MULTIPLE-MYELOMA - TREATMENT RECOMMENDATIONS

Multiple myeloma is a relatively common B cell neoplasm seen more frequently in older patients. Most patients require treatment at the time of diagnosis; however, asymptomatic patients with good prognostic factors may be safely observed, sometimes for extended periods, without chemotherapy. Several recently developed prognostic factors, in particular beta 2-microglobulin, have improved our ability to predict clinical outcome. Traditional chemotherapy with intermittent oral melphalan plus prednisone can induce remissions in approximately 50% of patients. More aggressive multiagent combination chemotherapy regimens can produce higher response rates compared with oral melphalan/prednisone, but whether this results in a survival benefit remains controversial. All patients treated with conventional dose chemotherapy will eventually relapse. Maintenance therapy with interferon-a can prolong the duration of remissions. Relapse is associated with more aggressive, less responsive, disease. Conventional salvage therapies are effective in the minority of patients, and responses are short lived. High dose chemotherapy, with or without total body irradiation, followed by autologous bone marrow or peripheral stem cell transplantation can induce remissions in some patients who have relapsed or whose disease is refractory to conventional salvage chemotherapy. Unfortunately, these responses are usually not durable. The results of autologous transplantation in a more favourable group of previously untreated or minimally treated patients have been encouraging. Increased response rates, more durable remissions and, probably, improved survival compared with conventional dose chemotherapy have been demonstrated. Further study is needed to determine if autologous transplantation will cure patients with myeloma. Allogeneic bone marrow transplantation, although of limited applicability and associated with high treatment-related mortality, has the greatest potential to provide patients with long term survival.