal level of calcium in the blood. In myeloma patients, it usually results from bone breakdown with release of calcium from the bone into the bloodstream. This condition can cause a number of symptoms, including loss of appetite, nausea, thirst, fatigue, muscle weakness, restlessness, and confusion. See “Calcium.”

Immune system: The body’s defense system that destroys infected and malignant cells, and removes cellular debris. The immune system includes white blood cells and organs and tissues of the lymphatic system.

Immunofixation electrophoresis (IFE): An immunologic test of the serum or urine used to identify proteins. For myeloma patients, it enables the doctor to identify the M-protein type (IgG, IgA, kappa, or lambda).

The most sensitive routine immunostaining technique, it identifies the exact heavy- and light-chain type of M-protein.

Immunoglobulin (Ig): A protein produced by plasma cells; an essential part of the body’s immune system. Immunoglobulins attach to foreign substances (antigens) and assist in destroying them. The classes (isotypes)

of immunoglobulins are IgG, IgA, IgD, IgE, and IgM. See “Antibody ” and “Antigen.”

• IgG, IgA – The most common types of myeloma. The G and A refer to the immunoglobulin heavy chain produced by the myeloma cells.

• IgD, IgEA – Types of myeloma that occur less frequently.

• IgMA – This is a rare type of myeloma. IgM myeloma is not the same as Waldenström macroglobulinemia.

Immunomodulatory agent: A drug that affects, enhances, or suppresses the immune system. Immunomodulatory drugs are sometimes called IMiD® compounds.

Induction therapy: The initial treatment given to a patient in preparation for an autologous stem cell transplant (ASCT). See “ Frontline therapy ” and “ Line of therapy.”

Lactate dehydrogenase (LDH): An energy-producing enzyme that is present in almost all of the tissues in the body. LDH levels in the bloodstream rise in response to cell damage. LDH may be used to monitor myeloma activity.

Lesion: An area of abnormal tissue; a lump or abscess that may be caused by injury or disease, such as cancer. In myeloma, “lesion” can refer to a plasmacytoma or a hole in the bone.

• Diffuse lesion – A spread-out pattern of myeloma bone marrow involvement in an area of bone.

• Focal lesion – A defined area of irregular cells seen in the bone marrow on MRI and PET-CT studies. In order to be considered diagnostic of myeloma, there must be at least 2 focal lesions seen on MRI that are at least 5mm in size.

• Lytic lesion – The damaged area of a bone that appears as a dark spot on an X-ray when at least 30% of the healthy bone in any one area is eaten away. Lytic lesions look like holes in the bone and are evidence that the bone is being weakened. See “ Lytic (lysis).”

Light chain deposition disease (LCDD): A rare type of monoclonal immunoglobulin deposition disease (MIDD) that is characterized by deposition of complete or partial monoclonal light chains in organs. LCDD usually affects the kidneys but can also affect other organs. The goal of treating LCDD is to slow damage to organs.

Line of therapy: A term used to calculate the number of therapies a patient has received. A line of therapy is 1 or more complete cycles of a regimen that can consist of a single agent, a combination of several drugs, or a planned sequential therapy of various regimens. Also see “ Induction therapy.”

M-spike: A monoclonal spike, the sharp pattern that occurs on protein electrophoresis tests, is a marker for the activity of myeloma cells. See “Monoclonal ” and “Monoclonal protein.”

Magnetic resonance imaging (MRI): Diagnostic imaging that uses magnetic fields and radio waves, not ionizing radiation, to produce detailed 2D or 3D images of structures inside the body. MRI can reveal the presence and distribution of myeloma in the bone marrow when X-rays show no bone damage. Can also reveal disease outside of bone. MRI gives very fine resolution of soft tissues, especially encroachments on the spinal cord, but is less accurate for bone lesions, which may be pressing on nerves and/or the spinal cord.

Malignant: Cancerous; capable of invading nearby tissue and spreading to other parts of the body.

Minimal residual disease (MRD): The presence of residual tumor cells after treatment has been completed and complete response (CR) has been attained. Even patients who have attained a stringent complete CR (sCR) may have MRD. Very sensitive new testing methods are now able to detect 1 myeloma cell among 1,000,000 sampled cells in blood or bone marrow. See “MRD-negative.”

Monoclonal: A clone or duplicate. Myeloma cells are derived from a “monoclone,” a single malignant plasma cell in the bone marrow. The type of myeloma protein produced is also monoclonal, a single form rather than many forms (polyclonal). The important practical aspect of a monoclonal protein is that it shows up as a sharp spike M-spike on the protein electrophoresis test. See “M-spike.”

Monoclonal gammopathy of undetermined significance (MGUS): A category of plasma cell disorder characterized by comparatively low levels of monoclonal protein in the blood and/or urine. Bone marrow plasma cell levels are low (< 10%). CRAB features are absent. See “CRAB criteria.”

Monoclonal protein (myeloma protein, M-protein): An abnormal protein produced by myeloma cells that accumulates in and damages bone and bone marrow. It is found in unusually large amounts in the blood and/or urine of myeloma patients. See “Monoclonal ” and “M-spike.”

Multiple myeloma: A cancer of the bone marrow plasma cells, white blood cells that make antibodies. The cancerous plasma cells are called myeloma cells.

Myeloablation: A severe form of myelosuppression, in which the consequence of high-dose chemotherapy or radiation is the complete or near-complete destruction of the bone marrow’s ability to produce blood cells. See “Myelosuppression.”

Myeloma-defining event (MDE): The diagnosis of myeloma requires evidence of one or more MDE, such as CRAB criteria, 60% or more clonal plasma cells in the bone marrow, serum involved/uninvolved free light chain (FLC) ratio that is equal or greater than 100, or more than 1 focal lesion on magnetic resonance imaging. Also see “CRAB criteria.”

Myelosuppression: A decrease in the production of red blood cells, platelets, and some of the white blood cells.

Non-secretory myeloma: Approximately 1% of myeloma patients do not have detectable M-protein in the blood (serum) and urine. Some of these patients can be successfully monitored using the serum free light chain assay; others may be monitored with bone marrow biopsy and/or PET-CT scan. Patients with non-secretory myeloma are treated in the same fashion as those with M-protein-secreting disease.

Oncologist: A doctor who specializes in treating cancer. Some oncologists specialize in a particular type of cancer.

Osteoblast: A bone cell associated with production of bone tissue. Osteoblasts produce osteoid, which then becomes mineralized with calcium to form new hard bone.

Osteoclast: A cell found at the junction between the bone marrow and the bone. It is responsible for breaking down or remodeling old bone tissue. In myeloma, the osteoclasts are overstimulated, while osteoblast activity is blocked. The combination of accelerated bone resorption and blocked new bone formation results in lytic lesions.

Overall survival (OS): The median number of individuals in a group who are alive after a particular duration of time. OS is often used as a measure of treatment efficacy in clinical trials. The lengthening duration of OS in myeloma trials makes it a difficult endpoint to use, leading to the effort to validate minimal residual disease (MRD) status as a new endpoint.

Peripheral neuropathy (PN): Peripheral neuropathy is a serious condition that affects nerves in the hands, feet, lower legs, and/or arms. Patients may experience PN from the effects of the myeloma itself and/or from treatments for myeloma. Symptoms may include a feeling of numbness, tingling, burning, and/or pain.

Plasma: The liquid part of the blood in which red blood cells, white blood cells, and platelets are suspended.

Plasma cells: White blood cells that produce antibodies. Myeloma cells are cancerous plasma cells, which produce monoclonal protein (M-protein) that can lead to organ and tissue damage (anemia, kidney damage, bone disease, and nerve damage).

Plasmacytoma: See “ Extramedullary plasmacytoma” and “Solitary plasmacytoma of bone (SPB).”

Plasmapheresis: The process of removing certain proteins from the blood. Plasmapheresis can be used to remove high levels of M-protein from the blood of myeloma patients.

Platelets: One of the three major types of blood cells, the others being red blood cells and white blood cells. Platelets plug up breaks in the blood vessel walls and release substances that stimulate blood clot formation. Platelets are the major defense against bleeding. Also called thrombocytes.

Positron emission tomography (PET): A sophisticated diagnostic test that uses a camera and computer to produce images of the body. PET scans show the difference between healthy and abnormally functioning tissues based upon the uptake of radiolabeled sugar by active cancer cells.

Progression-free survival (PFS): The length of time during and after the treatment of myeloma that a patient lives with the disease but the myeloma does not get worse. In a clinical trial, PFS is one way to measure how well the treatment is working. See “ Progressive disease.”

Progressive disease: Myeloma that is becoming worse or relapsing, as documented by tests. Defined as an increase of ≥ 25% from the lowest confirmed response value in the myeloma protein level and/or new evidence of disease.

Proteasome: A joined group (“complex”) of enzymes (“proteases”) that break down the damaged or unwanted proteins in both normal cells and cancer cells into smaller components. Proteasomes also carry out the regulated breakdown of undamaged proteins in the cell, a process that is necessary for the control of many critical cellular functions. These smaller protein components are then used to create new proteins required by the cell. This is important for maintaining balance within the cell and for regulating cell growth.

Proteasome inhibitor: Any drug that interferes with the normal function of the proteasome. See “ Proteasome.”

Proteins: Substances composed of amino acids. Proteins are an essential part of all living organisms, especially as structural components of body tissues such as muscle, hair, collagen, etc., as well as enzymes and antibodies.

Protocol: A detailed treatment plan, which includes the dose and schedule of any drugs used.

Radiation therapy: Treatment with X-rays, gamma rays, or electrons to damage or kill malignant cells. Radiation may be delivered from outside the body or from radioactive materials implanted directly in the tumor.

Red blood cells (RBC): Also called erythrocytes, these cells in the blood contain hemoglobin, deliver oxygen to all parts of the body, and take away carbon dioxide. Red blood cell production is stimulated by a hormone (erythropoietin) produced by the kidneys. Myeloma patients with damaged kidneys don’t produce enough erythropoietin and can become anemic. Myeloma patients can also become anemic because of myeloma cells’ effect on the ability of bone marrow to make new red blood cells.

Response or remission: Interchangeable terms to describe the complete or partial disappearance of the signs and symptoms of cancer.

• Stringent complete response (sCR) – sCR is CR (as defined below) plus normal FLC ratio and absence of clonal cells in bone marrow by immunohistochemistry or immunofluorescence.

• Complete response (CR) – For myeloma, CR is negative immunofixation on serum (blood) and urine, and disappearance of any soft tissue plasmacytomas, and ≤ 5% plasma cells in bone marrow. CR is not the same as a cure.

• Very good partial response (VGPR) – VGPR is less than CR. VGPR is serum M-protein and urine M-protein detectable by immunofixation but not on electrophoresis, or 90% or greater reduction in serum M-protein, plus urine M-protein less than 100 mg per 24 hours.

• Partial response (PR) – PR is a level of response in which there is at least a 50% reduction in M-protein, and reduction in 24-hour urinary M-protein by at least 90% (or to less than 200 mg per 24 hours).

Serum: The colorless, liquid part of blood in which the blood cells are suspended.

Smoldering multiple myeloma (SMM): SMM is a higher level of disease than MGUS, but SMM is still not active myeloma with CRAB criteria features indicating organ damage. Patients with standard-risk SMM do not require treatment but should be observed at regular intervals by a hematologist/oncologist. Patients with high-risk SMM may choose to participate in a clinical trial. See “CRAB criteria.”

Solitary plasmacytoma of bone (SPB): A discreet, single mass of monoclonal plasma cells in a bone. The diagnosis of SPB requires a solitary bone lesion, a biopsy of which shows infiltration by plasma cells;

negative imaging results for other bone lesions; absence of clonal plasma cells in a random sample of bone marrow; and no evidence of anemia, hypercalcemia, or renal involvement suggesting systemic myeloma.

Transplant (transplantation): There are several different types of transplantation.

• Autologous stem cell transplant (ASCT) – This is the type of transplant used most frequently in myeloma. ASCT is a procedure in which doctors remove healthy peripheral blood stem cells (PBSC) from the patient’s circulating blood. The collected stem cells are then frozen and stored for later use within days, weeks, or years. When the patient is ready to proceed with ASCT, myeloablative high-dose therapy (HDT) is administered to destroy myeloma cells in the bone marrow, but healthy blood cells are also destroyed. The patient’s frozen stem cells are then defrosted and returned to the patient, where these cells can produce new blood cells to replace cells destroyed by the HDT. ASCT can provide remission that is both long and deep.

• Allogeneic (allograft) transplant – This type of transplant uses stem cells or bone marrow harvested from one person (donor) who has been determined to be compatible with the patient (recipient) by human leukocyte antigen (HLA) matching. The donor cells are infused into the patient after myeloablative HDT. The donor’s immune system cells recognize the recipient’s myeloma cells as foreign and attack them. Unfortunately, the donor cells also attack other tissues in the recipient’s body, causing graft-versus-host disease (GVHD), which may cause complications or may even be fatal.

• Reduced-intensity conditioning (RIC) allogeneic transplant – A type of an allogeneic transplant, sometimes called “mini-allo” for short. RIC transplant is a newer and, for myeloma, a safer technique than a “full” allogeneic (allograft) transplant because RIC transplant is non-myeloablative. RIC transplant is usually performed within 180 days after a standard ASCT.

• Bone marrow transplant – A type of an autologous transplant where stem cells are collected from a patient’s bone marrow, not from a patient’s circulating peripheral blood. Currently, bone marrow transplantation is used infrequently in myeloma because the ASCT procedure is preferred. But bone marrow transplantation may be considered if stem cells could not be collected from the peripheral blood.

• Tandem transplant – A term used to indicate two autologous transplants done in succession. Tandem transplants are usually planned with 3-month to 6-month intervals between transplants.

Tandem transplantation has become less common in the United States in the era of effective novel therapies.

• Syngeneic transplant – A type of an allogeneic transplant where bone marrow or stem cells from one identical twin sibling (donor) are infused into the other identical twin (recipient).

• Matched unrelated donor (MUD) transplant – A type of an allogeneic transplant where stem cells are genetically matched to the patient but are not from a donor who is a family member. In myeloma, this type of transplant carries a high rate of GVHD and is therefore very rarely used.

• Umbilical cord stem cell transplant – A type of an allogeneic transplant where stem cells are harvested from multiple umbilical cords of newborns in order to obtain enough stem cells for an adult transplant. In myeloma, this type of transplant carries a high rate of GVHD and is therefore very rarely used.

Tumor: An abnormal mass of tissue that results from excessive cell division. In myeloma, a tumor is referred to as a plasmacytoma.

Vertebra: Any one of the 33 bony segments of the spinal column. Plural noun is “vertebrae.”

Virus: A small living particle that can infect cells and change how the cells function. The disease and the symptoms caused by a viral infection vary based on the type of virus and the type of cells that are infected.

Waldenström macroglobulinemia (WM): A rare type of non-Hodgkin’s lymphoma (NHL) that affects plasma cells. Excessive amounts of IgM protein are produced. WM is not a type of myeloma.

White blood cells (WBC): General term for a variety of leukocytes responsible for fighting invading germs, infections, and allergy-causing agents. These cells begin their development in bone marrow and then travel to other parts of the body. Specific white blood cells include neutrophils, basophils, eosinophils, lymphocytes, and monocytes.