My Treatment Approach: Bispecifics in Multiple Myeloma: Translating Evidence to Clinical Practice - Episode 1
Expert hematologist-oncologist Adriana Rossi, MD, shares a real-world patient scenario of triple-class refractory multiple myeloma managed with novel bispecific antibody therapy.
Luciano Costa, MD: Hello and welcome to this OncLive® My Treatment Approach program titled, “Bispecifics in Multiple Myeloma: Translating Evidence to Clinical Practice.” I’m Luciano Costa, professor of hematology and oncology in the Department of Medicine at the University of Alabama at Birmingham. I am joined today by my colleague Dr Adriana Rossi. Dr Rossi, would you like to introduce yourself?
Adriana Rossi, MD: Thank you so much. My name is Adriana Rossi. I’m an assistant professor at the Icahn School of Medicine in New York City, New York.
Luciano Costa, MD: Thanks, Dr Rossi. Welcome and thanks for joining us today. Today we’re going to discuss recent advances in the treatment of multiple myeloma, with a focus on bispecifics and the impact they will have in clinical practice. We present 2 real-world patient cases and discuss our treatment approach to illustrate how to incorporate recent data into our practice. Let’s get started with Dr Rossi presenting the first case.
Adriana Rossi, MD: Thank you so much. This was a patient I have known since her original diagnosis. She was 66 in 2014 when she was found to have 30% plasmacytosis in the marrow and took the title of smoldering myeloma, which she held for about 3 years, at which time we started to notice progressive anemia followed by renal insufficiency. At that time, she was found to have 70% plasmacytosis in her marrow, now with a FISH [fluorescence in situ hybridization] notable for a gain of 1q. At that time, she enrolled in a frontline clinical trial of carfilzomib, lenalidomide, and dex [dexamethasone] and did well. Her end organ dysfunction resolved, and her best response was a VGPR [very good partial response], which she was able to maintain for about 2 years. At time of first relapse, she received dara [daratumumab] with a plan to get her to transplant, but unfortunately had no response. She was then treated with bendamustine, bortezomib, and dexamethasone, to which she had a partial response, and was then able to go to melphalan 200 [mg/m2] with a stem cell salvage. At that point, she still had detectable disease and was put on pomalidomide maintenance, which lasted for about a year, still with some disease.
In 2001, she progressed again, this time quite rapidly with an M spike of 4.8 [mg/dL]. Marrow at that time was back up to 60% plasmacytosis, and her FISH had a new deletion 17. Her PET [positron emission tomography] had numerous FDG [fluorodeoxyglucose]-avid lesions but no extramedullary disease was noted. She’s generally a fit lady. She has a history of hypertension and diabetes, both of which are very well controlled on her regimen, and there is no other end organ dysfunction. In our program, she is certainly a very good candidate for a clinical trial. At that time, the best fit in our program was a BCMA [B‑cell maturation antigen]-targeting bispecific antibody, which she received in the step-up doses of 60, 30, and 1500 mg. I have her response to show she did quite well in her first 4 cycles.
Of course, it never goes just so smoothly. First, she did tolerate her step-up dosing quite well, but on her first full dose, she did have grade 1 CRS [cytokine release syndrome]. By that, she had fevers and a headache. She received 1 dose of tocilizumab, at which time her symptoms completely resolved. When she came back, she tolerated her day 15 dosing. Interestingly, when she came in for her cycle 1 day 22, she was, again, noted to have fevers. At this time, it was due to an infection. She was noted to be adenovirus positive. She later had a COVID-19 infection. While she did have a number of fevers and we’re always monitoring for cytokine release syndrome, many times there is the overlap of infections in CRS, which I thought made this an interesting case.
Luciano Costa, MD: Thank you, Dr Rossi. That’s clearly a very interesting and illustrative case, not only in terms of therapies, but you also can almost see the natural history of myeloma, going from the smoldering to active myeloma, and accumulating additional chromosome abnormalities that we know are so impactful on the outcome of those patients. I think a case like this illustrates well how we often make decisions, particularly in the earlier lines of therapy.
Transcript edited for clarity.