Multiple myeloma, induction

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Andrew J. Cowan, MD
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Are you looking for a regimen but can't find it here? It is possible that we've moved it to the historical regimens page. If you still can't find it, please let us know so we can add it!.
Note: due to its size/complexity, the multiple myeloma page has been split into three sub-pages:

39 regimens on this page
95 variants on this page

Contents


Guidelines

ASCO

BSH/UKMF

European Myeloma Network (EMN)

ESMO

IMWG

NCCN

First-line therapy (including transplant ineligible), randomized data

Note: most but not all multiple myeloma first-line regimens specify whether patients are transplant eligible, or not. The top-line inclusion criteria from each prospectively enrolling regimen are reported.

CPR

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CPR: Cyclophosphamide, Prednisone, Revlimid (Lenalidomide)

Regimen

Study Evidence Comparator Comparative Efficacy
Magarotto et al. 2016 (EMN01) Phase III (E) 1. MPR Might have inferior PFS
2. Rd Seems not superior

This regimen is intended for patients who were ineligible for high-dose therapy plus stem cell transplantation because of age (greater than or equal to 65 years) or coexisting comorbidities. This is the dosing used after a mid-protocol amendment.

Chemotherapy

Supportive medications

28-day cycle for 9 cycles

Subsequent treatment

References

  1. Magarotto V, Bringhen S, Offidani M, Benevolo G, Patriarca F, Mina R, Falcone AP, De Paoli L, Pietrantuono G, Gentili S, Musolino C, Giuliani N, Bernardini A, Conticello C, Pulini S, Ciccone G, Maisnar V, Ruggeri M, Zambello R, Guglielmelli T, Ledda A, Liberati AM, Montefusco V, Hajek R, Boccadoro M, Palumbo A. Triplet vs doublet lenalidomide-containing regimens for the treatment of elderly patients with newly diagnosed multiple myeloma. Blood. 2016 Mar 3;127(9):1102-8. Epub 2016 Jan 4. link to original article contains verified protocol PubMed

CTD

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CTD: Cyclophosphamide, Thalidomide, Dexamethasone
CTDa: Cyclophosphamide, Thalidomide, Dexamethasone, attenuated

Variant #1, CTD

Study Evidence Comparator Comparative Efficacy
Morgan et al. 2010 (MRC Myeloma IX) Phase III (E) CVAD Not reported

This is an intensive treatment pathway, as determined by performance status, informed discussion, and patient preference.

Chemotherapy

Supportive medications

21-day cycle for 4 to 6 cycles until maximum response

Subsequent treatment

Variant #2, CTDa

Study Evidence Comparator Comparative Efficacy
Morgan et al. 2010 (MRC Myeloma IX) Phase III (E) MP Not reported

This is a nonintensive treatment pathway, as determined by performance status, informed discussion, and patient preference.

Chemotherapy

Supportive medications

28-day cycle for 6 to 9 cycles

Subsequent treatment

References

  1. MRC Myeloma IX: Morgan GJ, Davies FE, Gregory WM, Cocks K, Bell SE, Szubert AJ, Navarro-Coy N, Drayson MT, Owen RG, Feyler S, Ashcroft AJ, Ross F, Byrne J, Roddie H, Rudin C, Cook G, Jackson GH, Child JA; National Cancer Research Institute Haematological Oncology Clinical Study Group. First-line treatment with zoledronic acid as compared with clodronic acid in multiple myeloma (MRC Myeloma IX): a randomised controlled trial. Lancet. 2010 Dec 11;376(9757):1989-99. Epub 2010 Dec 3. link to original article link to PMC article PubMed
    1. Update: Morgan GJ, Davies FE, Gregory WM, Russell NH, Bell SE, Szubert AJ, Navarro Coy N, Cook G, Feyler S, Byrne JL, Roddie H, Rudin C, Drayson MT, Owen RG, Ross FM, Jackson GH, Child JA; NCRI Haematological Oncology Study Group. Cyclophosphamide, thalidomide, and dexamethasone (CTD) as initial therapy for patients with multiple myeloma unsuitable for autologous transplantation. Blood. 2011 Aug 4;118(5):1231-8. Epub 2011 Jun 7. link to original article contains verified protocol link to PMC article PubMed
    2. Update: Morgan GJ, Gregory WM, Davies FE, Bell SE, Szubert AJ, Brown JM, Coy NN, Cook G, Russell NH, Rudin C, Roddie H, Drayson MT, Owen RG, Ross FM, Jackson GH, Child JA; National Cancer Research Institute Haematological Oncology Clinical Studies Group. The role of maintenance thalidomide therapy in multiple myeloma: MRC Myeloma IX results and meta-analysis. Blood. 2012 Jan 5;119(1):7-15. Epub 2011 Oct 20. link to original article contains verified protocol PubMed
    3. Update: Morgan GJ, Davies FE, Gregory WM, Bell SE, Szubert AJ, Navarro Coy N, Cook G, Feyler S, Johnson PR, Rudin C, Drayson MT, Owen RG, Ross FM, Russell NH, Jackson GH, Child JA; National Cancer Research Institute Haematological Oncology Clinical Studies Group. Cyclophosphamide, thalidomide, and dexamethasone as induction therapy for newly diagnosed multiple myeloma patients destined for autologous stem-cell transplantation: MRC Myeloma IX randomized trial results. Haematologica. 2012 Mar;97(3):442-50. Epub 2011 Nov 4. link to original article contains verified protocol link to PMC article PubMed
    4. Update: Morgan GJ, Davies FE, Gregory WM, Bell SE, Szubert AJ, Cook G, Drayson MT, Owen RG, Ross FM, Jackson G, Child JA. Long-term follow-up of MRC Myeloma IX trial: Survival outcomes with bisphosphonate and thalidomide treatment. Clin Cancer Res. 2013 Nov 1;19(21):6030-8. Epub 2013 Aug 30. link to original article PubMed

CVAD

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CVAD: Cyclophosphamide, Vincristine, Adriamycin (Doxorubicin), Dexamethasone

Regimen

Study Evidence Comparator Comparative Efficacy
Morgan et al. 2010 (MRC Myeloma IX) Phase III (C) CTD Not reported

This is an intensive treatment pathway, as determined by performance status, informed discussion, and patient preference. To our knowledge, this regimen was not tested as an experimental arm in an RCT prior to becoming a standard comparator arm.

Chemotherapy

Supportive medications

21-day cycle for 4 to 6 cycles until maximum response

Subsequent treatment

References

  1. MRC Myeloma IX: Morgan GJ, Davies FE, Gregory WM, Cocks K, Bell SE, Szubert AJ, Navarro-Coy N, Drayson MT, Owen RG, Feyler S, Ashcroft AJ, Ross F, Byrne J, Roddie H, Rudin C, Cook G, Jackson GH, Child JA; National Cancer Research Institute Haematological Oncology Clinical Study Group. First-line treatment with zoledronic acid as compared with clodronic acid in multiple myeloma (MRC Myeloma IX): a randomised controlled trial. Lancet. 2010 Dec 11;376(9757):1989-99. Epub 2010 Dec 3. link to original article link to PMC article PubMed
    1. Update: Morgan GJ, Davies FE, Gregory WM, Russell NH, Bell SE, Szubert AJ, Navarro Coy N, Cook G, Feyler S, Byrne JL, Roddie H, Rudin C, Drayson MT, Owen RG, Ross FM, Jackson GH, Child JA; NCRI Haematological Oncology Study Group. Cyclophosphamide, thalidomide, and dexamethasone (CTD) as initial therapy for patients with multiple myeloma unsuitable for autologous transplantation. Blood. 2011 Aug 4;118(5):1231-8. Epub 2011 Jun 7. link to original article contains verified protocol link to PMC article PubMed
    2. Update: Morgan GJ, Gregory WM, Davies FE, Bell SE, Szubert AJ, Brown JM, Coy NN, Cook G, Russell NH, Rudin C, Roddie H, Drayson MT, Owen RG, Ross FM, Jackson GH, Child JA; National Cancer Research Institute Haematological Oncology Clinical Studies Group. The role of maintenance thalidomide therapy in multiple myeloma: MRC Myeloma IX results and meta-analysis. Blood. 2012 Jan 5;119(1):7-15. Epub 2011 Oct 20. link to original article contains verified protocol PubMed
    3. Update: Morgan GJ, Davies FE, Gregory WM, Bell SE, Szubert AJ, Navarro Coy N, Cook G, Feyler S, Johnson PR, Rudin C, Drayson MT, Owen RG, Ross FM, Russell NH, Jackson GH, Child JA; National Cancer Research Institute Haematological Oncology Clinical Studies Group. Cyclophosphamide, thalidomide, and dexamethasone as induction therapy for newly diagnosed multiple myeloma patients destined for autologous stem-cell transplantation: MRC Myeloma IX randomized trial results. Haematologica. 2012 Mar;97(3):442-50. Epub 2011 Nov 4. link to original article contains verified protocol link to PMC article PubMed
    4. Update: Morgan GJ, Davies FE, Gregory WM, Bell SE, Szubert AJ, Cook G, Drayson MT, Owen RG, Ross FM, Jackson G, Child JA. Long-term follow-up of MRC Myeloma IX trial: Survival outcomes with bisphosphonate and thalidomide treatment. Clin Cancer Res. 2013 Nov 1;19(21):6030-8. Epub 2013 Aug 30. link to original article PubMed

Dara-Rd

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Dara-Rd: Daratumumab, Revlimid (Lenalidomide), Dexamethasone
D-Rd: Daratumumab, Revlimid (Lenalidomide), Dexamethasone

Regimen

Study Evidence Comparator Comparative Efficacy
Facon et al. 2019 (MAIA) Phase III (E) Rd Superior PFS

This regimen was intended for patients with newly diagnosed, documented multiple myeloma who were not eligible for high-dose chemotherapy with stem-cell transplantation owing to coexisting conditions or an age of 65 years or older.

Chemotherapy

  • Daratumumab (Darzalex) as follows:
    • Cycles 1 & 2: 16 mg/kg IV once per day on days 1, 8, 15, 22
    • Cycles 3 to 6: 16 mg/kg IV once per day on days 1 & 15
    • Cycle 7 onwards: 16 mg/kg IV once per cycle
  • Lenalidomide (Revlimid) 25 mg PO once per day on days 1 to 21
    • For patients with CrCl of 30 to 50 mL/min/1.73m2 a dose of 10 mg PO once per day on days 1 to 21 was recommended
  • Dexamethasone (Decadron) 40 mg PO once per day on days 1, 8, 15, 22
    • Patients older than 75 years or underweight (BMI less than 18.5) received 20 mg weekly

28-day cycles

References

  1. MAIA: Facon T, Kumar S, Plesner T, Orlowski RZ, Moreau P, Bahlis N, Basu S, Nahi H, Hulin C, Quach H, Goldschmidt H, O'Dwyer M, Perrot A, Venner CP, Weisel K, Mace JR, Raje N, Attal M, Tiab M, Macro M, Frenzel L, Leleu X, Ahmadi T, Chiu C, Wang J, Van Rampelbergh R, Uhlar CM, Kobos R, Qi M, Usmani SZ; MAIA Trial Investigators. Daratumumab plus lenalidomide and dexamethasone for untreated myeloma. N Engl J Med. 2019 May 30;380(22):2104-2115. link to original article contains verified protocol PubMed

Dara-VMP

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Dara-VMP: Daratumumab, Velcade (Bortezomib), Melphalan, Prednisone
D-VMP: Daratumumab, Velcade (Bortezomib), Melphalan, Prednisone

Regimen

Study Evidence Comparator Comparative Efficacy
Mateos et al. 2017 (ALCYONE) Phase III (E) VMP Superior PFS

This regimen was intended for patients with newly diagnosed, documented multiple myeloma who were not eligible for high-dose chemotherapy with stem-cell transplantation owing to coexisting conditions or an age of 65 years or older. Note that dexamethasone is substitute for prednisone on day 1.

Chemotherapy

  • Daratumumab (Darzalex) as follows:
    • Cycle 1: 16 mg/kg IV once per day on days 1, 8, 15, 22, 29, 36
    • Cycles 2 to 9: 16 mg/kg IV once per day on days 1 & 22
  • Bortezomib (Velcade) as follows:
    • Cycle 1: 1.3 mg/m2 SC once per day on days 1, 4, 8, 11, 22, 25, 29, 32
    • Cycles 2 to 9: 1.3 mg/m2 SC once per day on days 1, 8, 22, 29
  • Melphalan (Alkeran) 9 mg/m2 PO once per day on days 1 to 4
  • Prednisone (Sterapred) 60 mg/m2 PO once per day on days 2 to 4

Supportive medications

42-day cycle for 9 cycles

Subsequent treatment

References

  1. ALCYONE: Mateos MV, Dimopoulos MA, Cavo M, Suzuki K, Jakubowiak A, Knop S, Doyen C, Lucio P, Nagy Z, Kaplan P, Pour L, Cook M, Grosicki S, Crepaldi A, Liberati AM, Campbell P, Shelekhova T, Yoon SS, Iosava G, Fujisaki T, Garg M, Chiu C, Wang J, Carson R, Crist W, Deraedt W, Nguyen H, Qi M, San-Miguel J; ALCYONE Trial Investigators. Daratumumab plus bortezomib, melphalan, and prednisone for untreated myeloma. N Engl J Med. 2018 Feb 8;378(6):518-528. Epub 2017 Dec 12. link to original article contains verified protocol PubMed

KMP

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KMP: Kyprolis (Carfilzomib), Melphalan, Prednisone
CMP: Carfilzomib, Melphalan, Prednisone

Regimen

Study Evidence Comparator Comparative Efficacy
Moreau et al. 2015 (CARMYSAP) Phase I/II
Facon et al. 2019 (CLARION) Phase III (E) VMP Seems not superior

CARMYSAP was open to patients older than 65 years of age. Although not explicitly stated, this is considered to be a transplant ineligible population in France. The carfilzomib dose of 36 mg/m2 was considered to be the MTD in CARMYSAP. CLARION was open to transplant ineligible patients.

Chemotherapy

  • Carfilzomib (Kyprolis) as follows:
    • Cycle 1: 20 mg/m2 IV once per day on days 1 & 2, then 36 mg/m2 IV once per day on days 8, 9, 22, 23, 29, 30
    • Cycles 2 to 9: 36 mg/m2 IV once per day on days 1, 2, 8, 9, 22, 23, 29, 30
  • Melphalan (Alkeran) 9 mg/m2/day PO on days 1 to 4
  • Prednisone (Sterapred) 60 mg/m2/day PO on days 1 to 4

42-day cycle for 9 cycles

References

  1. CARMYSAP: Moreau P, Kolb B, Attal M, Caillot D, Benboubker L, Tiab M, Touzeau C, Leleu X, Roussel M, Chaleteix C, Planche L, Chiffoleau A, Fortin J, Avet-Loiseau H, Mary JY, Hulin C, Facon T. Phase 1/2 study of carfilzomib plus melphalan and prednisone in patients aged over 65 years with newly diagnosed multiple myeloma. Blood. 2015 May 14;125(20):3100-4. Epub 2015 Mar 17. link to original article contains verified protocol PubMed
  2. CLARION: Facon T, Lee JH, Moreau P, Niesvizky R, Dimopoulos M, Hajek R, Pour L, Jurczyszyn A, Qiu L, Klippel Z, Zahlten-Kumeli A, Osman M, Paiva B, San-Miguel J. Carfilzomib or bortezomib with melphalan-prednisone for transplant-ineligible patients with newly diagnosed multiple myeloma. Blood. 2019 May 2;133(18):1953-1963. Epub 2019 Feb 28. link to original article contains protocol PubMed

MPR

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MPR: Melphalan, Prednisone, Revlimid (Lenalidomide)
MPL: Melphalan, Prednisone, Lenalidomide

Variant #1, 0.13/1.5/10

Study Evidence Comparator Comparative Efficacy
Magarotto et al. 2016 (EMN01) Phase III (E) 1. CPR Might have superior PFS
2. Rd Might have superior PFS

This regimen is intended for patients who were ineligible for high-dose therapy plus stem cell transplantation because of age (greater than or equal to 65 years) or coexisting comorbidities. This variant was intended for patients older than 75.

Chemotherapy

Supportive medications

28-day cycle for 9 cycles

Subsequent treatment

Variant #2, 0.18/1.5/10

Study Evidence Comparator Comparative Efficacy
Magarotto et al. 2016 (EMN01) Phase III (E) 1. CPR Might have superior PFS
2. Rd Might have superior PFS

This regimen is intended for patients who were ineligible for high-dose therapy plus stem cell transplantation because of age (greater than or equal to 65 years) or coexisting comorbidities. This variant was intended for patients aged 65 to 75.

Chemotherapy

Supportive medications

28-day cycle for 9 cycles

Subsequent treatment

Variant #3, 0.18/2/10

Study Evidence Comparator Comparative Efficacy
Palumbo et al. 2007a Phase II
Palumbo et al. 2012 (MM-015) Phase III (E) 1. MP Superior PFS
2. MPR Superior PFS
Zweegman et al. 2016 (HOVON87/NMSG18) Phase III (E) MPT-T Seems not superior

In Palumbo et al. 2007a this regimen was intended for newly diagnosed multiple myeloma patients greater than or equal to 65 years, or younger if ineligible for high-dose therapy. In MM-015 this regimen was intended for patients with symptomatic, measurable, newly diagnosed multiple myeloma who were not candidates for transplantation (greater than or equal to 65 years of age). In HOVON87/NMSG18 this regimen was intended for patients greater than 65 years of age or patients less than or equal to 65 of age and not eligible for high-dose chemotherapy and peripheral stem cell transplantation with newly diagnosed symptomatic MM.

Chemotherapy

Supportive medications

28-day cycle for 9 cycles

Subsequent treatment

Variant #4, 5/100/10

Study Evidence Comparator Comparative Efficacy
Stewart et al. 2015 (ECOG E1A06) Phase III (E) MPT-T Seems to have non-inferior PFS

This regimen was intended for patients who were greater than or equal to 65 years or were less than 65 years and were not candidates for autologous hematopoietic cell transplantation or had declined transplant.

Chemotherapy

Supportive medications

  • Aspirin was required (dose not specified)
    • Full anticoagulation was used for patients at "higher risk" for DVT
  • Pamidronate (Aredia) 90 mg IV once per month recommended for patients with "active bone disease"

28-day cycle for 12 cycles

Subsequent treatment

References

  1. Palumbo A, Falco P, Corradini P, Falcone A, Di Raimondo F, Giuliani N, Crippa C, Ciccone G, Omedè P, Ambrosini MT, Gay F, Bringhen S, Musto P, Foà R, Knight R, Zeldis JB, Boccadoro M, Petrucci MT; GIMEMA--Italian Multiple Myeloma Network. Melphalan, prednisone, and lenalidomide treatment for newly diagnosed myeloma: a report from the GIMEMA--Italian Multiple Myeloma Network. J Clin Oncol. 2007 Oct 1;25(28):4459-65. Epub 2007 Sep 4. link to original article contains verified protocol PubMed
  2. MM-015: Palumbo A, Hajek R, Delforge M, Kropff M, Petrucci MT, Catalano J, Gisslinger H, Wiktor-Jedrzejczak W, Zodelava M, Weisel K, Cascavilla N, Iosava G, Cavo M, Kloczko J, Bladé J, Beksac M, Spicka I, Plesner T, Radke J, Langer C, Ben Yehuda D, Corso A, Herbein L, Yu Z, Mei J, Jacques C, Dimopoulos MA; MM-015 Investigators. Continuous lenalidomide treatment for newly diagnosed multiple myeloma. N Engl J Med. 2012 May 10;366(19):1759-69. Erratum in: N Engl J Med. 2012 Jul 19;367(3):285. link to original article contains verified protocol PubMed
  3. ECOG E1A06: Stewart AK, Jacobus S, Fonseca R, Weiss M, Callander NS, Chanan-Khan AA, Rajkumar SV. Melphalan, prednisone, and thalidomide vs melphalan, prednisone, and lenalidomide (ECOG E1A06) in untreated multiple myeloma. Blood. 2015 Sep 10;126(11):1294-301. Epub 2015 Jul 8. link to original article contains verified protocol link to PMC article PubMed
  4. EMN01: Magarotto V, Bringhen S, Offidani M, Benevolo G, Patriarca F, Mina R, Falcone AP, De Paoli L, Pietrantuono G, Gentili S, Musolino C, Giuliani N, Bernardini A, Conticello C, Pulini S, Ciccone G, Maisnar V, Ruggeri M, Zambello R, Guglielmelli T, Ledda A, Liberati AM, Montefusco V, Hajek R, Boccadoro M, Palumbo A. Triplet vs doublet lenalidomide-containing regimens for the treatment of elderly patients with newly diagnosed multiple myeloma. Blood. 2016 Mar 3;127(9):1102-8. Epub 2016 Jan 4. link to original article contains verified protocol PubMed
  5. HOVON87/NMSG18: Zweegman S, van der Holt B, Mellqvist UH, Salomo M, Bos GM, Levin MD, Visser-Wisselaar H, Hansson M, van der Velden AW, Deenik W, Gruber A, Coenen JL, Plesner T, Klein SK, Tanis BC, Szatkowski DL, Brouwer RE, Westerman M, Leys MR, Sinnige HA, Haukås E, van der Hem KG, Durian MF, Mattijssen EV, van de Donk NW, Stevens-Kroef MJ, Sonneveld P, Waage A. Melphalan, prednisone, and lenalidomide versus melphalan, prednisone, and thalidomide in untreated multiple myeloma. Blood. 2016 Mar 3;127(9):1109-16. Epub 2016 Jan 22. link to original article contains verified protocol PubMed

MPT

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MPT: Melphalan, Prednisone, Thalidomide

Variant #1, "MPT-T"

Study Evidence Comparator Comparative Efficacy
Zweegman et al. 2016 (HOVON87/NMSG18) Phase III (C) MPR-R Seems not superior

This regimen was intended for patients greater than 65 years of age or patients less than or equal to 65 of age and not eligible for high-dose chemotherapy and peripheral stem cell transplantation with newly diagnosed symptomatic MM.

Chemotherapy

Supportive medications

28-day cycle for 9 cycles

Subsequent treatment

Variant #2, "MPT-T"

Study Evidence Comparator Comparative Efficacy
Stewart et al. 2015 (ECOG E1A06) Phase III (C) mPR-R Seems to have non-inferior PFS

This regimen was intended for patients who were greater than or equal to 65 years or were less than 65 years and were not candidates for autologous hematopoietic cell transplantation or had declined transplant.

Chemotherapy

Supportive medications

  • Aspirin was required (dose not specified)
    • Full anticoagulation was used for patients at "higher risk" for DVT
  • Pamidronate (Aredia) 90 mg IV once per month recommended for patients with "active bone disease"

28-day cycle for 12 cycles

Subsequent treatment

Variant #3

Study Evidence Comparator Comparative Efficacy
Benboubker et al. 2014 (FIRST) Phase III (C) 1. Rd Inferior OS (*)
2. Rd18 Might have inferior OS

This regimen was intended for patients who had previously untreated, symptomatic, and measurable multiple myeloma and either were greater than or equal to 65 years of age or were less than 65 years of age and ineligible for stem-cell transplantation. See supplemental appendix for further details of dose reductions from starting dose. Efficacy compared to Rd continuous is based on the 2017 update.

Chemotherapy

  • Melphalan (Alkeran) starting dose as follows:
    • Age up to 75 years AND ANC at least 1500/uL AND platelets at least 100 x 109/L: 0.25 mg/kg PO once per day on days 1 to 4
    • Older than 75 years AND ANC at least 1500/uL AND platelets at least 100 x 109/L: 0.2 mg/kg PO once per day on days 1 to 4
    • Age up to 75 years AND ANC less than 1500/uL but greater than or equal to 1000/uL OR platelets less than 100 x 109/L but greater than or equal to 50 x 109/L: 0.125 mg/kg PO once per day on days 1 to 4
    • Older than 75 years AND ANC less than 1500/uL but greater than or equal to 1000/uL OR platelets less than 100 x 109/L but greater than or equal to 50 x 109/L: 0.1 mg/kg PO once per day on days 1 to 4
  • Prednisone (Sterapred) 2 mg/kg PO once per day on days 1 to 4
  • Thalidomide (Thalomid) starting dose as follows:
    • Age up to 75 years: 200 mg PO once per day
    • Older than 75 years: 100 mg PO once per day

42-day cycle for 12 cycles

Variant #4

Study Evidence Comparator Comparative Efficacy
Beksac et al. 2010 (TMSG-2005-001) Phase III (E) MP Seems to have superior ORR

This regimen was intended for patients with newly diagnosed, untreated, symptomatic, measurable myeloma who were not candidates for high-dose therapy plus stem-cell transplantation because of age (greater than or equal to 65 years) or coexisting conditions.

Chemotherapy

42-day cycle for 9 cycles

Variant #5

Study Evidence Comparator Comparative Efficacy
Waage et al. 2010 (NMSG12) Phase III (E) MP Seems not superior

This regimen was intended for patients with previously untreated symptomatic MM, who were not eligible for high-dose treatment with autologous stem cell support.

Chemotherapy

42-day cycles until plateau phase

Subsequent treatment

Variant #6, "MP-T"

Study Evidence Comparator Comparative Efficacy
Wijermans et al. 2010 (HOVON 49) Phase III (E) MP Might have superior OS

This regimen was intended for patients with previously untreated MM older than age 65 years.

Chemotherapy

Supportive medications

28-day cycle for 8 cycles

Subsequent treatment

Variant #7

Study Evidence Comparator Comparative Efficacy
Hulin et al. 2009 (IFM 01/01) Phase III (E) MP Seems to have superior OS

This regimen was intended for patients who had stage II or III newly diagnosed multiple myeloma according to the Durie-Salmon criteria and were at least 75 years of age. Certain stage I patients were allowed; see text for details.

Chemotherapy

42-day cycle for 12 cycles

Variant #8

Study Evidence Comparator Comparative Efficacy
Facon et al. 2007 (IFM 99-06) Phase III (E) 1. MP Superior OS
2. MEL100 Seems to have superior OS

This regimen was intended for patients with newly diagnosed multiple myeloma aged 65 to 75 years.

Chemotherapy

42-day cycle for 12 cycles

Variant #9

Study Evidence Comparator Comparative Efficacy
Palumbo et al. 2006 Phase III (E) MP Seems to have superior PFS

This regimen was intended for patients with newly diagnosed multiple myeloma aged 60 to 85 years.

Chemotherapy

Supportive medications

28-day cycle for 6 cycles

Subsequent treatment

References

  1. Palumbo A, Bringhen S, Caravita T, Merla E, Capparella V, Callea V, Cangialosi C, Grasso M, Rossini F, Galli M, Catalano L, Zamagni E, Petrucci MT, De Stefano V, Ceccarelli M, Ambrosini MT, Avonto I, Falco P, Ciccone G, Liberati AM, Musto P, Boccadoro M; Italian Multiple Myeloma Network (GIMEMA). Oral melphalan and prednisone chemotherapy plus thalidomide compared with melphalan and prednisone alone in elderly patients with multiple myeloma: randomised controlled trial. Lancet. 2006 Mar 11;367(9513):825-31. link to original article contains protocol PubMed
    1. Update: Palumbo A, Bringhen S, Liberati AM, Caravita T, Falcone A, Callea V, Montanaro M, Ria R, Capaldi A, Zambello R, Benevolo G, Derudas D, Dore F, Cavallo F, Gay F, Falco P, Ciccone G, Musto P, Cavo M, Boccadoro M. Oral melphalan, prednisone, and thalidomide in elderly patients with multiple myeloma: updated results of a randomized controlled trial. Blood. 2008 Oct 15;112(8):3107-14. Epub 2008 May 27. link to original article contains protocol PubMed
  2. IFM 99-06: Facon T, Mary JY, Hulin C, Benboubker L, Attal M, Pegourie B, Renaud M, Harousseau JL, Guillerm G, Chaleteix C, Dib M, Voillat L, Maisonneuve H, Troncy J, Dorvaux V, Monconduit M, Martin C, Casassus P, Jaubert J, Jardel H, Doyen C, Kolb B, Anglaret B, Grosbois B, Yakoub-Agha I, Mathiot C, Avet-Loiseau H; Intergroupe Francophone du Myélome. Melphalan and prednisone plus thalidomide versus melphalan and prednisone alone or reduced-intensity autologous stem cell transplantation in elderly patients with multiple myeloma (IFM 99-06): a randomised trial. Lancet. 2007 Oct 6;370(9594):1209-18. link to original article contains verified protocol PubMed content property of HemOnc.org
  3. IFM 01/01: Hulin C, Facon T, Rodon P, Pegourie B, Benboubker L, Doyen C, Dib M, Guillerm G, Salles B, Eschard JP, Lenain P, Casassus P, Azaïs I, Decaux O, Garderet L, Mathiot C, Fontan J, Lafon I, Virion JM, Moreau P. Efficacy of melphalan and prednisone plus thalidomide in patients older than 75 years with newly diagnosed multiple myeloma: IFM 01/01 trial. J Clin Oncol. 2009 Aug 1;27(22):3664-70. Epub 2009 May 18. link to original article contains verified protocol PubMed
  4. NMSG12: Waage A, Gimsing P, Fayers P, Abildgaard N, Ahlberg L, Björkstrand B, Carlson K, Dahl IM, Forsberg K, Gulbrandsen N, Haukås E, Hjertner O, Hjorth M, Karlsson T, Knudsen LM, Nielsen JL, Linder O, Mellqvist UH, Nesthus I, Rolke J, Strandberg M, Sørbø JH, Wisløff F, Juliusson G, Turesson I; Nordic Myeloma Study Group. Melphalan and prednisone plus thalidomide or placebo in elderly patients with multiple myeloma. Blood. 2010 Sep 2;116(9):1405-12. Epub 2010 May 6. link to original article contains verified protocol PubMed
  5. HOVON 49: Wijermans P, Schaafsma M, Termorshuizen F, Ammerlaan R, Wittebol S, Sinnige H, Zweegman S, van Marwijk Kooy M, van der Griend R, Lokhorst H, Sonneveld P; Dutch-Belgium Cooperative Group HOVON. Phase III study of the value of thalidomide added to melphalan plus prednisone in elderly patients with newly diagnosed multiple myeloma: the HOVON 49 Study. J Clin Oncol. 2010 Jul 1;28(19):3160-6. Epub 2010 Jun 1. link to original article contains verified protocol PubMed
  6. TMSG-2005-001: Beksac M, Haznedar R, Firatli-Tuglular T, Ozdogu H, Aydogdu I, Konuk N, Sucak G, Kaygusuz I, Karakus S, Kaya E, Ali R, Gulbas Z, Ozet G, Goker H, Undar L. Addition of thalidomide to oral melphalan/prednisone in patients with multiple myeloma not eligible for transplantation: results of a randomized trial from the Turkish Myeloma Study Group. Eur J Haematol. 2011 Jan;86(1):16-22. Epub 2010 Nov 22. link to original article contains protocol PubMed
  7. Meta-analysis: Fayers PM, Palumbo A, Hulin C, Waage A, Wijermans P, Beksaç M, Bringhen S, Mary JY, Gimsing P, Termorshuizen F, Haznedar R, Caravita T, Moreau P, Turesson I, Musto P, Benboubker L, Schaafsma M, Sonneveld P, Facon T; Nordic Myeloma Study Group; Italian Multiple Myeloma Network; Turkish Myeloma Study Group; Hemato-Oncologie voor Volwassenen Nederland; Intergroupe Francophone du Myélome; European Myeloma Network. Thalidomide for previously untreated elderly patients with multiple myeloma: meta-analysis of 1685 individual patient data from 6 randomized clinical trials. Blood. 2011 Aug 4;118(5):1239-47. Epub 2011 Jun 13. link to original article PubMed
  8. FIRST: Benboubker L, Dimopoulos MA, Dispenzieri A, Catalano J, Belch AR, Cavo M, Pinto A, Weisel K, Ludwig H, Bahlis N, Banos A, Tiab M, Delforge M, Cavenagh J, Geraldes C, Lee JJ, Chen C, Oriol A, de la Rubia J, Qiu L, White DJ, Binder D, Anderson K, Fermand JP, Moreau P, Attal M, Knight R, Chen G, Van Oostendorp J, Jacques C, Ervin-Haynes A, Avet-Loiseau H, Hulin C, Facon T; FIRST Trial Team. Lenalidomide and dexamethasone in transplant-ineligible patients with myeloma. N Engl J Med. 2014 Sep 4;371(10):906-17. link to original article link to supplemental appendix contains verified protocol PubMed
    1. Update: Hulin C, Belch A, Shustik C, Petrucci MT, Dührsen U, Lu J, Song K, Rodon P, Pégourié B, Garderet L, Hunter H, Azais I, Eek R, Gisslinger H, Macro M, Dakhil S, Goncalves C, LeBlanc R, Romeril K, Royer B, Doyen C, Leleu X, Offner F, Leupin N, Houck V, Chen G, Ervin-Haynes A, Dimopoulos MA, Facon T. Updated outcomes and impact of age with lenalidomide and low-dose dexamethasone or melphalan, prednisone, and thalidomide in the randomized, phase III FIRST trial. J Clin Oncol. 2016 Oct;34(30):3609-17. Epub 2016 Jun 20. link to original article PubMed
    2. Update: Facon T, Dimopoulos MA, Dispenzieri A, Catalano JV, Belch A, Cavo M, Pinto A, Weisel K, Ludwig H, Bahlis NJ, Banos A, Tiab M, Delforge M, Cavenagh JD, Geraldes C, Lee JJ, Chen C, Oriol A, De La Rubia J, White D, Binder D, Lu J, Anderson KC, Moreau P, Attal M, Perrot A, Arnulf B, Qiu L, Roussel M, Boyle E, Manier S, Mohty M, Avet-Loiseau H, Leleu X, Ervin-Haynes A, Chen G, Houck V, Benboubker L, Hulin C. Final analysis of survival outcomes in the phase 3 FIRST trial of up-front treatment for multiple myeloma. Blood. 2018 Jan 18;131(3):301-310. Epub 2017 Nov 17. link to original article PubMed
  9. ECOG E1A06: Stewart AK, Jacobus S, Fonseca R, Weiss M, Callander NS, Chanan-Khan AA, Rajkumar SV. Melphalan, prednisone, and thalidomide vs melphalan, prednisone, and lenalidomide (ECOG E1A06) in untreated multiple myeloma. Blood. 2015 Sep 10;126(11):1294-301. Epub 2015 Jul 8. link to original article contains verified protocol link to PMC article PubMed
  10. HOVON87/NMSG18: Zweegman S, van der Holt B, Mellqvist UH, Salomo M, Bos GM, Levin MD, Visser-Wisselaar H, Hansson M, van der Velden AW, Deenik W, Gruber A, Coenen JL, Plesner T, Klein SK, Tanis BC, Szatkowski DL, Brouwer RE, Westerman M, Leys MR, Sinnige HA, Haukås E, van der Hem KG, Durian MF, Mattijssen EV, van de Donk NW, Stevens-Kroef MJ, Sonneveld P, Waage A. Melphalan, prednisone, and lenalidomide versus melphalan, prednisone, and thalidomide in untreated multiple myeloma. Blood. 2016 Mar 3;127(9):1109-16. Epub 2016 Jan 22. link to original article contains verified protocol PubMed

PAD

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PAD: PS-341 (Bortezomib), Adriamycin (Doxorubicin), Dexamethasone
PAd: PS-341 (Bortezomib), Adriamycin (Doxorubicin), low-dose dexamethasone
Note that this regimen is sometimes called VAD but this can create a lot of confusion with the "original" VAD which uses Vincristine.
VAD: Velcade (Bortezomib), Adriamycin (Doxorubicin), Dexamethasone
BDD: Bortezomib, Doxorubicin, Dexamethasone

Variant #1, 1/9/40, IV bortezomib

Study Evidence
Ludwig et al. 2010a Phase II

Note: This is not specifically a first-line regimen but most patients enrolled on the phase II trial were untreated (50 out of 68). The route of bortezomib was not clearly described in the manuscript but has been confirmed with the authors.

Chemotherapy

  • Bortezomib (Velcade) 1 mg/m2 IV once per day on days 1, 4, 8, 11
    • Patients without grade 3 or 4 toxicity during the first two cycles could have bortezomib dose increased to 1.3 mg/m2 (route not specified) once per day on days 1, 4, 8, 11
  • Doxorubicin (Adriamycin) 9 mg/m2 IV once per day on days 1 & 4
    • Patients without grade 3 or 4 toxicity during the first two cycles could have number of doxorubicin doses increased to 9 mg/m2 IV once per day on days 1, 4, 8, 11
  • Dexamethasone (Decadron) 40 mg (route not specified) once per day on days 1, 4, 8, 11

21-day cycle for up to 8 cycles

Variant #2, 1.3/9/20, SC bortezomib ("PAd")

Study Evidence Comparator Comparative Efficacy
Mai et al. 2015 (GMMG-MM5) Phase III (E) VCD Non-inferior VGPR or better rate

This regimen was intended for patients 18 to 70 years of age with newly diagnosed MM who required systemic chemotherapy based on the CRAB criteria. Note that the bortezomib route was changed from IV to SC with a mid-protocol amendment.

Chemotherapy

Supportive medications

28-day cycle for 3 cycles

Subsequent treatment

Variant #3, 1.3/9/40 x 3, IV bortezomib

Study Evidence Comparator Comparative Efficacy
Sonneveld et al. 2012 (HOVON-65) Phase III (E) VAD Superior PFS (*)
Sonneveld et al. 2012 (GMMG-HD4) Phase III (E) VAD Superior PFS (*)

This regimen was intended for patients 18 to 65 years of age with newly diagnosed MM, Durie-Salmon stage II to III, WHO performance status 0 to 2, or WHO 3 when caused by MM. Note that in the initial publication, this arm seemed to have an overall survival advantage; this was no longer present in the updated report of 2017; PFS was the primary endpoint. Stem cells collected 4 to 6 weeks after induction therapy

Chemotherapy

Supportive medications

(described in the appendix of Sonneveld et al. 2012):

  • One of the following bisphosphonates recommended:
  • "Prophylactic antibiotics" (no further specifics) during induction therapy
  • Erythropoietin and pain medications at physician discretion
  • One of the following for Herpes zoster prophylaxis throughout bortezomib induction:
    • Acyclovir (Zovirax) 800 mg PO per day (did not specify whether taken once per day or as a divided twice per day dose)
    • Valacyclovir (Valtrex) 1000 mg PO per day (did not specify whether taken once per day or as a divided twice per day dose)

28-day cycle for 3 cycles

Subsequent treatment

Variant #4, 1.3/9/40 x 4, IV bortezomib

Study Evidence
Oakervee et al. 2005 Phase II, <20 pts (*)

Note that while this is reported as a phase II, it was also a dose-finding study; only 14 patients were treated at the dose here.

Chemotherapy

21-day cycle for 4 cycles

Subsequent treatment

References

  1. Oakervee HE, Popat R, Curry N, Smith P, Morris C, Drake M, Agrawal S, Stec J, Schenkein D, Esseltine DL, Cavenagh JD. PAD combination therapy (PS-341/bortezomib, doxorubicin and dexamethasone) for previously untreated patients with multiple myeloma. Br J Haematol. 2005 Jun;129(6):755-62. link to original article contains verified protocol PubMed
  2. Ludwig H, Adam Z, Hajek R, Greil R, Tóthová E, Keil F, Autzinger EM, Thaler J, Gisslinger H, Lang A, Egyed M, Womastek I, Zojer N. Light chain-induced acute renal failure can be reversed by bortezomib-doxorubicin-dexamethasone in multiple myeloma: results of a phase II study. J Clin Oncol. 2010 Oct 20;28(30):4635-41. Epub 2010 Sep 7. link to original article contains verified protocol PubMed
  3. HOVON-65/GMMG-HD4: Sonneveld P, Schmidt-Wolf IG, van der Holt B, El Jarari L, Bertsch U, Salwender H, Zweegman S, Vellenga E, Broyl A, Blau IW, Weisel KC, Wittebol S, Bos GM, Stevens-Kroef M, Scheid C, Pfreundschuh M, Hose D, Jauch A, van der Velde H, Raymakers R, Schaafsma MR, Kersten MJ, van Marwijk-Kooy M, Duehrsen U, Lindemann W, Wijermans PW, Lokhorst HM, Goldschmidt HM. Bortezomib induction and maintenance treatment in patients with newly diagnosed multiple myeloma: results of the randomized phase III HOVON-65/ GMMG-HD4 trial. J Clin Oncol. 2012 Aug 20;30(24):2946-55. Epub 2012 Jul 16. link to original article contains verified protocol PubMed
    1. Subgroup analysis: Neben K, Lokhorst HM, Jauch A, Bertsch U, Hielscher T, van der Holt B, Salwender H, Blau IW, Weisel K, Pfreundschuh M, Scheid C, Dührsen U, Lindemann W, Schmidt-Wolf IG, Peter N, Teschendorf C, Martin H, Haenel M, Derigs HG, Raab MS, Ho AD, van de Velde H, Hose D, Sonneveld P, Goldschmidt H. Administration of bortezomib before and after autologous stem cell transplantation improves outcome in multiple myeloma patients with deletion 17p. Blood. 2012 Jan 26;119(4):940-8. Epub 2011 Dec 8. link to original article PubMed
    2. Update: Goldschmidt H, Lokhorst HM, Mai EK, van der Holt B, Blau IW, Zweegman S, Weisel KC, Vellenga E, Pfreundschuh M, Kersten MJ, Scheid C, Croockewit S, Raymakers R, Hose D, Potamianou A, Jauch A, Hillengass J, Stevens-Kroef M, Raab MS, Broijl A, Lindemann HW, Bos GMJ, Brossart P, van Marwijk Kooy M, Ypma P, Duehrsen U, Schaafsma RM, Bertsch U, Hielscher T, Jarari L, Salwender HJ, Sonneveld P. Bortezomib before and after high-dose therapy in myeloma: long-term results from the phase III HOVON-65/GMMG-HD4 trial. Leukemia. 2018 Feb;32(2):383-390. Epub 2017 Jul 4. link to original article PubMed
  4. GMMG-MM5: Mai EK, Bertsch U, Dürig J, Kunz C, Haenel M, Blau IW, Munder M, Jauch A, Schurich B, Hielscher T, Merz M, Huegle-Doerr B, Seckinger A, Hose D, Hillengass J, Raab MS, Neben K, Lindemann HW, Zeis M, Gerecke C, Schmidt-Wolf IG, Weisel K, Scheid C, Salwender H, Goldschmidt H. Phase III trial of bortezomib, cyclophosphamide and dexamethasone (VCD) versus bortezomib, doxorubicin and dexamethasone (PAd) in newly diagnosed myeloma. Leukemia. 2015 Aug;29(8):1721-9. Epub 2015 Mar 19. link to original article contains verified protocol PubMed
    1. Subgroup analysis: Merz M, Salwender H, Haenel M, Mai EK, Bertsch U, Kunz C, Hielscher T, Blau IW, Scheid C, Hose D, Seckinger A, Jauch A, Hillengass J, Raab MS, Schurich B, Munder M, Schmidt-Wolf IG, Gerecke C, Lindemann HW, Zeis M, Weisel K, Duerig J, Goldschmidt H. Subcutaneous versus intravenous bortezomib in two different induction therapies for newly diagnosed multiple myeloma: an interim analysis from the prospective GMMG-MM5 trial. Haematologica. 2015 Jul;100(7):964-9. Epub 2015 Apr 3. link to original article link to PMC article PubMed

Rd

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Rd: Revlimid (Lenalidomide) & low-dose dexamethasone
RevDex: Revlimid (Lenalidomide) & Dexamethasone
Ld: Lenalidomide & low-dose dexamethasone
LenDex: Lenalidomide & Dexamethasone

Variant #1, limited duration (4 cycles)

Study Evidence Comparator Comparative Efficacy
Rajkumar et al. 2009 (ECOG E4A03) Phase III (E) RD Superior OS
Gay et al. 2010 Retrospective
Palumbo et al. 2014 (MPRvsMEL200) Non-randomized portion of RCT
Gay et al. 2015 (EMN-441) Non-randomized portion of RCT

In ECOG E4A03 this is the low-dose dexamethasone arm, and was intended for patients with previously untreated symptomatic multiple myeloma, bone marrow plasmacytosis (greater than or equal to 10% plasma cells or sheets of plasma cells) or a biopsy-proven plasmacytoma, and measurable disease defined as serum monoclonal protein more than 1 g/dL and/or urine monoclonal protein greater than or equal to 200 mg/24 h. MPRvsMEL200 was intended for patients with symptomatic, measurable, newly diagnosed multiple myeloma who were 65 years of age or younger. EMN-441 was intended for transplant-eligible patients with newly diagnosed myeloma aged 65 years or younger.

Chemotherapy

Supportive medications

(as described in Rajkumar et al. 2009):

  • One of the following bisphosphonates:
  • Thromboprophylaxis mandatory (added mid-protocol after excess rates of DVT)

28-day cycle for 4 cycles (see below)

Subsequent treatment

Variant #2, limited duration (6 cycles)

Study Evidence Comparator Comparative Efficacy
Durie et al. 2016 (SWOG S0777) Phase III (C) VRd Seems to have inferior OS

Chemotherapy

28-day cycle for 6 cycles

Subsequent treatment

Variant #3, limited duration (9 cycles)

Study Evidence Comparator Comparative Efficacy
Magarotto et al. 2016 (EMN01) Phase III (E) 1. CPR Seems not superior
2. MPR Might have inferior PFS

This regimen is intended for patients who were ineligible for high-dose therapy plus stem cell transplantation because of age (greater than or equal to 65 years) or coexisting comorbidities.

Chemotherapy

Supportive medications

28-day cycle for 9 cycles

Subsequent treatment

Variant #4, limited duration (18 cycles, "Rd18")

Study Evidence Comparator Comparative Efficacy
Benboubker et al. 2014 (FIRST) Phase III (E) 1. MPT Superior OS (*)
2. Rd continuous Seems not superior (*)

This regimen was intended for patients who had previously untreated, symptomatic, and measurable multiple myeloma and either were greater than or equal to 65 years of age or were less than 65 years of age and ineligible for stem-cell transplantation. See supplemental appendix for further details of dose reductions from starting dose. Efficacy based on the 2017 update.

Chemotherapy

  • Lenalidomide (Revlimid) starting dose as follows:
    • Normal renal function: 25 mg PO once per day on days 1 to 21
    • Moderate renal impairment (CrCl 30 to 50 mL/min/1.73m2): 10 mg PO once per day on days 1 to 21
    • Severe renal impairment (CrCl less than 30 mL/min/1.73m2): 15 mg PO once every other day on days 1 to 21
  • Dexamethasone (Decadron) starting dose as follows:
    • Age less than or equal to 75: 40 mg PO once per day on days 1, 8, 15, 22
    • Age greater than 75: 20 mg PO once per day on days 1, 8, 15, 22

28-day cycle for 18 cycles

Variant #5, indefinite 28-day cycles

Study Evidence Comparator Comparative Efficacy
Benboubker et al. 2014 (FIRST) Phase III (E) 1. MPT Seems to have superior OS
2. Rd18 Seems not superior (*)

This regimen was intended for patients who had previously untreated, symptomatic, and measurable multiple myeloma and either were greater than or equal to 65 years of age or were less than 65 years of age and ineligible for stem-cell transplantation. See supplemental appendix for further details of dose reductions from starting dose. Efficacy compared to Rd18 based on the 2017 update.

Chemotherapy

  • Lenalidomide (Revlimid) starting dose as follows:
    • Normal renal function: 25 mg PO once per day on days 1 to 21
    • Moderate renal impairment (CrCl 30 to 50 mL/min/1.73m2): 10 mg PO once per day on days 1 to 21
    • Severe renal impairment (CrCl less than 30 mL/min/1.73m2): 15 mg PO once every other day on days 1 to 21
  • Dexamethasone (Decadron) starting dose as follows:
    • Age up to 75 years: 40 mg PO once per day on days 1, 8, 15, 22
    • Older than 75 years: 20 mg PO once per day on days 1, 8, 15, 22

28-day cycles

Variant #6, indefinite with 35-day induction cycles

Study Evidence Comparator Comparative Efficacy
Zonder et al. 2010 (SWOG S0232) Phase III (E) Dexamethasone Superior PFS

This regimen was intended for transplantation-ineligible or -denying patients who had to have symptomatic disease with a measurable M-protein, be at least 18 years old, and have a performance status less than 3 (unless resulting from myeloma). Note that the first 3 cycles, termed "induction" in the protocol, were 35-day cycles.

Chemotherapy

  • Lenalidomide (Revlimid) as follows:
    • Cycles 1 to 3: 25 mg PO once per day on days 1 to 28 of a 35-day cycle
    • Cycle 4 onwards: 25 mg PO once per day on days 1 to 21
  • Dexamethasone (Decadron) as follows:
    • Cycles 1 to 3: 40 mg PO once per day on days 1 to 4, 9 to 12, 17 to 20 of a 35-day cycle
    • Cycle 4 onwards: 40 mg PO once per day on days 1 to 4

Supportive medications

  • Aspirin 325 mg PO once per day unless already on anticoagulation therapy

28-day cycles (*)

Variant #7, indefinite 28-day cycles, first 4 with high-dose dex

Study Evidence
Rajkumar et al. 2005 Phase II

Chemotherapy

Supportive medications

  • Thromboprophylaxis: Aspirin 80 mg or 325 mg PO once per day

28-day cycles

References

  1. Rajkumar SV, Hayman SR, Lacy MQ, Dispenzieri A, Geyer SM, Kabat B, Zeldenrust SR, Kumar S, Greipp PR, Fonseca R, Lust JA, Russell SJ, Kyle RA, Witzig TE, Gertz MA. Combination therapy with lenalidomide plus dexamethasone (Rev/Dex) for newly diagnosed myeloma. Blood. 2005 Dec 15;106(13):4050-3. Epub 2005 Aug 23. link to original article contains protocol link to PMC article PubMed
  2. ECOG E4A03: Rajkumar SV, Jacobus S, Callander NS, Fonseca R, Vesole DH, Williams ME, Abonour R, Siegel DS, Katz M, Greipp PR; Eastern Cooperative Oncology Group. Lenalidomide plus high-dose dexamethasone versus lenalidomide plus low-dose dexamethasone as initial therapy for newly diagnosed multiple myeloma: an open-label randomised controlled trial. Lancet Oncol. 2010 Jan;11(1):29-37. Epub 2009 Oct 21. Erratum in: Lancet Oncol. 2010 Jan;11(1):14. link to original article contains verified protocol link to PMC article PubMed
    1. Subgroup analysis: Jacobus SJ, Kumar S, Uno H, Van Wier SA, Ahmann GJ, Henderson KJ, Callander NS, Williams ME, Siegel DS, Greipp PR, Rajkumar SV, Fonseca R. Impact of high-risk classification by FISH: an eastern cooperative oncology group (ECOG) study E4A03. Br J Haematol. 2011 Nov;155(3):340-8. Epub 2011 Sep 9. link to original article link to PMC article PubMed
  3. Retrospective: Gay F, Rajkumar SV, Coleman M, Kumar S, Mark T, Dispenzieri A, Pearse R, Gertz MA, Leonard J, Lacy MQ, Chen-Kiang S, Roy V, Jayabalan DS, Lust JA, Witzig TE, Fonseca R, Kyle RA, Greipp PR, Stewart AK, Niesvizky R. Clarithromycin (Biaxin)-lenalidomide-low-dose dexamethasone (BiRd) versus lenalidomide-low-dose dexamethasone (Rd) for newly diagnosed myeloma. Am J Hematol. 2010 Sep;85(9):664-9. link to original article contains verified protocol link to PMC article PubMed
  4. SWOG S0232: Zonder JA, Crowley J, Hussein MA, Bolejack V, Moore DF Sr, Whittenberger BF, Abidi MH, Durie BG, Barlogie B. Lenalidomide and high-dose dexamethasone compared with dexamethasone as initial therapy for multiple myeloma: a randomized Southwest Oncology Group trial (S0232). Blood. 2010 Dec 23;116(26):5838-41. Epub 2010 Sep 27. link to original article link to PMC article contains verified protocol PubMed
  5. MPRvsMEL200: Palumbo A, Cavallo F, Gay F, Di Raimondo F, Ben Yehuda D, Petrucci MT, Pezzatti S, Caravita T, Cerrato C, Ribakovsky E, Genuardi M, Cafro A, Marcatti M, Catalano L, Offidani M, Carella AM, Zamagni E, Patriarca F, Musto P, Evangelista A, Ciccone G, Omedé P, Crippa C, Corradini P, Nagler A, Boccadoro M, Cavo M. Autologous transplantation and maintenance therapy in multiple myeloma. N Engl J Med. 2014 Sep 4;371(10):895-905. link to original article contains verified protocol PubMed
  6. FIRST: Benboubker L, Dimopoulos MA, Dispenzieri A, Catalano J, Belch AR, Cavo M, Pinto A, Weisel K, Ludwig H, Bahlis N, Banos A, Tiab M, Delforge M, Cavenagh J, Geraldes C, Lee JJ, Chen C, Oriol A, de la Rubia J, Qiu L, White DJ, Binder D, Anderson K, Fermand JP, Moreau P, Attal M, Knight R, Chen G, Van Oostendorp J, Jacques C, Ervin-Haynes A, Avet-Loiseau H, Hulin C, Facon T; FIRST Trial Team. Lenalidomide and dexamethasone in transplant-ineligible patients with myeloma. N Engl J Med. 2014 Sep 4;371(10):906-17. link to original article link to supplemental appendix contains verified protocol PubMed
    1. Update: Hulin C, Belch A, Shustik C, Petrucci MT, Dührsen U, Lu J, Song K, Rodon P, Pégourié B, Garderet L, Hunter H, Azais I, Eek R, Gisslinger H, Macro M, Dakhil S, Goncalves C, LeBlanc R, Romeril K, Royer B, Doyen C, Leleu X, Offner F, Leupin N, Houck V, Chen G, Ervin-Haynes A, Dimopoulos MA, Facon T. Updated outcomes and impact of age with lenalidomide and low-dose dexamethasone or melphalan, prednisone, and thalidomide in the randomized, phase III FIRST trial. J Clin Oncol. 2016 Oct;34(30):3609-17. Epub 2016 Jun 20. link to original article PubMed
    2. Update: Facon T, Dimopoulos MA, Dispenzieri A, Catalano JV, Belch A, Cavo M, Pinto A, Weisel K, Ludwig H, Bahlis NJ, Banos A, Tiab M, Delforge M, Cavenagh JD, Geraldes C, Lee JJ, Chen C, Oriol A, De La Rubia J, White D, Binder D, Lu J, Anderson KC, Moreau P, Attal M, Perrot A, Arnulf B, Qiu L, Roussel M, Boyle E, Manier S, Mohty M, Avet-Loiseau H, Leleu X, Ervin-Haynes A, Chen G, Houck V, Benboubker L, Hulin C. Final analysis of survival outcomes in the phase 3 FIRST trial of up-front treatment for multiple myeloma. Blood. 2018 Jan 18;131(3):301-310. Epub 2017 Nov 17. link to original article PubMed
  7. Gay F, Oliva S, Petrucci MT, Conticello C, Catalano L, Corradini P, Siniscalchi A, Magarotto V, Pour L, Carella A, Malfitano A, Petrò D, Evangelista A, Spada S, Pescosta N, Omedè P, Campbell P, Liberati AM, Offidani M, Ria R, Pulini S, Patriarca F, Hajek R, Spencer A, Boccadoro M, Palumbo A. Chemotherapy plus lenalidomide versus autologous transplantation, followed by lenalidomide plus prednisone versus lenalidomide maintenance, in patients with multiple myeloma: a randomised, multicentre, phase 3 trial. Lancet Oncol. 2015 Dec;16(16):1617-29. Epub 2015 Nov 17. link to original article contains protocol PubMed
  8. Magarotto V, Bringhen S, Offidani M, Benevolo G, Patriarca F, Mina R, Falcone AP, De Paoli L, Pietrantuono G, Gentili S, Musolino C, Giuliani N, Bernardini A, Conticello C, Pulini S, Ciccone G, Maisnar V, Ruggeri M, Zambello R, Guglielmelli T, Ledda A, Liberati AM, Montefusco V, Hajek R, Boccadoro M, Palumbo A. Triplet vs doublet lenalidomide-containing regimens for the treatment of elderly patients with newly diagnosed multiple myeloma. Blood. 2016 Mar 3;127(9):1102-8. Epub 2016 Jan 4. link to original article contains verified protocol PubMed
  9. SWOG S0777: Durie BG, Hoering A, Abidi MH, Rajkumar SV, Epstein J, Kahanic SP, Thakuri M, Reu F, Reynolds CM, Sexton R, Orlowski RZ, Barlogie B, Dispenzieri A. Bortezomib with lenalidomide and dexamethasone versus lenalidomide and dexamethasone alone in patients with newly diagnosed myeloma without intent for immediate autologous stem-cell transplant (SWOG S0777): a randomised, open-label, phase 3 trial. Lancet. 2017 Feb 4;389(10068):519-527. Epub 2016 Dec 22. link to original article contains verified protocol PubMed

RVD

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RVD: Revlimid (Lenalidomide), Velcade (Bortezomib), Dexamethasone
VDR: Velcade (Bortezomib), Dexamethasone, Revlimid (Lenalidomide)
VRD: Velcade (Bortezomib), Revlimid (Lenalidomide), Dexamethasone
VRd: Velcade (Bortezomib), Revlimid (Lenalidomide), low-dose dexamethasone

Synopsis

Induction therapy prior to autologous stem cell transplantation (ASCT) has evolved dramatically from early days, to its current form of lenalidomide, bortezomib, and dexamethasone (RVD). Both lenalidomide and bortezomib, in combination with dexamethasone, demonstrated promising activity in relapsed/refractory multiple myeloma, before being studied in newly-diagnosed patients.

The most relevant studies that have informed clinical practice have demonstrated conclusively that the combination of an immunomodulatory agent (IMiD) and proteasome inhibitor (PI) are most efficacious for disease control and long term outcomes. Intergroup trial SWOG S0777 was a randomized study comparing RVD to Rd for patients with newly diagnosed multiple myeloma, without intention for ASCT (Durie B et al, Lancet 2017 Feb 4). This trial showed a median progression-free survival (PFS) of 75 months for the RVD arm, as compared with 64 months for the Rd arm. The IFM 2013-04, next, compared outcomes with an IMiD/PI combination induction (bortezomib, thalidomide, dexamethasone – VTD) with the standard at the time, bortezomib, cyclophosphamide and dexamethasone (VCD) (Moreau P et al Blood 2016 May 26). Responses to VTD were superior to those for VCD, including rates of CR (19% vs 6%), thus establishing the IMiD and PI combination as the preferred induction regimen. As of 2018, we lack randomized data regarding the addition of daratumumab to RVD vs RVD alone, and also whether carfilzomib, lenalidomide, and dexamethasone (KRD) is superior to RVD, though both of these questions are being examined in ongoing clinical trials.

Most variation in this protocol is based on whether it is intended as induction prior to transplant or whether it is part of a transplant-ineligible approach. For the former, 3 cycles are usually given; for the latter, up to 8 cycles are given before transition to maintenance. There is also some variation in how the steroid component is given. To our knowledge, none of the major published trials have used SC bortezomib, although this has been common practice in the clinic since 2010.

Variant #1, 3 cycles, bi-weekly dexamethasone

Study Evidence
Attal et al. 2017 (IFM 2009) Non-randomized portion of RCT

This regimen is intended for patients 65 years of age or younger with symptomatic, measurable, newly diagnosed multiple myeloma.

Chemotherapy

21-day cycle for 3 cycles

Subsequent treatment

Variant #2, 3 cycles, weekly dexamethasone

Study Evidence
Roussel et al. 2014 Phase II

Chemotherapy

Supportive medications

21-day cycle for 3 cycles

Subsequent treatment

Variant #3, 8 cycles, bi-weekly dexamethasone

Study Evidence Comparator Comparative Efficacy
Durie et al. 2016 (SWOG S0777) Phase III (E) Rd Seems to have superior OS

This regimen is intended for patients with previously untreated multiple myeloma who were not planned for immediate autologous stem-cell transplant.

Chemotherapy

21-day cycle for 8 cycles

Subsequent treatment

Variant #4, 8 cycles, weekly dexamethasone

Study Evidence Comparator Comparative Efficacy
Kumar et al. 2012 (EVOLUTION) Randomized Phase II (C) 1. VDC Seems not superior
2. VDC-mod Seems not superior
3. VDCR Seems not superior

This regimen was intended for patients greater than or equal to 18 years of age with previously untreated symptomatic MM, with measurable disease and a Karnofsky Performance Status greater than or equal to 50%, regardless of their eligibility for autologous hematopoietic cell transplantation.

Chemotherapy

21-day cycle for 8 cycles

Subsequent treatment

Variant #5, 8 cycles, tapered bi-weekly dexamethasone

Study Evidence
Richardson et al. 2010 Phase I/II

This is the MTD level "4M" described in the manuscript.

Chemotherapy

Supportive medications

21-day cycle for 8 cycles

Subsequent treatment

  • Patients who responded and tolerated therapy could optionally proceed to RVD maintenance

References

  1. Richardson PG, Weller E, Lonial S, Jakubowiak AJ, Jagannath S, Raje NS, Avigan DE, Xie W, Ghobrial IM, Schlossman RL, Mazumder A, Munshi NC, Vesole DH, Joyce R, Kaufman JL, Doss D, Warren DL, Lunde LE, Kaster S, Delaney C, Hideshima T, Mitsiades CS, Knight R, Esseltine DL, Anderson KC. Lenalidomide, bortezomib, and dexamethasone combination therapy in patients with newly diagnosed multiple myeloma. Blood. 2010 Aug 5;116(5):679-86. Epub 2010 Apr 12. link to original article contains verified protocol link to PMC article PubMed
  2. Kumar S, Flinn I, Richardson PG, Hari P, Callander N, Noga SJ, Stewart AK, Turturro F, Rifkin R, Wolf J, Estevam J, Mulligan G, Shi H, Webb IJ, Rajkumar SV. Randomized, multicenter, phase 2 study (EVOLUTION) of combinations of bortezomib, dexamethasone, cyclophosphamide, and lenalidomide in previously untreated multiple myeloma. Blood. 2012 May 10;119(19):4375-82. Epub 2012 Mar 15. link to original article contains verified protocol PubMed
  3. Roussel M, Lauwers-Cances V, Robillard N, Hulin C, Leleu X, Benboubker L, Marit G, Moreau P, Pegourie B, Caillot D, Fruchart C, Stoppa AM, Gentil C, Wuilleme S, Huynh A, Hebraud B, Corre J, Chretien ML, Facon T, Avet-Loiseau H, Attal M. Front-line transplantation program with lenalidomide, bortezomib, and dexamethasone combination as induction and consolidation followed by lenalidomide maintenance in patients with multiple myeloma: a phase II study by the Intergroupe Francophone du Myélome. J Clin Oncol. 2014 Sep 1;32(25):2712-7. Epub 2014 Jul 14. link to original article contains verified protocol PubMed
  4. SWOG S0777: Durie BG, Hoering A, Abidi MH, Rajkumar SV, Epstein J, Kahanic SP, Thakuri M, Reu F, Reynolds CM, Sexton R, Orlowski RZ, Barlogie B, Dispenzieri A. Bortezomib with lenalidomide and dexamethasone versus lenalidomide and dexamethasone alone in patients with newly diagnosed myeloma without intent for immediate autologous stem-cell transplant (SWOG S0777): a randomised, open-label, phase 3 trial. Lancet. 2017 Feb 4;389(10068):519-527. Epub 2016 Dec 22. link to original article contains verified protocol PubMed
  5. Attal M, Lauwers-Cances V, Hulin C, Leleu X, Caillot D, Escoffre M, Arnulf B, Macro M, Belhadj K, Garderet L, Roussel M, Payen C, Mathiot C, Fermand JP, Meuleman N, Rollet S, Maglio ME, Zeytoonjian AA, Weller EA, Munshi N, Anderson KC, Richardson PG, Facon T, Avet-Loiseau H, Harousseau JL, Moreau P; IFM 2009 Study. Lenalidomide, bortezomib, and dexamethasone with transplantation for myeloma. N Engl J Med. 2017 Apr 6;376(14):1311-1320. link to original article contains verified protocol PubMed

RVDC

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RVDC: Revlimid (Lenalidomide), Velcade (Bortezomib), Dexamethasone, Cyclophosphamide
VDCR: Velcade (Bortezomib), Dexamethasone, Cyclophosphamide, Revlimid (Lenalidomide)

Regimen

Study Evidence Comparator Comparative Efficacy
Kumar et al. 2012 (EVOLUTION) Randomized Phase II (E) 1. VDC Seems not superior
2. VDC-mod Seems not superior
3. VDR Seems not superior

This regimen was intended for patients greater than or equal to 18 years of age with previously untreated symptomatic MM, with measurable disease and a Karnofsky Performance Status greater than or equal to 50%, regardless of their eligibility for autologous hematopoietic cell transplantation.

Chemotherapy

Supportive medications

21-day cycle for 8 cycles

Subsequent treatment

References

  1. Kumar S, Flinn I, Richardson PG, Hari P, Callander N, Noga SJ, Stewart AK, Turturro F, Rifkin R, Wolf J, Estevam J, Mulligan G, Shi H, Webb IJ, Rajkumar SV. Randomized, multicenter, phase 2 study (EVOLUTION) of combinations of bortezomib, dexamethasone, cyclophosphamide, and lenalidomide in previously untreated multiple myeloma. Blood. 2012 May 10;119(19):4375-82. Epub 2012 Mar 15. link to original article contains verified protocol PubMed

TAD (Thalidomide)

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TAD: Thalidomide, Adriamycin (Doxorubicin), Dexamethasone

Regimen

Study Evidence Comparator Comparative Efficacy
Lokhorst et al. 2009 (HOVON-50) Phase III (E) See link See link

Chemotherapy

28-day cycle for 3 cycles

Subsequent treatment

References

  1. HOVON-50: Lokhorst HM, van der Holt B, Zweegman S, Vellenga E, Croockewit S, van Oers MH, von dem Borne P, Wijermans P, Schaafsma R, de Weerdt O, Wittebol S, Delforge M, Berenschot H, Bos GM, Jie KS, Sinnige H, van Marwijk-Kooy M, Joosten P, Minnema MC, van Ammerlaan R, Sonneveld P; Dutch-Belgian Hemato-Oncology Group (HOVON). A randomized phase 3 study on the effect of thalidomide combined with adriamycin, dexamethasone, and high-dose melphalan, followed by thalidomide maintenance in patients with multiple myeloma. Blood. 2010 Feb 11;115(6):1113-20. Epub 2009 Oct 30. link to original article contains verified protocol PubMed
    1. Update: van de Donk NW, van der Holt B, Minnema MC, Vellenga E, Croockewit S, Kersten MJ, von dem Borne PA, Ypma P, Schaafsma R, de Weerdt O, Klein SK, Delforge M, Levin MD, Bos GM, Jie KG, Sinnige H, Coenen JL, de Waal EG, Zweegman S, Sonneveld P, Lokhorst HM. Thalidomide before and after autologous stem cell transplantation in recently diagnosed multiple myeloma (HOVON-50): long-term results from the phase 3, randomised controlled trial. Lancet Haematol. 2018 Oct;5(10):e479-e492. link to original article PubMed

TD

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TD: Thalidomide & Dexamethasone
Thal-Dex: Thalidomide & Dexamethasone

Variant #1, 50 -> 200 mg/d, 6 cycles

Study Evidence Comparator Comparative Efficacy
Rosiñol et al. 2012 (GEM05/MENOS65) Phase III (C) 1. VTD Seems to have inferior PFS
2. VBMCP/VBAD/B Not reported

This regimen was intended for patients with newly diagnosed and untreated symptomatic MM who were less than or equal to 65 years of age with measurable serum and/or urine M protein.

Chemotherapy

Supportive medications

28-day cycle for 6 cycles

Variant #2, 50 -> 200 mg/d, indefinite

Study Evidence Comparator Comparative Efficacy
Rajkumar et al. 2008 Phase III (E) Dexamethasone Superior TTP

This regimen was intended for patients with previously untreated symptomatic multiple myeloma, bone marrow plasmacytosis (greater than or equal to 10% plasma cells or sheets of plasma cells) or a biopsy-proven plasmacytoma, and measurable disease defined as serum monoclonal protein more than 1 g/dL and/or urine monoclonal protein greater than or equal to 200 mg/24 h.

Chemotherapy

  • Thalidomide (Thalomid) as follows:
    • Cycle 1: 50 mg PO once per day on days 1 to 14, then 100 mg PO once per day on days 15 to 28
    • Cycle 2 onwards: 200 mg PO once per day on days 1 to 28
  • Dexamethasone (Decadron) as folows:
    • Cycles 1 to 4: 40 mg PO once per day on days 1 to 4, 9 to 12, 17 to 20
    • Cycle 5 onwards: 40 mg PO once per day on days 1 to 4

28-day cycles

Variant #3, 100 -> 200 mg/d, 3 cycles

Study Evidence Comparator Comparative Efficacy
Cavo et al. 2010 (GIMEMA MM-BO2005) Phase III (C) VTD Inferior CR/nCR rate

This regimen was intended for patients aged 18 to 65 years with previously untreated symptomatic myeloma.

Chemotherapy

  • Thalidomide (Thalomid) as follows:
    • Cycle 1: 100 mg PO once per day on days 1 to 14, then 200 mg PO once per day on days 15 to 21
    • Cycles 2 & 3: 200 mg PO once per day on days 1 to 21
  • Dexamethasone (Decadron) 40 mg PO once per day on days 1 to 4, 9 to 12

21-day cycle for 3 cycles

Subsequent treatment

Variant #4, 100 -> 200 mg/d, 4 cycles

Study Evidence
Cavo et al. 2004 (Bologna 2002) Phase II

Chemotherapy

  • Thalidomide (Thalomid) as follows:
    • Cycle 1: 100 mg PO once per day on days 1 to 14, then 200 mg PO once per day on days 15 to end of cycle
    • Cycles 2 to 4: 200 mg PO once per day
  • Dexamethasone (Decadron) as follows:
    • Cycles 1 & 3: 40 mg PO once per day on days 1 to 4, 9 to 12, 17 to 20
    • Cycles 2 & 4: 40 mg PO once per day on days 1 to 4

1-month cycle for 4 cycles

Subsequent treatment

Variant #5, 100 -> 400 mg/day

Study Evidence
Weber et al. 2003 Phase I/II

Chemotherapy

  • Thalidomide (Thalomid) as follows:
    • Cycle 1: 100 mg PO once per day on days 1 to 7, then 200 mg PO once per day on days 8 to 14, then 300 mg PO once per day on days 15 to 21, then 400 mg PO once per day on days 22 to 29
    • Cycle 2 onwards: 400 mg PO once per day
  • Dexamethasone (Decadron) 20 mg/m2 PO once per day on days 1 to 4, 9 to 12, 17 to 20

29-day cycles

Variant #6, 200 mg/day

Study Evidence Comparator Comparative Efficacy Comparative Toxicity
Rajkumar et al. 2002 Phase II
Rajkumar et al. 2005 (ECOG E1A00) Phase III (E) Dexamethasone Seems to have superior RR Inferior toxicity

In ECOG E1A00 this regimen was intended for patients with previously untreated symptomatic multiple myeloma, bone marrow plasmacytosis (greater than or equal to 10% plasma cells or sheets of plasma cells) or a biopsy-proven plasmacytoma, and measurable disease defined as serum monoclonal protein more than 1 g/dL and/or urine monoclonal protein greater than or equal to 200 mg/24 h.

Chemotherapy

  • Thalidomide (Thalomid) 200 mg PO once per day on days 1 to 28
  • Dexamethasone (Decadron) as follows:
    • Odd-numbered cycles: 40 mg PO once per day on days 1 to 4, 9 to 12, 17 to 20
    • Even-numbered cycles: 40 mg PO once per day on days 1 to 4

28-day cycles

References

  1. Rajkumar SV, Hayman S, Gertz MA, Dispenzieri A, Lacy MQ, Greipp PR, Geyer S, Iturria N, Fonseca R, Lust JA, Kyle RA, Witzig TE. Combination therapy with thalidomide plus dexamethasone for newly diagnosed myeloma. J Clin Oncol. 2002 Nov 1;20(21):4319-23. link to original article contains protocol PubMed
  2. Weber D, Rankin K, Gavino M, Delasalle K, Alexanian R. Thalidomide alone or with dexamethasone for previously untreated multiple myeloma. J Clin Oncol. 2003 Jan 1;21(1):16-9. link to original article contains protocol PubMed
  3. Bologna 2002: Cavo M, Zamagni E, Tosi P, Cellini C, Cangini D, Tacchetti P, Testoni N, Tonelli M, de Vivo A, Palareti G, Tura S, Baccarani M. First-line therapy with thalidomide and dexamethasone in preparation for autologous stem cell transplantation for multiple myeloma. Haematologica. 2004 Jul;89(7):826-31. link to original article contains protocol PubMed
    1. Sub-analysis: Cavo M, Zamagni E, Tosi P, Tacchetti P, Cellini C, Cangini D, de Vivo A, Testoni N, Nicci C, Terragna C, Grafone T, Perrone G, Ceccolini M, Tura S, Baccarani M; Bologna 2002 study. Superiority of thalidomide and dexamethasone over vincristine-doxorubicindexamethasone (VAD) as primary therapy in preparation for autologous transplantation for multiple myeloma. Blood. 2005 Jul 1;106(1):35-9. Epub 2005 Mar 10. link to original article contains protocol PubMed
  4. ECOG E1A00: Rajkumar SV, Blood E, Vesole D, Fonseca R, Greipp PR; Eastern Cooperative Oncology Group. Phase III clinical trial of thalidomide plus dexamethasone compared with dexamethasone alone in newly diagnosed multiple myeloma: a clinical trial coordinated by the Eastern Cooperative Oncology Group. J Clin Oncol. 2006 Jan 20;24(3):431-6. Epub 2005 Dec 19. link to original article contains protocol PubMed
  5. Rajkumar SV, Rosiñol L, Hussein M, Catalano J, Jedrzejczak W, Lucy L, Olesnyckyj M, Yu Z, Knight R, Zeldis JB, Bladé J. Multicenter, randomized, double-blind, placebo-controlled study of thalidomide plus dexamethasone compared with dexamethasone as initial therapy for newly diagnosed multiple myeloma. J Clin Oncol. 2008 May 1;26(13):2171-7. Epub 2008 Mar 24. link to original article contains verified protocol link to PMC article PubMed
  6. GIMEMA MM-BO2005: Cavo M, Tacchetti P, Patriarca F, Petrucci MT, Pantani L, Galli M, Di Raimondo F, Crippa C, Zamagni E, Palumbo A, Offidani M, Corradini P, Narni F, Spadano A, Pescosta N, Deliliers GL, Ledda A, Cellini C, Caravita T, Tosi P, Baccarani M; GIMEMA Italian Myeloma Network. Bortezomib with thalidomide plus dexamethasone compared with thalidomide plus dexamethasone as induction therapy before, and consolidation therapy after, double autologous stem-cell transplantation in newly diagnosed multiple myeloma: a randomised phase 3 study. Lancet. 2010 Dec 18;376(9758):2075-85. Epub 2010 Dec 9. Erratum in: Lancet. 2011 Nov 26;378(9806):1846. link to original article PubMed
    1. Update: Cavo M, Pantani L, Petrucci MT, Patriarca F, Zamagni E, Donnarumma D, Crippa C, Boccadoro M, Perrone G, Falcone A, Nozzoli C, Zambello R, Masini L, Furlan A, Brioli A, Derudas D, Ballanti S, Dessanti ML, De Stefano V, Carella AM, Marcatti M, Nozza A, Ferrara F, Callea V, Califano C, Pezzi A, Baraldi A, Grasso M, Musto P, Palumbo A; GIMEMA (Gruppo Italiano Malattie Ematologiche dell'Adulto) Italian Myeloma Network. Bortezomib-thalidomide-dexamethasone is superior to thalidomide-dexamethasone as consolidation therapy after autologous hematopoietic stem cell transplantation in patients with newly diagnosed multiple myeloma. Blood. 2012 Jul 5;120(1):9-19. Epub 2012 Apr 12. link to original article contains verified protocol PubMed
  7. GEM05/MENOS65: Rosiñol L, Oriol A, Teruel AI, Hernández D, López-Jiménez J, de la Rubia J, Granell M, Besalduch J, Palomera L, González Y, Etxebeste MA, Díaz-Mediavilla J, Hernández MT, de Arriba F, Gutiérrez NC, Martín-Ramos ML, Cibeira MT, Mateos MV, Martínez J, Alegre A, Lahuerta JJ, San Miguel J, Bladé J; Programa para el Estudio y la Terapéutica de las Hemopatías Malignas/Grupo Español de Mieloma (PETHEMA/GEM) group. Superiority of bortezomib, thalidomide, and dexamethasone (VTD) as induction pretransplantation therapy in multiple myeloma: a randomized phase 3 PETHEMA/GEM study. Blood. 2012 Aug 3;120(8):1589-96. Epub 2012 Jul 12. link to original article contains verified protocol PubMed
    1. Update: Rosiñol L, Oriol A, Teruel AI, de la Guía AL, Blanchard M, de la Rubia J, Granell M, Sampol M, Palomera L, González Y, Etxebeste M, Martínez-Martínez R, Hernández MT, de Arriba F, Alegre A, Cibeira M, Mateos M, Martínez-López J, Lahuerta JJ, San Miguel J, Bladé J. Bortezomib and thalidomide maintenance after stem cell transplantation for multiple myeloma: a PETHEMA/GEM trial. Leukemia. 2017 Sep;31(9):1922-1927. Epub 2017 Jan 23. link to original article contains verified protocol PubMed

TVAD doxil

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TVAD doxil: Thalidomide, Vincristine, Adriamycin liposomal (Doxil), Dexamethasone

Regimen

Study Evidence Comparator Comparative Efficacy
Zervas et al. 2007 Phase III (E) VAD doxil Seems to have superior OS

This trial was open to patients aged 18 to 75 years old with previously untreated symptomatic MM and a life expectancy of greater than 6 months.

Chemotherapy

28-day cycle for 4 cycles

References

  1. Zervas K, Mihou D, Katodritou E, Pouli A, Mitsouli CH, Anagnostopoulos A, Delibasi S, Kyrtsonis MC, Anagnostopoulos N, Terpos E, Zikos P, Maniatis A, Dimopoulos MA; Greek Myeloma Study Group. VAD-doxil versus VAD-doxil plus thalidomide as initial treatment for multiple myeloma: results of a multicenter randomized trial of the Greek Myeloma Study Group. Ann Oncol. 2007 Aug;18(8):1369-75. link to original article contains verified protocol PubMed

VAD doxil

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DVD: Doxil (Liposomal Doxorubicin), Vincristine, Dexamethasone
DVd: Doxil (Liposomal Doxorubicin), Vincristine, low-dose dexamethasone
VAD doxil: Vincristine, Adriamycin liposomal (Doxil), Dexamethasone

Variant #1, indefinite ("DVd")

Study Evidence Comparator Comparative Efficacy
Rifkin et al. 2006 Phase III (E) VAd Non-inferior ORR

This regimen was intended for patients greater than or equal to 18 years and fulfilling a diagnosis of stage II or III MM according to the Durie and Salmon criteria.

Chemotherapy

28-day cycles

Variant #2, limited duration (4 cycles)

Study Evidence Comparator Comparative Efficacy
Dimopoulos et al. 2003 Phase III (E) VAD Seems not superior
Zervas et al. 2007 Phase III (C) TVAD-Doxil Seems to have inferior OS

Dimopoulos et al. 2003 was open to all patients with previously untreated multiple myeloma who were considered candidates for systemic treatment. Zervas et al. 2007 was open to patients aged 18 to 75 years old with previously untreated symptomatic MM and a life expectancy of greater than 6 months.

Chemotherapy

Supportive medications

28-day cycle for 4 cycles

Variant #3, limited duration (6 to 8 cycles)

Study Evidence
Hussein et al. 2002 Phase II

Chemotherapy

Supportive medications

  • Vitamin B6 200 mg PO once per day to help reduce risk of palmar-plantar erythrodysesthesia (PPE)

28-day cycle for 6 to 8 cycles

References

  1. Hussein MA, Wood L, Hsi E, Srkalovic G, Karam M, Elson P, Bukowski RM. A Phase II trial of pegylated liposomal doxorubicin, vincristine, and reduced-dose dexamethasone combination therapy in newly diagnosed multiple myeloma patients. Cancer. 2002 Nov 15;95(10):2160-8. link to original article contains protocol PubMed
  2. Dimopoulos MA, Pouli A, Zervas K, Grigoraki V, Symeonidis A, Repoussis P, Mitsouli C, Papanastasiou C, Margaritis D, Tokmaktsis A, Katodritou I, Kokkini G, Terpos E, Vyniou N, Tzilianos M, Chatzivassili A, Kyrtsonis MC, Panayiotidis P, Maniatis A; Greek Myeloma Study Group. Prospective randomized comparison of vincristine, doxorubicin and dexamethasone (VAD) administered as intravenous bolus injection and VAD with liposomal doxorubicin as first-line treatment in multiple myeloma. Ann Oncol. 2003 Jul;14(7):1039-44. link to original article contains protocol PubMed
  3. Rifkin RM, Gregory SA, Mohrbacher A, Hussein MA. Pegylated liposomal doxorubicin, vincristine, and dexamethasone provide significant reduction in toxicity compared with doxorubicin, vincristine, and dexamethasone in patients with newly diagnosed multiple myeloma: a phase III multicenter randomized trial. Cancer. 2006 Feb 15;106(4):848-58. link to original article contains verified protocol PubMed
  4. Zervas K, Mihou D, Katodritou E, Pouli A, Mitsouli CH, Anagnostopoulos A, Delibasi S, Kyrtsonis MC, Anagnostopoulos N, Terpos E, Zikos P, Maniatis A, Dimopoulos MA; Greek Myeloma Study Group. VAD-doxil versus VAD-doxil plus thalidomide as initial treatment for multiple myeloma: results of a multicenter randomized trial of the Greek Myeloma Study Group. Ann Oncol. 2007 Aug;18(8):1369-75. link to original article contains verified protocol PubMed

VAD-P

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VAD-P: Vincristine, Adriamycin (Doxorubicin), Dexamethasone, Prednisone

Regimen

Study Evidence Comparator Comparative Efficacy
Berenson et al. 2002 (SWOG 9210) Phase III (C) VAD-P/Q Seems not superior

Note: to our knowledge, this regimen was not tested as an experimental arm in an RCT prior to becoming a standard comparator arm.

Chemotherapy

  • Vincristine (Oncovin) 0.4 mg/day IV continuous infusion over 96 hours, started on day 1 (total dose per cycle: 1.6 mg)
  • Doxorubicin (Adriamycin) 9 mg/m2/day IV continuous infusion over 96 hours, started on day 1 (total dose per cycle: 36 mg/m2)
    • Poor-risk patients received 6.75 mg/m2/day in cycle 1 (total dose 27 mg/m2), with increase to full dose starting cycle 2 if no undue toxicity
  • Dexamethasone (Decadron) 40 mg PO once per day on days 1 to 4
  • Prednisone (Sterapred) 50 mg PO once per day on days 9, 11, 13, 15, 17, 19

21-day cycles for at least 6 months or until at least 25% regression of disease

Subsequent treatment

  • Patients with at least 50% regression in 6 months or 25% regression in 9 to 12 months of therapy: low-dose prednisone versus high-dose prednisone maintenance

References

  1. SWOG 9210: Berenson JR, Crowley JJ, Grogan TM, Zangmeister J, Briggs AD, Mills GM, Barlogie B, Salmon SE. Maintenance therapy with alternate-day prednisone improves survival in multiple myeloma patients. Blood. 2002 May 1;99(9):3163-8. link to original article contains protocol PubMed

VAD-P/Q

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VAD-P/Q: Vincristine, Adriamycin (Doxorubicin), Dexamethasone, Prednisone, Quinine

Regimen

Study Evidence Comparator Comparative Efficacy
Berenson et al. 2002 (SWOG 9210) Phase III (E) VAD-P Seems not superior

Chemotherapy

  • Vincristine (Oncovin) 0.4 mg/day IV continuous infusion over 96 hours, started on day 2 (total dose per cycle: 1.6 mg)
  • Doxorubicin (Adriamycin) 9 mg/m2/day IV continuous infusion over 96 hours, started on day 2 (total dose per cycle: 36 mg/m2)
    • Poor-risk patients received 6.75 mg/m2/day in cycle 1 (total dose 27 mg/m2), with increase to full dose starting cycle 2 if no undue toxicity
  • Dexamethasone (Decadron) 40 mg PO once per day on days 2 to 5
  • Prednisone (Sterapred) 50 mg PO once per day on days 10, 12, 14, 16, 18, 20
  • Quinine (Qualaquin) 400 mg PO three times per day on days 1 to 6

21-day cycle for at least 6 months or until at least 25% regression of disease

Subsequent treatment

  • Patients with at least 50% regression in 6 months or 25% regression in 9 to 12 months of therapy: low-dose prednisone versus high-dose prednisone maintenance

References

  1. SWOG 9210: Berenson JR, Crowley JJ, Grogan TM, Zangmeister J, Briggs AD, Mills GM, Barlogie B, Salmon SE. Maintenance therapy with alternate-day prednisone improves survival in multiple myeloma patients. Blood. 2002 May 1;99(9):3163-8. link to original article contains protocol PubMed

VD

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VD: Velcade (Bortezomib), Dexamethasone
BD: Bortezomib, Dexamethasone
Bd: Bortezomib, low-dose dexamethasone
Bort-Dex: Bortezomib, Dexamethasone
Vd: Velcade (Bortezomib), low-dose dexamethasone

Variant #1

Study Evidence Comparator Comparative Efficacy
Niesvizky et al. 2015 (UPFRONT) Phase IIIb (E) 1. VMP Seems not superior
2. VTD Seems not superior

This regimen was meant for transplant ineligible patients.

Chemotherapy

  • Bortezomib (Velcade) 1.3 mg/m2 IV once per day on days 1, 4, 8, 11
  • Dexamethasone (Decadron) as follows:
    • Cycles 1 to 4: 20 mg PO once per day on days 1, 2, 4, 5, 8, 9, 11, 12
    • Cycles 5 to 8: 20 mg PO once per day on days 1, 2, 4, 5

21-day cycle for 8 cycles

Subsequent treatment

Variant #2

Study Evidence Comparator Comparative Efficacy
Moreau et al. 2011 (IFM 2007-02) Phase III (C) vtD Inferior VGPR rate

This regimen was intended for patients aged 65 years or younger with untreated symptomatic MM with measurable paraprotein in serum (greater than 1 g/dL) or urine (greater than 0.2 g/24 hours).

Chemotherapy

  • Bortezomib (Velcade) 1.3 mg/m2 IV once per day on days 1, 4, 8, 11
  • Dexamethasone (Decadron) as follows:
    • Cycles 1 & 2: 40 mg (route not specified) once per day on days 1 to 4, 9 to 12
    • Cycles 3 & 4: 40 mg (route not specified) once per day on days 1 to 4

21-day cycle for 4 cycles

Subsequent treatment

Variant #3

Study Evidence Comparator Comparative Efficacy
Harousseau et al. 2010 (IFM 2005-01) Phase III (E) VAD Might have superior PFS

This regimen was intended for patients age less than or equal to 65 years with untreated symptomatic MM with measurable paraprotein in serum (greater than 1 g/dL) or urine (greater than 0.2 g/24 h).

Chemotherapy

Supportive medications

  • One of the following bisphosphonates recommended:
  • "Antibiotics, antifungal agents, and antiviral prophylaxis in accordance with local practice."

21-day cycle for 4 cycles

Subsequent treatment

Variant #4, weekly bortezomib

Study Evidence
Girnius et al. 2014 (X05153) Phase II

Chemotherapy

35-day cycle for up to 6 cycles based on response and tolerance of side effects

References

  1. IFM 2005-01: Harousseau JL, Attal M, Avet-Loiseau H, Marit G, Caillot D, Mohty M, Lenain P, Hulin C, Facon T, Casassus P, Michallet M, Maisonneuve H, Benboubker L, Maloisel F, Petillon MO, Webb I, Mathiot C, Moreau P. Bortezomib plus dexamethasone is superior to vincristine plus doxorubicin plus dexamethasone as induction treatment prior to autologous stem-cell transplantation in newly diagnosed multiple myeloma: results of the IFM 2005-01 phase III trial. J Clin Oncol. 2010 Oct 20;28(30):4621-9. Epub 2010 Sep 7. link to original article contains verified protocol PubMed
    1. Subgroup analysis: Avet-Loiseau H, Leleu X, Roussel M, Moreau P, Guérin-Charbonnel C, Caillot D, Marit G, Benboubker L, Voillat L, Mathiot C, Kolb B, Macro M, Campion L, Wetterwald M, Stoppa AM, Hulin C, Facon T, Attal M, Minvielle S, Harousseau JL. Bortezomib plus dexamethasone induction improves outcome of patients with t(4;14) myeloma but not outcome of patients with del(17p). J Clin Oncol. 2010 Oct 20;28(30):4630-4. Epub 2010 Jul 19. link to original article PubMed
  2. IFM 2007-02: Moreau P, Avet-Loiseau H, Facon T, Attal M, Tiab M, Hulin C, Doyen C, Garderet L, Randriamalala E, Araujo C, Lepeu G, Marit G, Caillot D, Escoffre M, Lioure B, Benboubker L, Pégourié B, Kolb B, Stoppa AM, Fuzibet JG, Decaux O, Dib M, Berthou C, Chaleteix C, Sebban C, Traullé C, Fontan J, Wetterwald M, Lenain P, Mathiot C, Harousseau JL. Bortezomib plus dexamethasone versus reduced-dose bortezomib, thalidomide plus dexamethasone as induction treatment before autologous stem cell transplantation in newly diagnosed multiple myeloma. Blood. 2011 Nov 24;118(22):5752-8. Epub 2011 Aug 17. link to original article contains verified protocol PubMed
  3. X05153: Girnius SK, Lee S, Kambhampati S, Rose MG, Mohiuddin A, Houranieh A, Zimelman A, Grady T, Mehta P, Behler C, Hayes TG, Efebera YA, Prabhala RH, Han A, Yellapragada SV, Klein CE, Roodman GD, Lichtenstein A, Munshi NC. A phase II trial of weekly bortezomib and dexamethasone in veterans with newly diagnosed multiple myeloma not eligible for or who deferred autologous stem cell transplantation. Br J Haematol. 2015 Apr;169(1):36-43. Epub 2015 Jan 8. Epub 2014 Sep 18. link to original article contains verified protocol PubMed
  4. UPFRONT: Niesvizky R, Flinn IW, Rifkin R, Gabrail N, Charu V, Clowney B, Essell J, Gaffar Y, Warr T, Neuwirth R, Zhu Y, Elliott J, Esseltine DL, Niculescu L, Reeves J. Community-based phase IIIB trial of three UPFRONT bortezomib-based myeloma regimens. J Clin Oncol. 2015 Nov 20;33(33):3921-9. Epub 2015 Jun 8. link to original article contains verified protocol PubMed

VDC

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VDC: Velcade (Bortezomib), Dexamethasone, Cyclophosphamide
VDC-mod: Velcade (Bortezomib), Dexamethasone, Cyclophosphamide (modified dose)
VCD: Velcade (Bortezomib), Cyclophosphamide, Dexamethasone
CyBorD: Cyclophosphamide, Bortezomib, Dexamethasone

Variant #1

Study Evidence Comparator Comparative Efficacy
Moreau et al. 2016 (IFM 2013-04) Phase III (E) VTD Seems to have inferior ORR rate

This regimen was intended for patients aged 65 years or younger with untreated symptomatic MM with measurable paraprotein in serum (greater than 1 g/dL) or urine (greater than 0.2 g/24 hours).

Chemotherapy

21-day cycle for 4 cycles

Subsequent treatment

  • Autologous hematopoietic cell transplant, with choice of conditioning regimen, whether to perform tandem transplant, and whether to give maintenance at the discretion of the treating center

Variant #2, "VCD"

Study Evidence Comparator Comparative Efficacy
Mai et al. 2015 (GMMG-MM5) Phase III (E) PAd Non-inferior VGPR or better rate

This regimen was intended for patients 18 to 70 years of age with newly diagnosed MM who required systemic chemotherapy based on the CRAB criteria. Note that the bortezomib route was changed from IV to SC with a mid-protocol amendment.

Chemotherapy

Supportive medications

21-day cycle for 3 cycles

Subsequent treatment

Variant #3, "VDC"

Study Evidence Comparator Comparative Efficacy
Kumar et al. 2012 (EVOLUTION) Randomized Phase II (C) 1. VDR Seems not superior
2. VDCR Seems not superior

This regimen was intended for patients greater than or equal to 18 years of age with previously untreated symptomatic MM, with measurable disease and a Karnofsky Performance Status greater than or equal to 50%, regardless of their eligibility for autologous hematopoietic cell transplantation. The only difference between this regimen and VDC-mod is the number of cyclophosphamide doses.

Chemotherapy

Supportive medications

21-day cycle for 8 cycles

Subsequent treatment

Variant #4, "VDC-mod"

Study Evidence Comparator Comparative Efficacy
Kumar et al. 2012 (EVOLUTION) Randomized Phase II, less than 20 in this arm (C) 1. VDR Seems not superior
2. VDCR Seems not superior

This regimen was intended for patients greater than or equal to 18 years of age with previously untreated symptomatic MM, with measurable disease and a Karnofsky Performance Status greater than or equal to 50%, regardless of their eligibility for autologous hematopoietic cell transplantation. This arm only had 17 patients enrolled; other arms of the EVOLUTION trial all had greater than 20 patients enrolled. The only difference between this and regimen #1 is the number of cyclophosphamide doses.

Chemotherapy

Supportive medications

21-day cycle for 8 cycles

Subsequent treatment

Variant #5, "CyBorD", once per week bortezomib

Study Evidence
Reeder et al. 2010 Phase II

This regimen was described in a letter to the editor of Blood.

Chemotherapy

28-day cycle for 4 cycles

Variant #6, "CyBorD"

Study Evidence
Reeder et al. 2009 Phase II

Chemotherapy

Supportive medications

28-day cycle for 4 to 12 cycles

References

  1. Reeder CB, Reece DE, Kukreti V, Chen C, Trudel S, Hentz J, Noble B, Pirooz NA, Spong JE, Piza JG, Zepeda VH, Mikhael JR, Leis JF, Bergsagel PL, Fonseca R, Stewart AK. Cyclophosphamide, bortezomib and dexamethasone induction for newly diagnosed multiple myeloma: high response rates in a phase II clinical trial. Leukemia. 2009 Jul;23(7):1337-41. Epub 2009 Feb 19. link to original article contains verified protocol link to PMC article PubMed
  2. Reeder CB, Reece DE, Kukreti V, Chen C, Trudel S, Laumann K, Hentz J, Pirooz NA, Piza JG, Tiedemann R, Mikhael JR, Bergsagel PL, Leis JF, Fonseca R, Stewart AK. Once- versus twice-weekly bortezomib induction therapy with CyBorD in newly diagnosed multiple myeloma. Blood. 2010 Apr 22;115(16):3416-7. link to original letter contains verified protocol PubMed
  3. Kumar S, Flinn I, Richardson PG, Hari P, Callander N, Noga SJ, Stewart AK, Turturro F, Rifkin R, Wolf J, Estevam J, Mulligan G, Shi H, Webb IJ, Rajkumar SV. Randomized, multicenter, phase 2 study (EVOLUTION) of combinations of bortezomib, dexamethasone, cyclophosphamide, and lenalidomide in previously untreated multiple myeloma. Blood. 2012 May 10;119(19):4375-82. Epub 2012 Mar 15. link to original article contains verified protocol PubMed
  4. Meta-Analysis: Leiba M, Kedmi M, Duek A, Freidman T, Weiss M, Leiba R, Nagler A, Avigdor A. Bortezomib-Cyclophosphamide-Dexamethasone (VCD) versus Bortezomib-Thalidomide-Dexamethasone (VTD) -based regimens as induction therapies in newly diagnosed transplant eligible patients with multiple myeloma: a meta-analysis. Br J Haematol. 2014 Sep;166(5):702-10. Epub 2014 May 26. link to original article PubMed
  5. GMMG-MM5: Mai EK, Bertsch U, Dürig J, Kunz C, Haenel M, Blau IW, Munder M, Jauch A, Schurich B, Hielscher T, Merz M, Huegle-Doerr B, Seckinger A, Hose D, Hillengass J, Raab MS, Neben K, Lindemann HW, Zeis M, Gerecke C, Schmidt-Wolf IG, Weisel K, Scheid C, Salwender H, Goldschmidt H. Phase III trial of bortezomib, cyclophosphamide and dexamethasone (VCD) versus bortezomib, doxorubicin and dexamethasone (PAd) in newly diagnosed myeloma. Leukemia. 2015 Aug;29(8):1721-9. Epub 2015 Mar 19. link to original article contains verified protocol PubMed
    1. Subgroup analysis: Merz M, Salwender H, Haenel M, Mai EK, Bertsch U, Kunz C, Hielscher T, Blau IW, Scheid C, Hose D, Seckinger A, Jauch A, Hillengass J, Raab MS, Schurich B, Munder M, Schmidt-Wolf IG, Gerecke C, Lindemann HW, Zeis M, Weisel K, Duerig J, Goldschmidt H. Subcutaneous versus intravenous bortezomib in two different induction therapies for newly diagnosed multiple myeloma: an interim analysis from the prospective GMMG-MM5 trial. Haematologica. 2015 Jul;100(7):964-9. Epub 2015 Apr 3. link to original article link to PMC article PubMed
  6. IFM2013-04: Moreau P, Hulin C, Macro M, Caillot D, Chaleteix C, Roussel M, Garderet L, Royer B, Brechignac S, Tiab M, Puyade M, Escoffre M, Stoppa AM, Facon T, Pegourie B, Chaoui D, Jaccard A, Slama B, Marit G, Laribi K, Godmer P, Luycx O, Eisenmann JC, Allangba O, Dib M, Araujo C, Fontan J, Belhadj K, Wetterwald M, Dorvaux V, Fermand JP, Rodon P, Kolb B, Glaisner S, Malfuson JV, Lenain P, Biron L, Planche L, Caillon H, Avet-Loiseau H, Dejoie T, Attal M. VTD is superior to VCD prior to intensive therapy in multiple myeloma: results of the prospective IFM2013-04 trial. Blood. 2016 May 26;127(21):2569-74. Epub 2016 Mar 21. link to original article contains verified protocol PubMed

VMP

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VMP: Velcade (Bortezomib), Melphalan, Prednisone
MPV: Melphalan, Prednisone, Velcade (Bortezomib)

Variant #1, 4 cycles

Study Evidence
Mateos et al. 2006 Phase I/II

Note: this was the phase II portion of this phase I/II study.

Chemotherapy

42-day cycle for 4 cycles

Subsequent treatment

Variant #2, 6 cycles, bi-weekly bortezomib

Study Evidence
Gasparetto et al. 2009 Phase II

Chemotherapy

Supportive medications

28-day cycle for up to 6 cycles; treatment could be given beyond 6 cycles at investigator discretion

Variant #3, 6 cycles, bi-weekly bortezomib x 1, then weekly bortezomib x 5

Study Evidence Comparator Comparative Efficacy
Mateos et al. 2010 (GEM2005) Phase III (C) VTP Seems to have superior OS (*)

This regimen was intended for patients with untreated multiple myeloma, 65 years and older. Efficacy is based on the 2014 update.

Chemotherapy

Supportive medications

42-day cycle for 1 cycle, then 35-day cycle for 5 cycles

Subsequent treatment

  • VP versus VT maintenance

Variant #4, 8 cycles

Study Evidence Comparator Comparative Efficacy
Niesvizky et al. 2015 (UPFRONT) Phase III (E) 1. VD Seems not superior
2. VTD Seems not superior

This regimen was meant for transplant ineligible patients.

Chemotherapy

21-day cycle for 8 cycles

Subsequent treatment

Variant #5, 9 cycles, bi-weekly bortezomib x 1, then weekly bortezomib x 8

Study Evidence Comparator Comparative Efficacy
Mateos et al. 2017 (ALCYONE) Phase III (C) Dara-VMP Inferior PFS

This regimen was intended for patients with newly diagnosed, documented multiple myeloma who were not eligible for high-dose chemotherapy with stem-cell transplantation owing to coexisting conditions or an age of 65 years or older.

Chemotherapy

42-day cycle for 9 cycles

Variant #6, 9 cycles, bi-weekly bortezomib x 4, then weekly bortezomib x 5

Study Evidence Comparator Comparative Efficacy
San Miguel et al. 2008 (VISTA) Phase III (E) MP Superior OS
Palumbo et al. 2010 (GIMEMA MM-03-05) Phase III (C) VMPT-VT Seems to have inferior OS
San-Miguel et al. 2014 (CR015901) Randomized Phase II (C) VMP & Siltuximab Seems not superior
Facon et al. 2019 (CLARION) Phase III (C) KMP Seems not superior

In GIMEMA MM-03-05, VISTA, and CLARION this regimen was intended for patients with newly diagnosed, untreated, symptomatic, measurable myeloma who were not candidates for high-dose therapy plus stem-cell transplantation because of age (greater than or equal to 65 years) or coexisting conditions.

Chemotherapy

  • Bortezomib (Velcade) as follows:
    • Cycles 1 to 4: 1.3 mg/m2 IV or SC once per day on days 1, 4, 8, 11, 22, 25, 29, 32
    • Cycles 5 to 9: 1.3 mg/m2 IV or SC once per day on days 1, 8, 22, 29
  • Melphalan (Alkeran) 9 mg/m2 PO once per day on days 1 to 4
  • Prednisone (Sterapred) 60 mg/m2 PO once per day on days 1 to 4

Supportive medications

  • Bisphosphonates given to patients with myeloma-associated bone disease unless contraindicated (only mentioned in San Miguel et al. 2008)

42-day cycle for 9 cycles

Variant #7, 9 cycles, weekly bortezomib

Study Evidence Comparator Comparative Efficacy
Palumbo et al. 2010 (GIMEMA MM-03-05) Phase III (C) VMPT-VT Seems to have inferior OS

This regimen was intended for patients with newly diagnosed, untreated, symptomatic, measurable myeloma who were not candidates for high-dose therapy plus stem-cell transplantation because of age (greater than or equal to 65 years) or coexisting conditions. This dosing is the result of a mid-protocol amendment.

Chemotherapy

35-day cycle for 9 cycles

References

  1. Mateos MV, Hernández JM, Hernández MT, Gutiérrez NC, Palomera L, Fuertes M, Díaz-Mediavilla J, Lahuerta JJ, de la Rubia J, Terol MJ, Sureda A, Bargay J, Ribas P, de Arriba F, Alegre A, Oriol A, Carrera D, García-Laraña J, García-Sanz R, Bladé J, Prósper F, Mateo G, Esseltine DL, van de Velde H, San Miguel JF. Bortezomib plus melphalan and prednisone in elderly untreated patients with multiple myeloma: results of a multicenter phase 1/2 study. Blood. 2006 Oct 1;108(7):2165-72. Epub 2006 Jun 13. link to original article contains verified protocol PubMed
    1. Update: Mateos MV, Hernández JM, Hernández MT, Gutiérrez NC, Palomera L, Fuertes M, Garcia-Sanchez P, Lahuerta JJ, de la Rubia J, Terol MJ, Sureda A, Bargay J, Ribas P, Alegre A, de Arriba F, Oriol A, Carrera D, García-Laraña J, García-Sanz R, Bladé J, Prósper F, Mateo G, Esseltine DL, van de Velde H, San Miguel JF. Bortezomib plus melphalan and prednisone in elderly untreated patients with multiple myeloma: updated time-to-events results and prognostic factors for time to progression. Haematologica. 2008 Apr;93(4):560-5. Epub 2008 Mar 5. link to original article PubMed
  2. VISTA: San Miguel JF, Schlag R, Khuageva NK, Dimopoulos MA, Shpilberg O, Kropff M, Spicka I, Petrucci MT, Palumbo A, Samoilova OS, Dmoszynska A, Abdulkadyrov KM, Schots R, Jiang B, Mateos MV, Anderson KC, Esseltine DL, Liu K, Cakana A, van de Velde H, Richardson PG; VISTA Trial Investigators. Bortezomib plus melphalan and prednisone for initial treatment of multiple myeloma. N Engl J Med. 2008 Aug 28;359(9):906-17. link to original article contains protocol PubMed
    1. Update: Mateos MV, Richardson PG, Schlag R, Khuageva NK, Dimopoulos MA, Shpilberg O, Kropff M, Spicka I, Petrucci MT, Palumbo A, Samoilova OS, Dmoszynska A, Abdulkadyrov KM, Schots R, Jiang B, Esseltine DL, Liu K, Cakana A, van de Velde H, San Miguel JF. Bortezomib plus melphalan and prednisone compared with melphalan and prednisone in previously untreated multiple myeloma: updated follow-up and impact of subsequent therapy in the phase III VISTA trial. J Clin Oncol. 2010 May 1;28(13):2259-66. Epub 2010 Apr 5. link to original article contains protocol PubMed
    2. Update: San Miguel JF, Schlag R, Khuageva NK, Dimopoulos MA, Shpilberg O, Kropff M, Spicka I, Petrucci MT, Palumbo A, Samoilova OS, Dmoszynska A, Abdulkadyrov KM, Delforge M, Jiang B, Mateos MV, Anderson KC, Esseltine DL, Liu K, Deraedt W, Cakana A, van de Velde H, Richardson PG. Persistent overall survival benefit and no increased risk of second malignancies with bortezomib-melphalan-prednisone versus melphalan-prednisone in patients with previously untreated multiple myeloma. J Clin Oncol. 2013 Feb 1;31(4):448-55. Epub 2012 Dec 10. link to original article PubMed
  3. Gasparetto C, Gockerman JP, Diehl LF, de Castro CM, Moore JO, Long GD, Horwitz ME, Keogh G, Chute JP, Sullivan KM, Neuwirth R, Davis PH, Sutton LM, Anderson RD, Chao NJ, Rizzieri D. "Short course" bortezomib plus melphalan and prednisone as induction prior to transplant or as frontline therapy for nontransplant candidates in patients with previously untreated multiple myeloma. Biol Blood Marrow Transplant. 2010 Jan;16(1):70-7. Epub 2009 Sep 3. link to original article contains verified protocol PubMed
  4. Mateos MV, Oriol A, Martínez-López J, Gutiérrez N, Teruel AI, de Paz R, García-Laraña J, Bengoechea E, Martín A, Mediavilla JD, Palomera L, de Arriba F, González Y, Hernández JM, Sureda A, Bello JL, Bargay J, Peñalver FJ, Ribera JM, Martín-Mateos ML, García-Sanz R, Cibeira MT, Ramos ML, Vidriales MB, Paiva B, Montalbán MA, Lahuerta JJ, Bladé J, Miguel JF. Bortezomib, melphalan, and prednisone versus bortezomib, thalidomide, and prednisone as induction therapy followed by maintenance treatment with bortezomib and thalidomide versus bortezomib and prednisone in elderly patients with untreated multiple myeloma: a randomised trial. Lancet Oncol. 2010 Oct;11(10):934-41. Epub 2010 Aug 23. link to original article contains verified protocol PubMed
    1. Subgroup analysis: Mateos MV, Gutiérrez NC, Martín-Ramos ML, Paiva B, Montalbán MA, Oriol A, Martínez-López J, Teruel AI, Bengoechea E, Martín A, Díaz-Mediavilla J, de Arriba F, Palomera L, Hernández JM, Sureda A, Bargay J, Peñalver FJ, Ribera JM, Martín-Mateos ML, Fernández M, García-Sanz R, Vidriales MB, Bladé J, Lahuerta JJ, San Miguel JF. Outcome according to cytogenetic abnormalities and DNA ploidy in myeloma patients receiving short induction with weekly bortezomib followed by maintenance. Blood. 2011 Oct 27;118(17):4547-53. Epub 2011 Sep 6. link to original article PubMed
    2. Update: Mateos MV, Oriol A, Martínez-López J, Gutiérrez N, Teruel AI, López de la Guía A, López J, Bengoechea E, Pérez M, Polo M, Palomera L, de Arriba F, González Y, Hernández JM, Granell M, Bello JL, Bargay J, Peñalver FJ, Ribera JM, Martín-Mateos ML, García-Sanz R, Lahuerta JJ, Bladé J, San-Miguel JF. Maintenance therapy with bortezomib plus thalidomide or bortezomib plus prednisone in elderly multiple myeloma patients included in the GEM2005MAS65 trial. Blood. 2012 Sep 27;120(13):2581-8. Epub 2012 Aug 13. link to original article PubMed
    3. Update: Mateos MV, Oriol A, Martínez-López J, Teruel AI, López de la Guía A, López J, Bengoechea E, Pérez M, Martínez R, Palomera L, de Arriba F, González Y, Hernández JM, Granell M, Bello JL, Bargay J, Peñalver FJ, Martín-Mateos ML, Paiva B, Montalbán MA, Bladé J, Lahuerta JJ, San-Miguel JF. Update of the GEM2005 trial comparing VMP/VTP as induction in elderly multiple myeloma patients: do we still need alkylators?. Blood. 2014 Sep 18;124(12):1887-93. Epub 2014 Aug 7. link to original article contains verified protocol PubMed
  5. GIMEMA MM-03-05: Palumbo A, Bringhen S, Rossi D, Cavalli M, Larocca A, Ria R, Offidani M, Patriarca F, Nozzoli C, Guglielmelli T, Benevolo G, Callea V, Baldini L, Morabito F, Grasso M, Leonardi G, Rizzo M, Falcone AP, Gottardi D, Montefusco V, Musto P, Petrucci MT, Ciccone G, Boccadoro M. Bortezomib-melphalan-prednisone-thalidomide followed by maintenance with bortezomib-thalidomide compared with bortezomib-melphalan-prednisone for initial treatment of multiple myeloma: a randomized controlled trial. J Clin Oncol. 2010 Dec 1;28(34):5101-9. Epub 2010 Oct 12. link to original article contains verified protocol PubMed
    1. Post-hoc analysis: Bringhen S, Larocca A, Rossi D, Cavalli M, Genuardi M, Ria R, Gentili S, Patriarca F, Nozzoli C, Levi A, Guglielmelli T, Benevolo G, Callea V, Rizzo V, Cangialosi C, Musto P, De Rosa L, Liberati AM, Grasso M, Falcone AP, Evangelista A, Cavo M, Gaidano G, Boccadoro M, Palumbo A. Efficacy and safety of once-weekly bortezomib in multiple myeloma patients. Blood. 2010 Dec 2;116(23):4745-53. Epub 2010 Aug 31. link to original article contains verified protocol PubMed
    2. Subgroup analysis: Morabito F, Gentile M, Mazzone C, Rossi D, Di Raimondo F, Bringhen S, Ria R, Offidani M, Patriarca F, Nozzoli C, Petrucci MT, Benevolo G, Vincelli I, Guglielmelli T, Grasso M, Marasca R, Baldini L, Montefusco V, Musto P, Cascavilla N, Majolino I, Musolino C, Cavo M, Boccadoro M, Palumbo A. Safety and efficacy of bortezomib-melphalan-prednisone-thalidomide followed by bortezomib-thalidomide maintenance (VMPT-VT) versus bortezomib-melphalan-prednisone (VMP) in untreated multiple myeloma patients with renal impairment. Blood. 2011 Nov 24;118(22):5759-66. Epub 2011 Sep 27. link to original article PubMed
    3. Update: Palumbo A, Bringhen S, Larocca A, Rossi D, Di Raimondo F, Magarotto V, Patriarca F, Levi A, Benevolo G, Vincelli ID, Grasso M, Franceschini L, Gottardi D, Zambello R, Montefusco V, Falcone AP, Omedé P, Marasca R, Morabito F, Mina R, Guglielmelli T, Nozzoli C, Passera R, Gaidano G, Offidani M, Ria R, Petrucci MT, Musto P, Boccadoro M, Cavo M. Bortezomib-melphalan-prednisone-thalidomide followed by maintenance with bortezomib-thalidomide compared with bortezomib-melphalan-prednisone for initial treatment of multiple myeloma: updated follow-up and improved survival. J Clin Oncol. 2014 Mar 1;32(7):634-40. Epub 2014 Jan 21. link to original article contains verified protocol PubMed
  6. CR015901: San-Miguel J, Bladé J, Shpilberg O, Grosicki S, Maloisel F, Min CK, Polo Zarzuela M, Robak T, Prasad SV, Tee Goh Y, Laubach J, Spencer A, Mateos MV, Palumbo A, Puchalski T, Reddy M, Uhlar C, Qin X, van de Velde H, Xie H, Orlowski RZ. Phase 2 randomized study of bortezomib-melphalan-prednisone with or without siltuximab (anti-IL-6) in multiple myeloma. Blood. 2014 Jun 26;123(26):4136-42. Epub 2014 May 15. Erratum in: Blood. 2014 Aug 14;124(7):1201. link to original article refers to protocol in San Miguel et al. 2008 link to PMC article PubMed
  7. UPFRONT: Niesvizky R, Flinn IW, Rifkin R, Gabrail N, Charu V, Clowney B, Essell J, Gaffar Y, Warr T, Neuwirth R, Zhu Y, Elliott J, Esseltine DL, Niculescu L, Reeves J. Community-based phase IIIB trial of three UPFRONT bortezomib-based myeloma regimens. J Clin Oncol. 2015 Nov 20;33(33):3921-9. Epub 2015 Jun 8. link to original article contains verified protocol PubMed
  8. ALCYONE: Mateos MV, Dimopoulos MA, Cavo M, Suzuki K, Jakubowiak A, Knop S, Doyen C, Lucio P, Nagy Z, Kaplan P, Pour L, Cook M, Grosicki S, Crepaldi A, Liberati AM, Campbell P, Shelekhova T, Yoon SS, Iosava G, Fujisaki T, Garg M, Chiu C, Wang J, Carson R, Crist W, Deraedt W, Nguyen H, Qi M, San-Miguel J; ALCYONE Trial Investigators. Daratumumab plus bortezomib, melphalan, and prednisone for untreated myeloma. N Engl J Med. 2018 Feb 8;378(6):518-528. Epub 2017 Dec 12. link to original article contains verified protocol PubMed
  9. CLARION: Facon T, Lee JH, Moreau P, Niesvizky R, Dimopoulos M, Hajek R, Pour L, Jurczyszyn A, Qiu L, Klippel Z, Zahlten-Kumeli A, Osman M, Paiva B, San-Miguel J. Carfilzomib or bortezomib with melphalan-prednisone for transplant-ineligible patients with newly diagnosed multiple myeloma. Blood. 2019 May 2;133(18):1953-1963. Epub 2019 Feb 28. link to original article contains verified protocol PubMed

VMP, then Rd

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VMP, then Rd: Velcade (Bortezomib), Melphalan, Prednisone, followed by Revlimid (Lenalidomide), low dose dexamethasone

Regimen

Study Evidence Comparator Comparative Efficacy
Mateos et al. 2015 (PETHEMA GEM05) Phase III (E) VMP/Rd Seems not superior

This regimen was intended for patients aged greater than or equal to 65 years with newly diagnosed, untreated, symptomatic, measurable MM.

Chemotherapy, VMP portion, first cycle

42-day cycle for 1 cycle, then:

Chemotherapy, VMP portion, remainder

28-day cycle for 8 cycles, followed by:

Chemotherapy, Rd portion

28-day cycle for 9 cycles

Supportive medications

References

  1. PETHEMA GEM05: Mateos MV, Martínez-López J, Hernández MT, Ocio EM, Rosiñol L, Martínez R, Teruel AI, Gutiérrez NC, Martín Ramos ML, Oriol A, Bargay J, Bengoechea E, González Y, Pérez de Oteyza J, Gironella M, Encinas C, Martín J, Cabrera C, Paiva B, Cedena MT, Puig N, Bladé J, Lahuerta JJ, San-Miguel J. Sequential vs alternating administration of VMP and Rd in elderly patients with newly diagnosed MM. Blood. 2016 Jan 28;127(4):420-5. Epub 2015 Oct 23. link to original article contains verified protocol PubMed

VMP/Rd

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VMP/Rd: Velcade (Bortezomib), Melphalan, Prednisone alternating with Revlimid (Lenalidomide), low dose dexamethasone

Regimen

Study Evidence Comparator Comparative Efficacy
Mateos et al. 2015 (PETHEMA GEM05) Phase III (E) VMP, then Rd Seems not superior

This regimen was intended for patients aged greater than or equal to 65 years with newly diagnosed, untreated, symptomatic, measurable MM.

Chemotherapy, VMP portion, first cycle

42-day cycle for 1 cycle, then Rd cycle #1:

Chemotherapy, VMP portion, remaining cycles

28-day cycle for 8 cycles, alternating with Rd:

Chemotherapy, Rd portion

28-day cycle alternating with VMP x 9 cycles

Supportive medications

References

  1. PETHEMA GEM05: Mateos MV, Martínez-López J, Hernández MT, Ocio EM, Rosiñol L, Martínez R, Teruel AI, Gutiérrez NC, Martín Ramos ML, Oriol A, Bargay J, Bengoechea E, González Y, Pérez de Oteyza J, Gironella M, Encinas C, Martín J, Cabrera C, Paiva B, Cedena MT, Puig N, Bladé J, Lahuerta JJ, San-Miguel J. Sequential vs alternating administration of VMP and Rd in elderly patients with newly diagnosed MM. Blood. 2016 Jan 28;127(4):420-5. Epub 2015 Oct 23. link to original article contains verified protocol PubMed

VMPT

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VMPT: Velcade (Bortezomib), Melphalan, Prednisone, Thalidomide

Variant #1

Study Evidence Comparator Comparative Efficacy
Palumbo et al. 2010 (GIMEMA MM-03-05) Phase III (E) VMP Seems to have superior OS

This regimen was intended for patients with newly diagnosed myeloma who were not candidates for high-dose therapy plus stem-cell transplantation because of age (greater than or equal to 65 years) or coexisting comorbidities.

Chemotherapy

42-day cycle for 9 cycles

Subsequent treatment

Variant #2

Study Evidence Comparator Comparative Efficacy
Palumbo et al. 2010 (GIMEMA MM-03-05) Phase III (E) VMP Seems to have superior OS

This regimen was intended for patients with newly diagnosed myeloma who were not candidates for high-dose therapy plus stem-cell transplantation because of age (greater than or equal to 65 years) or coexisting comorbidities. This variant represents a mid-protocol change (in 2007) where cycle length was decreased from 6 to 5 weeks and bortezomib was changed to weekly dosing.

Chemotherapy

35-day cycle for 9 cycles

Subsequent treatment

References

  1. GIMEMA MM-03-05: Palumbo A, Bringhen S, Rossi D, Cavalli M, Larocca A, Ria R, Offidani M, Patriarca F, Nozzoli C, Guglielmelli T, Benevolo G, Callea V, Baldini L, Morabito F, Grasso M, Leonardi G, Rizzo M, Falcone AP, Gottardi D, Montefusco V, Musto P, Petrucci MT, Ciccone G, Boccadoro M. Bortezomib-melphalan-prednisone-thalidomide followed by maintenance with bortezomib-thalidomide compared with bortezomib-melphalan-prednisone for initial treatment of multiple myeloma: a randomized controlled trial. J Clin Oncol. 2010 Dec 1;28(34):5101-9. Epub 2010 Oct 12. link to original article contains verified protocol PubMed
    1. Post-hoc analysis: Bringhen S, Larocca A, Rossi D, Cavalli M, Genuardi M, Ria R, Gentili S, Patriarca F, Nozzoli C, Levi A, Guglielmelli T, Benevolo G, Callea V, Rizzo V, Cangialosi C, Musto P, De Rosa L, Liberati AM, Grasso M, Falcone AP, Evangelista A, Cavo M, Gaidano G, Boccadoro M, Palumbo A. Efficacy and safety of once-weekly bortezomib in multiple myeloma patients. Blood. 2010 Dec 2;116(23):4745-53. Epub 2010 Aug 31. link to original article contains verified protocol PubMed
    2. Subgroup analysis: Morabito F, Gentile M, Mazzone C, Rossi D, Di Raimondo F, Bringhen S, Ria R, Offidani M, Patriarca F, Nozzoli C, Petrucci MT, Benevolo G, Vincelli I, Guglielmelli T, Grasso M, Marasca R, Baldini L, Montefusco V, Musto P, Cascavilla N, Majolino I, Musolino C, Cavo M, Boccadoro M, Palumbo A. Safety and efficacy of bortezomib-melphalan-prednisone-thalidomide followed by bortezomib-thalidomide maintenance (VMPT-VT) versus bortezomib-melphalan-prednisone (VMP) in untreated multiple myeloma patients with renal impairment. Blood. 2011 Nov 24;118(22):5759-66. Epub 2011 Sep 27. link to original article PubMed
    3. Update: Palumbo A, Bringhen S, Larocca A, Rossi D, Di Raimondo F, Magarotto V, Patriarca F, Levi A, Benevolo G, Vincelli ID, Grasso M, Franceschini L, Gottardi D, Zambello R, Montefusco V, Falcone AP, Omedé P, Marasca R, Morabito F, Mina R, Guglielmelli T, Nozzoli C, Passera R, Gaidano G, Offidani M, Ria R, Petrucci MT, Musto P, Boccadoro M, Cavo M. Bortezomib-melphalan-prednisone-thalidomide followed by maintenance with bortezomib-thalidomide compared with bortezomib-melphalan-prednisone for initial treatment of multiple myeloma: updated follow-up and improved survival. J Clin Oncol. 2014 Mar 1;32(7):634-40. Epub 2014 Jan 21. link to original article contains verified protocol PubMed

VTD

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VTD: Velcade (Bortezomib), Thalidomide, Dexamethasone
vTD: low-dose velcade (Bortezomib), Thalidomide, Dexamethasone

Variant #1

Study Evidence Comparator Comparative Efficacy
Moreau et al. 2016 (IFM 2013-04) Phase III (E) VCD Seems to have superior ORR rate

This regimen was intended for patients aged 65 years or younger with untreated symptomatic MM with measurable paraprotein in serum (greater than 1 g/dL) or urine (greater than 0.2 g/24 hours).

Chemotherapy

21-day cycle for 4 cycles

Subsequent treatment

  • Autologous hematopoietic cell transplant, with choice of conditioning regimen, whether to perform tandem transplant, and whether to give maintenance at the discretion of the treating center

Variant #2

Study Evidence Comparator Comparative Efficacy
Niesvizky et al. 2015 (UPFRONT) Phase III (E) 1. VD Seems not superior
2. VMP Seems not superior

This regimen was intended for patients with newly diagnosed, symptomatic, measurable MM requiring systemic therapy, and who were ineligible for stem-cell transplantation because of age (greater than or equal to 65 years), comorbidities, or personal preference.

Chemotherapy

21-day cycle for 8 cycles

Subsequent treatment

Variant #3

Study Evidence Comparator Comparative Efficacy
Ludwig et al. 2013 Randomized Phase II (C) VTDC Seems not superior

This regimen was intended for patients aged 18 to 70 years with previously untreated, measurable MM requiring systemic therapy, who were candidates for high-dose chemotherapy and autologous hematopoietic cell transplant.

Chemotherapy

21-day cycle for 4 cycles

Subsequent treatment

Variant #4

Study Evidence Comparator Comparative Efficacy
Rosiñol et al. 2012 (GEM05/MENOS65) Phase III (E) 1. TD Seems to have superior PFS
2. VBMCP/VBAD/B Seems to have superior PFS

This regimen was intended for patients with newly diagnosed and untreated symptomatic MM who were 65 years of age or younger with measurable serum and/or urine M protein.

Chemotherapy

Supportive medications

28-day cycle for 6 cycles

Subsequent treatment

Variant #5, "vTD"

Study Evidence Comparator Comparative Efficacy
Moreau et al. 2011 (IFM 2007-02) Phase III (E) VD Superior VGPR rate
Lok et al. 2014 Non-randomized

IFM 2007-02 was intended for patients aged 65 years or younger with untreated symptomatic MM with measurable paraprotein in serum (greater than 1 g/dL) or urine (greater than 0.2 g/24 hours). Lok et al. 2014 uses the same dosing except that bortezomib is given SC.

Chemotherapy

21-day cycle for 4 cycles

Subsequent treatment

Variant #6

Study Evidence Comparator Comparative Efficacy
Cavo et al. 2010 (GIMEMA MM-BO2005) Phase III (E) TD Superior CR/nCR rate

This regimen was intended for patients aged 18 to 65 years with previously untreated symptomatic myeloma.

Chemotherapy

21-day cycle for 3 cycles

Subsequent treatment

Variant #7

Study Evidence
Kaufman et al. 2010 Retrospective

Chemotherapy

Supportive medications

  • Aspirin prophylaxis to decrease risk of DVTs
  • Prophylactic "treatment with antiviral and antibiotic medications"

21-day cycle for 3 to 4 cycles

References

  1. Retrospective: Kaufman JL, Nooka A, Vrana M, Gleason C, Heffner LT, Lonial S. Bortezomib, thalidomide, and dexamethasone as induction therapy for patients with symptomatic multiple myeloma: a retrospective study. Cancer. 2010 Jul 1;116(13):3143-51. link to original article contains protocol PubMed
  2. GIMEMA MM-BO2005: Cavo M, Tacchetti P, Patriarca F, Petrucci MT, Pantani L, Galli M, Di Raimondo F, Crippa C, Zamagni E, Palumbo A, Offidani M, Corradini P, Narni F, Spadano A, Pescosta N, Deliliers GL, Ledda A, Cellini C, Caravita T, Tosi P, Baccarani M; GIMEMA Italian Myeloma Network. Bortezomib with thalidomide plus dexamethasone compared with thalidomide plus dexamethasone as induction therapy before, and consolidation therapy after, double autologous stem-cell transplantation in newly diagnosed multiple myeloma: a randomised phase 3 study. Lancet. 2010 Dec 18;376(9758):2075-85. Epub 2010 Dec 9. link to original article contains protocol PubMed
    1. Update: Cavo M, Pantani L, Petrucci MT, Patriarca F, Zamagni E, Donnarumma D, Crippa C, Boccadoro M, Perrone G, Falcone A, Nozzoli C, Zambello R, Masini L, Furlan A, Brioli A, Derudas D, Ballanti S, Dessanti ML, De Stefano V, Carella AM, Marcatti M, Nozza A, Ferrara F, Callea V, Califano C, Pezzi A, Baraldi A, Grasso M, Musto P, Palumbo A; GIMEMA (Gruppo Italiano Malattie Ematologiche dell'Adulto) Italian Myeloma Network. Bortezomib-thalidomide-dexamethasone is superior to thalidomide-dexamethasone as consolidation therapy after autologous hematopoietic stem cell transplantation in patients with newly diagnosed multiple myeloma. Blood. 2012 Jul 5;120(1):9-19. Epub 2012 Apr 12. link to original article contains verified protocol PubMed
  3. IFM 2007-02: Moreau P, Avet-Loiseau H, Facon T, Attal M, Tiab M, Hulin C, Doyen C, Garderet L, Randriamalala E, Araujo C, Lepeu G, Marit G, Caillot D, Escoffre M, Lioure B, Benboubker L, Pégourié B, Kolb B, Stoppa AM, Fuzibet JG, Decaux O, Dib M, Berthou C, Chaleteix C, Sebban C, Traullé C, Fontan J, Wetterwald M, Lenain P, Mathiot C, Harousseau JL. Bortezomib plus dexamethasone versus reduced-dose bortezomib, thalidomide plus dexamethasone as induction treatment before autologous stem cell transplantation in newly diagnosed multiple myeloma. Blood. 2011 Nov 24;118(22):5752-8. Epub 2011 Aug 17. link to original article contains verified protocol PubMed
  4. GEM05/MENOS65: Rosiñol L, Oriol A, Teruel AI, Hernández D, López-Jiménez J, de la Rubia J, Granell M, Besalduch J, Palomera L, González Y, Etxebeste MA, Díaz-Mediavilla J, Hernández MT, de Arriba F, Gutiérrez NC, Martín-Ramos ML, Cibeira MT, Mateos MV, Martínez J, Alegre A, Lahuerta JJ, San Miguel J, Bladé J; Programa para el Estudio y la Terapéutica de las Hemopatías Malignas/Grupo Español de Mieloma (PETHEMA/GEM) group. Superiority of bortezomib, thalidomide, and dexamethasone (VTD) as induction pretransplantation therapy in multiple myeloma: a randomized phase 3 PETHEMA/GEM study. Blood. 2012 Aug 3;120(8):1589-96. Epub 2012 Jul 12. link to original article contains verified protocol PubMed
    1. Update: Rosiñol L, Oriol A, Teruel AI, de la Guía AL, Blanchard M, de la Rubia J, Granell M, Sampol M, Palomera L, González Y, Etxebeste M, Martínez-Martínez R, Hernández MT, de Arriba F, Alegre A, Cibeira M, Mateos M, Martínez-López J, Lahuerta JJ, San Miguel J, Bladé J. Bortezomib and thalidomide maintenance after stem cell transplantation for multiple myeloma: a PETHEMA/GEM trial. Leukemia. 2017 Sep;31(9):1922-1927. Epub 2017 Jan 23. link to original article contains verified protocol PubMed
  5. Ludwig H, Viterbo L, Greil R, Masszi T, Spicka I, Shpilberg O, Hajek R, Dmoszynska A, Paiva B, Vidriales MB, Esteves G, Stoppa AM, Robinson D Jr, Ricci D, Cakana A, Enny C, Feng H, van de Velde H, Harousseau JL. Randomized phase II study of bortezomib, thalidomide, and dexamethasone with or without cyclophosphamide as induction therapy in previously untreated multiple myeloma. J Clin Oncol. 2013 Jan 10;31(2):247-55. Epub 2012 Oct 22. link to original article contains verified protocol PubMed
    1. Update: Ludwig H, Greil R, Masszi T, Spicka I, Shpilberg O, Hajek R, Dmoszynska A, Paiva B, Vidriales MB, Esteves G, Stoppa AM, Robinson D Jr, Chaturvedi S, Ataman O, Enny C, Feng H, van de Velde H, Viterbo L. Bortezomib, thalidomide and dexamethasone, with or without cyclophosphamide, for patients with previously untreated multiple myeloma: 5-year follow-up. Br J Haematol. 2015 Nov;171(3):344-54. Epub 2015 Jul 7. link to original article link to PMC article PubMed
  6. Lok A, Mocquard J, Bourcier J, Redelsperger L, Bonnet A, Chauvin C, Thomare P, Mahe B, Touzeau C, Moreau P. Subcutaneous bortezomib incorporated into the bortezomib-thalidomide-dexamethasone regimen as part of frontline therapy in the context of autologous stem-cell transplantation for multiple myeloma. Haematologica. 2014 Mar;99(3):e33-4. Epub 2014 Feb 14. link to original article contains verified protocol link to PMC article PubMed
  7. Meta-Analysis: Leiba M, Kedmi M, Duek A, Freidman T, Weiss M, Leiba R, Nagler A, Avigdor A. Bortezomib-Cyclophosphamide-Dexamethasone (VCD) versus Bortezomib-Thalidomide-Dexamethasone (VTD) -based regimens as induction therapies in newly diagnosed transplant eligible patients with multiple myeloma: a meta-analysis. Br J Haematol. 2014 Sep;166(5):702-10. Epub 2014 May 26. link to original article PubMed
  8. UPFRONT: Niesvizky R, Flinn IW, Rifkin R, Gabrail N, Charu V, Clowney B, Essell J, Gaffar Y, Warr T, Neuwirth R, Zhu Y, Elliott J, Esseltine DL, Niculescu L, Reeves J. Community-based phase IIIB trial of three UPFRONT bortezomib-based myeloma regimens. J Clin Oncol. 2015 Nov 20;33(33):3921-9. Epub 2015 Jun 8. link to original article contains verified protocol PubMed
  9. IFM2013-04: Moreau P, Hulin C, Macro M, Caillot D, Chaleteix C, Roussel M, Garderet L, Royer B, Brechignac S, Tiab M, Puyade M, Escoffre M, Stoppa AM, Facon T, Pegourie B, Chaoui D, Jaccard A, Slama B, Marit G, Laribi K, Godmer P, Luycx O, Eisenmann JC, Allangba O, Dib M, Araujo C, Fontan J, Belhadj K, Wetterwald M, Dorvaux V, Fermand JP, Rodon P, Kolb B, Glaisner S, Malfuson JV, Lenain P, Biron L, Planche L, Caillon H, Avet-Loiseau H, Dejoie T, Attal M. VTD is superior to VCD prior to intensive therapy in multiple myeloma: results of the prospective IFM2013-04 trial. Blood. 2016 May 26;127(21):2569-74. Epub 2016 Mar 21. link to original article contains verified protocol PubMed

VTP

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VTP: Velcade (Bortezomib), Thalidomide, Prednisone

Regimen

Study Evidence Comparator Comparative Efficacy
Mateos et al. 2010 (GEM2005) Phase III (E) VMP Seems to have inferior OS (*)

This regimen was intended for patients with untreated multiple myeloma, 65 years and older. Efficacy is based on the 2014 update.

Chemotherapy

  • Bortezomib (Velcade) as follows:
    • Cycle 1: 1.3 mg/m2 IV once per day on days 1, 4, 8, 11, 22, 25, 29, 32
    • Cycles 2 to 6: 1.3 mg/m2 IV once per day on days 1, 8, 15, 22
  • Thalidomide (Thalomid) as follows:
    • Cycle 1: 50 mg PO once per day on days 1 to 15, then 100 mg PO once per day on days 16 to 42
    • Cycles 2 to 6: 100 mg PO once per day
  • Prednisone (Sterapred) 60 mg/m2 PO once per day on days 1 to 4

Supportive medications

42-day cycle for 1 cycle, then 35-day cycle for 5 cycles

Subsequent treatment

  • VP versus VT maintenance

References

  1. GEM2005: Mateos MV, Oriol A, Martínez-López J, Gutiérrez N, Teruel AI, de Paz R, García-Laraña J, Bengoechea E, Martín A, Mediavilla JD, Palomera L, de Arriba F, González Y, Hernández JM, Sureda A, Bello JL, Bargay J, Peñalver FJ, Ribera JM, Martín-Mateos ML, García-Sanz R, Cibeira MT, Ramos ML, Vidriales MB, Paiva B, Montalbán MA, Lahuerta JJ, Bladé J, Miguel JF. Bortezomib, melphalan, and prednisone versus bortezomib, thalidomide, and prednisone as induction therapy followed by maintenance treatment with bortezomib and thalidomide versus bortezomib and prednisone in elderly patients with untreated multiple myeloma: a randomised trial. Lancet Oncol. 2010 Oct;11(10):934-41. Epub 2010 Aug 23. link to original article contains verified protocol PubMed
    1. Subgroup analysis: Mateos MV, Gutiérrez NC, Martín-Ramos ML, Paiva B, Montalbán MA, Oriol A, Martínez-López J, Teruel AI, Bengoechea E, Martín A, Díaz-Mediavilla J, de Arriba F, Palomera L, Hernández JM, Sureda A, Bargay J, Peñalver FJ, Ribera JM, Martín-Mateos ML, Fernández M, García-Sanz R, Vidriales MB, Bladé J, Lahuerta JJ, San Miguel JF. Outcome according to cytogenetic abnormalities and DNA ploidy in myeloma patients receiving short induction with weekly bortezomib followed by maintenance. Blood. 2011 Oct 27;118(17):4547-53. Epub 2011 Sep 6. link to original article PubMed
    2. Update: Mateos MV, Oriol A, Martínez-López J, Gutiérrez N, Teruel AI, López de la Guía A, López J, Bengoechea E, Pérez M, Polo M, Palomera L, de Arriba F, González Y, Hernández JM, Granell M, Bello JL, Bargay J, Peñalver FJ, Ribera JM, Martín-Mateos ML, García-Sanz R, Lahuerta JJ, Bladé J, San-Miguel JF. Maintenance therapy with bortezomib plus thalidomide or bortezomib plus prednisone in elderly multiple myeloma patients included in the GEM2005MAS65 trial. Blood. 2012 Sep 27;120(13):2581-8. Epub 2012 Aug 13. link to original article PubMed
    3. Update: Mateos MV, Oriol A, Martínez-López J, Teruel AI, López de la Guía A, López J, Bengoechea E, Pérez M, Martínez R, Palomera L, de Arriba F, González Y, Hernández JM, Granell M, Bello JL, Bargay J, Peñalver FJ, Martín-Mateos ML, Paiva B, Montalbán MA, Bladé J, Lahuerta JJ, San-Miguel JF. Update of the GEM2005 trial comparing VMP/VTP as induction in elderly multiple myeloma patients: do we still need alkylators?. Blood. 2014 Sep 18;124(12):1887-93. Epub 2014 Aug 7. link to original article contains verified protocol PubMed

Zoledronic acid therapy

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Regimen

Study Evidence Comparator Comparative Efficacy
Morgan et al. 2010 (MRC Myeloma IX) Phase III (E) Clodronic acid Seems to have superior OS

Note: this agent was not given as monotherapy, but is included separately from the regimens that it was given with, based on the RCT design.

Supportive therapy

  • Zoledronic acid (Zometa) as follows:
    • During induction: 4 mg IV over 15 minutes once every 3 to 4 weeks
    • Consolidation onwards: 4 mg IV over 15 minutes once every 4 weeks

Continued indefinitely

References

  1. MRC Myeloma IX: Morgan GJ, Davies FE, Gregory WM, Cocks K, Bell SE, Szubert AJ, Navarro-Coy N, Drayson MT, Owen RG, Feyler S, Ashcroft AJ, Ross F, Byrne J, Roddie H, Rudin C, Cook G, Jackson GH, Child JA; National Cancer Research Institute Haematological Oncology Clinical Study Group. First-line treatment with zoledronic acid as compared with clodronic acid in multiple myeloma (MRC Myeloma IX): a randomised controlled trial. Lancet. 2010 Dec 11;376(9757):1989-99. Epub 2010 Dec 3. link to original article link to PMC article PubMed
    1. Update: Morgan GJ, Davies FE, Gregory WM, Russell NH, Bell SE, Szubert AJ, Navarro Coy N, Cook G, Feyler S, Byrne JL, Roddie H, Rudin C, Drayson MT, Owen RG, Ross FM, Jackson GH, Child JA; NCRI Haematological Oncology Study Group. Cyclophosphamide, thalidomide, and dexamethasone (CTD) as initial therapy for patients with multiple myeloma unsuitable for autologous transplantation. Blood. 2011 Aug 4;118(5):1231-8. Epub 2011 Jun 7. link to original article contains verified protocol link to PMC article PubMed
    2. Update: Morgan GJ, Gregory WM, Davies FE, Bell SE, Szubert AJ, Brown JM, Coy NN, Cook G, Russell NH, Rudin C, Roddie H, Drayson MT, Owen RG, Ross FM, Jackson GH, Child JA; National Cancer Research Institute Haematological Oncology Clinical Studies Group. The role of maintenance thalidomide therapy in multiple myeloma: MRC Myeloma IX results and meta-analysis. Blood. 2012 Jan 5;119(1):7-15. Epub 2011 Oct 20. link to original article contains verified protocol PubMed
    3. Update: Morgan GJ, Davies FE, Gregory WM, Bell SE, Szubert AJ, Navarro Coy N, Cook G, Feyler S, Johnson PR, Rudin C, Drayson MT, Owen RG, Ross FM, Russell NH, Jackson GH, Child JA; National Cancer Research Institute Haematological Oncology Clinical Studies Group. Cyclophosphamide, thalidomide, and dexamethasone as induction therapy for newly diagnosed multiple myeloma patients destined for autologous stem-cell transplantation: MRC Myeloma IX randomized trial results. Haematologica. 2012 Mar;97(3):442-50. Epub 2011 Nov 4. link to original article contains verified protocol link to PMC article PubMed
    4. Update: Morgan GJ, Davies FE, Gregory WM, Bell SE, Szubert AJ, Cook G, Drayson MT, Owen RG, Ross FM, Jackson G, Child JA. Long-term follow-up of MRC Myeloma IX trial: Survival outcomes with bisphosphonate and thalidomide treatment. Clin Cancer Res. 2013 Nov 1;19(21):6030-8. Epub 2013 Aug 30. link to original article PubMed

First-line therapy (including transplant ineligible), non-randomized or retrospective data

Note: most but not all multiple myeloma first-line regimens specify whether patients are transplant eligible, or not. We will begin to break this section in those respective subsections.

BBD

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BBD: Bendamustine, Bortezomib, Dexamethasone

Regimen

Study Evidence
Berdeja et al. 2017 (SCRI MM 23) Phase II

Note: this is the modified treatment schema.

Chemotherapy

Supportive medications

  • Mandatory VZV prophylaxis

28-day cycle for 8 cycles

Subsequent treatment

References

  1. SCRI MM 23: Berdeja JG, Bauer T, Arrowsmith E, Essell J, Murphy P, Reeves JA Jr, Boccia RV, Donnellan W, Flinn I. Phase II study of bendamustine, bortezomib and dexamethasone (BBD) in the first-line treatment of patients with multiple myeloma who are not candidates for high dose chemotherapy. Br J Haematol. 2017 Apr;177(2):254-262. Epub 2017 Feb 7. link to original article contains verified protocol PubMed

BiRD

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BiRD: Biaxin, Revlimid (Lenalidomide), Dexamethasone

Regimen

Study Evidence
Niesvizky et al. 2007 Phase II

Chemotherapy

  • Clarithromycin (Biaxin) as follows:
    • Cycle 1: 500 mg PO twice per day on days 2 to 28
    • Cycle 2 onwards: 500 mg PO twice per day on days 1 to 28
  • Lenalidomide (Revlimid) as follows:
    • Cycle 1: 25 mg PO once per day on days 3 to 21
    • Cycle 2 onwards: 25 mg PO once per day on days 1 to 21
  • Dexamethasone (Decadron) as follows:
    • Cycle 1: 40 mg PO once per day on days 1, 2, 3, 8, 15, 22
    • Cycle 2 onwards: 40 mg PO once per day on days 1, 8, 15, 22

Supportive medications

28-day cycles

References

  1. Niesvizky R, Jayabalan DS, Christos PJ, Furst JR, Naib T, Ely S, Jalbrzikowski J, Pearse RN, Zafar F, Pekle K, Larow A, Lent R, Mark T, Cho HJ, Shore T, Tepler J, Harpel J, Schuster MW, Mathew S, Leonard JP, Mazumdar M, Chen-Kiang S, Coleman M. BiRD (Biaxin [clarithromycin]/Revlimid [lenalidomide]/dexamethasone) combination therapy results in high complete- and overall-response rates in treatment-naive symptomatic multiple myeloma. Blood. 2008 Feb 1;111(3):1101-9. Epub 2007 Nov 7. link to original article contains protocol PubMed
    1. Update: Rossi A, Mark T, Jayabalan D, Christos P, Zafar F, Pekle K, Pearse R, Chen-Kiang S, Coleman M, Niesvizky R. BiRd (clarithromycin, lenalidomide, dexamethasone): an update on long-term lenalidomide therapy in previously untreated patients with multiple myeloma. Blood. 2013 Mar 14;121(11):1982-1985. Epub 2013 Jan 8. link to original article contains protocol link to PMC article PubMed
  2. Retrospective: Gay F, Rajkumar SV, Coleman M, Kumar S, Mark T, Dispenzieri A, Pearse R, Gertz MA, Leonard J, Lacy MQ, Chen-Kiang S, Roy V, Jayabalan DS, Lust JA, Witzig TE, Fonseca R, Kyle RA, Greipp PR, Stewart AK, Niesvizky R. Clarithromycin (Biaxin)-lenalidomide-low-dose dexamethasone (BiRd) versus lenalidomide-low-dose dexamethasone (Rd) for newly diagnosed myeloma. Am J Hematol. 2010 Sep;85(9):664-9. link to original article contains protocol link to PMC article PubMed

CRd

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CRd: Cyclophosphamide, Revlimid (Lenalidomide), low-dose dexamethasone

Regimen

Study Evidence
Kumar et al. 2011 (RV-MM-PI-0116) Phase II

Chemotherapy

Supportive medications

28-day cycle for 4 to 12 cycles

Subsequent treatment

  • At physician discretion, patient could proceed to lenalidomide maintenance +/- dexamethasone, after the 12th cycle, until progression

References

  1. RV-MM-PI-0116: Kumar SK, Lacy MQ, Hayman SR, Stewart K, Buadi FK, Allred J, Laumann K, Greipp PR, Lust JA, Gertz MA, Zeldenrust SR, Bergsagel PL, Reeder CB, Witzig TE, Fonseca R, Russell SJ, Mikhael JR, Dingli D, Rajkumar SV, Dispenzieri A. Lenalidomide, cyclophosphamide and dexamethasone (CRd) for newly diagnosed multiple myeloma: results from a phase 2 trial. Am J Hematol. 2011 Aug;86(8):640-5. contains verified protocol link to PMC article PubMed

CYKLONE

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CYKLONE: Cyclophosphamide, Kyprolis (Carfilzomib), ThaLlidomide, DexamethasONE

Regimen

Study Evidence
Mikhael et al. 2015 Phase II

The carfilzomib dose here is the MTD dose, tested in N=29 patients. The authors state that patients could proceed to autologous hematopoietic cell transplant after four cycles but do not provide criteria to undergo transplant as opposed to continuing CYKLONE.

Chemotherapy

Supportive medications

28-day cycle for 4 to 12 cycles (see note)

References

  1. Mikhael JR, Reeder CB, Libby EN, Costa LJ, Bergsagel PL, Buadi F, Mayo A, Nagi Reddy SK, Gano K, Dueck AC, Stewart AK. Phase Ib/II trial of CYKLONE (cyclophosphamide, carfilzomib, thalidomide and dexamethasone) for newly diagnosed myeloma. Br J Haematol. 2015 Apr;169(2):219-27. Epub 2015 Feb 13. link to original article contains verified protocol link to PMC article PubMed

IRd

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IRd: Ixazomib, Revlimid (Lenalidomide), low-dose dexamethasone

Regimen

Study Evidence
Kumar et al. 2014 Phase I/II

This is the MTD dose of this phase I/II trial.

Chemotherapy

28-day cycle for up to 12 cycles

Subsequent treatment

References

  1. Kumar SK, Berdeja JG, Niesvizky R, Lonial S, Laubach JP, Hamadani M, Stewart AK, Hari P, Roy V, Vescio R, Kaufman JL, Berg D, Liao E, Di Bacco A, Estevam J, Gupta N, Hui AM, Rajkumar V, Richardson PG. Safety and tolerability of ixazomib, an oral proteasome inhibitor, in combination with lenalidomide and dexamethasone in patients with previously untreated multiple myeloma: an open-label phase 1/2 study. Lancet Oncol. 2014 Dec;15(13):1503-12. link to original article PubMed

KCd

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KCd: Kyprolis (Carfilzomib), Cyclophosphamide, dexamethasone
CCyd: Carfilzomib, Cyclophosphamide, dexamethasone
KCyd: Kyprolis (Carfilzomib), Cyclophosphamide, dexamethasone

Variant #1, bi-weekly carfilzomib

Study Evidence
Bringhen et al. 2014 (IST-CAR-506) Phase II

Chemotherapy

28-day cycle for 9 cycles

Subsequent treatment

Variant #2, weekly carfilzomib ("wKCyd")

Study Evidence
Bringhen et al. 2017 (IST-CAR-561) Phase I/II

Note: this is the MTD established for the phase II portion of the trial.

Chemotherapy

28-day cycle for 9 cycles

Subsequent treatment

References

  1. IST-CAR-506: Bringhen S, Petrucci MT, Larocca A, Conticello C, Rossi D, Magarotto V, Musto P, Boccadifuoco L, Offidani M, Omedé P, Gentilini F, Ciccone G, Benevolo G, Genuardi M, Montefusco V, Oliva S, Caravita T, Tacchetti P, Boccadoro M, Sonneveld P, Palumbo A. Carfilzomib, cyclophosphamide, and dexamethasone in patients with newly diagnosed multiple myeloma: a multicenter, phase 2 study. Blood. 2014 Jul 3;124(1):63-9. Epub 2014 May 22. link to original article contains verified protocol PubMed
  2. IST-CAR-561: Bringhen S, D'Agostino M, De Paoli L, Montefusco V, Liberati AM, Galieni P, Grammatico S, Muccio VE, Esma F, De Angelis C, Musto P, Ballanti S, Offidani M, Petrucci MT, Gaidano G, Corradini P, Palumbo A, Sonneveld P, Boccadoro M. Phase 1/2 study of weekly carfilzomib, cyclophosphamide, dexamethasone in newly diagnosed transplant-ineligible myeloma. Leukemia. 2018 Apr;32(4):979-985. Epub 2017 Nov 16. link to original article contains verified protocol PubMed

KRd

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KRd: Kyprolis (Carfilzomib), Revlimid (Lenalidomide), low-dose dexamethasone
CRd: Carfilzomib, Revlimid (Lenalidomide), low-dose dexamethasone

Variant #1

Study Evidence
Korde et al. 2016 (NCI 11-C-0221) Phase II

The minimal difference between this and variant #2 below is the steroid dosing.

Chemotherapy

  • Carfilzomib (Kyprolis) as follows:
    • Cycle 1: 20 mg/m2 IV once per day on days 1, 2, then 36 mg/m2 IV once per day on days 8, 9, 15, 16
    • Cycles 2 to 8: 36 mg/m2 IV once per day on days 1, 2, 8, 9, 15, 16
  • Lenalidomide (Revlimid) 25 mg PO once per day on days 1 to 21
  • Dexamethasone (Decadron) as follows:
    • Cycle 1: 20 mg IV or PO once per day on days 1, 2, 8, 9, 15, 16, 22, 23
    • Cycles 2 to 4: 20 mg IV or PO once per day on days 1, 2, 8, 9, 15, 16, 22, 23
    • Cycles 5 to 8: 10 mg IV or PO once per day on days 1, 2, 8, 9, 15, 16, 22, 23

28-day cycle for 8 cycles

Subsequent treatment

  • Transplant eligible patients underwent stem cell collection after the 4th cycle but were not obligated to proceed to transplant.
  • If transplant was not undertaken, patients proceeded to lenalidomide maintenance after the 8th cycle

Variant #2

Study Evidence
Jakubowiak et al. 2012 (UMCC 2009.056) Phase I/II

This is the MTD dosing in this phase I/II trial.

Chemotherapy

  • Carfilzomib (Kyprolis) as follows:
    • Cycle 1: 20 mg/m2 IV once per day on days 1, 2, then 36 mg/m2 IV once per day on days 8, 9, 15, 16
    • Cycles 2 to 8: 36 mg/m2 IV once per day on days 1, 2, 8, 9, 15, 16
  • Lenalidomide (Revlimid) 25 mg PO once per day on days 1 to 21
  • Dexamethasone (Decadron) as follows:
    • Cycles 1 to 4: 40 mg (route not specified) once per day on days 1, 8, 15, 22
    • Cycles 1 & 2 at clinician's discretion: 4 mg IV or PO once per day on days 2, 9, 16 (in addition to above)
    • Cycles 5 to 8: 20 mg (route not specified) once per day on days 1, 8, 15, 22

28-day cycle for 8 cycles

Subsequent treatment

  • Transplant eligible patients underwent stem cell collection after the 4th cycle but were not obligated to proceed to transplant
  • If transplant was not undertaken, patients proceeded to CRd maintenance after the 8th cycle

References

  1. UMCC 2009.056: Jakubowiak AJ, Dytfeld D, Griffith KA, Lebovic D, Vesole DH, Jagannath S, Al-Zoubi A, Anderson T, Nordgren B, Detweiler-Short K, Stockerl-Goldstein K, Ahmed A, Jobkar T, Durecki DE, McDonnell K, Mietzel M, Couriel D, Kaminski M, Vij R. A phase 1/2 study of carfilzomib in combination with lenalidomide and low-dose dexamethasone as a frontline treatment for multiple myeloma. Blood. 2012 Aug 30;120(9):1801-9. Epub 2012 Jun 4. link to original article contains verified protocol link to PMC article PubMed
  2. NCI 11-C-0221: Korde N, Roschewski M, Zingone A, Kwok M, Manasanch EE, Bhutani M, Tageja N, Kazandjian D, Mailankody S, Wu P, Morrison C, Costello R, Zhang Y, Burton D, Mulquin M, Zuchlinski D, Lamping L, Carpenter A, Wall Y, Carter G, Cunningham SC, Gounden V, Sissung TM, Peer C, Maric I, Calvo KR, Braylan R, Yuan C, Stetler-Stevenson M, Arthur DC, Kong KA, Weng L, Faham M, Lindenberg L, Kurdziel K, Choyke P, Steinberg SM, Figg W, Landgren O. Treatment With carfilzomib-lenalidomide-dexamethasone with lenalidomide extension in patients with smoldering or newly diagnosed multiple myeloma. JAMA Oncol. 2015 Sep;1(6):746-54. link to original article contains verified protocol PubMed

KTd

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KTd: Kyprolis (Carfilzomib), Thalidomide, dexamethasone

Regimen

Study Evidence
Sonneveld et al. 2014 Phase II

Three cohorts are reported; optimal dose of carfilzomib is not described.

Chemotherapy

  • Carfilzomib (Kyprolis) as follows:
    • Cycle 1: 20 mg/m2 IV once per day on days 1 & 2, and:
    • Cohort 1: 27 mg/m2 IV once per day on days 8, 9, 15, 16 of cycle 1 and days 1, 2, 8, 9, 15, 16 of subsequent cycles
    • Cohort 2: 36 mg/m2 IV once per day on days 8, 9, 15, 16 of cycle 1 and days 1, 2, 8, 9, 15, 16 of subsequent cycles
    • Cohort 3: 45 mg/m2 IV once per day on days 8, 9, 15, 16 of cycle 1 and days 1, 2, 8, 9, 15, 16 of subsequent cycles
  • Thalidomide (Thalomid) 200 mg PO once per day
  • Dexamethasone (Decadron) 40 mg PO once per day on days 1, 8, 15, 22

28-day cycle for 4 cycles

Subsequent treatment

References

  1. Sonneveld P, Asselbergs E, Zweegman S, van der Holt B, Kersten MJ, Vellenga E, van Marwijk-Kooy M, Broyl A, de Weerdt O, Lonergan S, Palumbo A, Lokhorst H. Phase 2 study of carfilzomib, thalidomide and dexamethasone as induction/consolidation therapy for newly diagnosed multiple myeloma. Blood. 2015 Jan 15;125(3):449-56. Epub 2014 Nov 14. link to original article contains verified protocol link to PMC article PubMed

PAD doxil

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PAD doxil: PS-341 (Bortezomib), liposomal Adriamycin (Doxorubicin), Dexamethasone
DVD: Doxil (Liposomal doxorubicin), Velcade (Bortezomib), Dexamethasone
VDD: Velcade (Bortezomib), Doxil (Liposomal doxorubicin), Dexamethasone

Variant #1

Study Evidence
Berenson et al. 2011 Phase II

Chemotherapy

28-day cycle for up to 8 cycles

Variant #2

Study Evidence
Palumbo et al. 2010 Phase II

Chemotherapy

Supportive medications

21-day cycle for 4 cycles

Subsequent treatment

Variant #3

Study Evidence
Jakubowiak et al. 2009 Phase II

Chemotherapy

Supportive medications

  • Low-molecular weight heparin 40 mg SC once per day or Aspirin 81 mg PO once per day for DVT prophylaxis
  • Acyclovir (Zovirax) 400 mg PO twice per day for Herpes zoster prophylaxis

21-day cycle for 6 cycles

References

  1. Jakubowiak AJ, Kendall T, Al-Zoubi A, Khaled Y, Mineishi S, Ahmed A, Campagnaro E, Brozo C, Braun T, Talpaz M, Kaminski MS. Phase II trial of combination therapy with bortezomib, pegylated liposomal doxorubicin, and dexamethasone in patients with newly diagnosed myeloma. J Clin Oncol. 2009 Oct 20;27(30):5015-22. Epub 2009 Sep 8. link to original article contains verified protocol PubMed
    1. Update: Dytfeld D, Griffith KA, Friedman J, Lebovic D, Harvey C, Kaminski MS, Jakubowiak AJ. Superior overall survival of patients with myeloma achieving very good partial response or better to initial treatment with bortezomib, pegylated liposomal doxorubicin, and dexamethasone, predicted after two cycles by a free light chain- and M-protein-based model: extended follow-up of a phase II trial. Leuk Lymphoma. 2011 Jul;52(7):1271-80. link to original article contains verified protocol PubMed
  2. Palumbo A, Gay F, Falco P, Crippa C, Montefusco V, Patriarca F, Rossini F, Caltagirone S, Benevolo G, Pescosta N, Guglielmelli T, Bringhen S, Offidani M, Giuliani N, Petrucci MT, Musto P, Liberati AM, Rossi G, Corradini P, Boccadoro M. Bortezomib as induction before autologous transplantation, followed by lenalidomide as consolidation-maintenance in untreated multiple myeloma patients. J Clin Oncol. 2010 Feb 10;28(5):800-7. Epub 2010 Jan 4. Erratum in: J Clin Oncol. 2010 May 1;28(13):2314. link to original article contains verified protocol PubMed
    1. Update: Gay F, Magarotto V, Crippa C, Pescosta N, Guglielmelli T, Cavallo F, Pezzatti S, Ferrari S, Liberati AM, Oliva S, Patriarca F, Offidani M, Omedé P, Montefusco V, Petrucci MT, Giuliani N, Passera R, Pietrantuono G, Boccadoro M, Corradini P, Palumbo A. Bortezomib induction, reduced-intensity transplantation, and lenalidomide consolidation-maintenance for myeloma: updated results. Blood. 2013 Aug 22;122(8):1376-83. Epub 2013 Jun 17. link to original article contains protocol PubMed
  3. Berenson JR, Yellin O, Chen CS, Patel R, Bessudo A, Boccia RV, Yang HH, Vescio R, Yung E, Mapes R, Eades B, Hilger JD, Wirtschafter E, Hilger J, Nassir Y, Swift RA. A modified regimen of pegylated liposomal doxorubicin, bortezomib and dexamethasone (DVD) is effective and well tolerated for previously untreated multiple myeloma patients. Br J Haematol. 2011 Dec;155(5):580-7. Epub 2011 Sep 26. link to original article contains verified protocol PubMed

RP

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RP: Revlimid (Lenalidomide) & Prednisone

Regimen

Study Evidence
Falco et al. 2012 Phase II

Note: this is a component of the sequential "RP-MPR-RP" protocol; to our knowledge there are no references to support using it as a stand-alone treatment.

Chemotherapy

Supportive medications

  • Thromboprophylaxis: Aspirin 100 mg PO once per day, taken during Lenalidomide (Revlimid) treatment (unclear from protocol if this also means off weeks)
  • Antiviral prophylaxis if history of VZV.

28-day cycle for 4 cycles

Subsequent treatment

References

  1. Falco P, Cavallo F, Larocca A, Rossi D, Guglielmelli T, Rocci A, Grasso M, Siez ML, De Paoli L, Oliva S, Molica S, Mina R, Gay F, Benevolo G, Musto P, Omedè P, Freilone R, Bringhen S, Carella AM, Gaidano G, Boccadoro M, Palumbo A. Lenalidomide-prednisone induction followed by lenalidomide-melphalan-prednisone consolidation and lenalidomide-prednisone maintenance in newly diagnosed elderly unfit myeloma patients. Leukemia. 2013 Mar;27(3):695-701. Epub 2012 Sep 21. link to original article contains verified protocol PubMed

Total Therapy

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Regimen

Study Evidence
Barlogie et al. 1997 (Total Therapy 1) Prospective
Barlogie et al. 2006 (Total Therapy 2) Prospective with randomization
Barlogie et al. 2007 (Total Therapy 3) Prospective

Total Therapy is a very complicated regimen, you are highly recommended to refer to the original protocols for further details. Total Therapy 3 is replicated here; the references for Total Therapy 2 are provided below but there are no plans to add this regimen here, for now.

Chemotherapy, induction (VTD-PACE)

VTD-PACE: Velcade (Bortezomib), Thalidomide, Dexamethasone, Platinum (Cisplatin), Adriamycin (Doxorubicin), Cyclophosphamide, Etoposide

  • Bortezomib (Velcade) 1 mg/m2 SC once per day on days 1, 4, 8, 11
  • Thalidomide (Thalomid) 200 mg PO once per day on days 4 to 7
  • Dexamethasone (Decadron) 40 mg PO once per day on days 4 to 7
  • Cisplatin (Platinol) 10 mg/m2/day IV continuous infusion over 96 hours, started on day 4 (total dose per cycle: 40 mg/m2)
  • Doxorubicin (Adriamycin) 10 mg/m2/day IV continuous infusion over 96 hours, started on day 4 (total dose per cycle: 40 mg/m2)
  • Cyclophosphamide (Cytoxan) 400 mg/m2/day IV continuous infusion over 96 hours, started on day 4 (total dose per cycle: 1600 mg/m2)
  • Etoposide (Vepesid) 40 mg/m2/day IV continuous infusion over 96 hours, started on day 4 (total dose per cycle: 160 mg/m2)
  • Peripheral blood stem cells (PBSC) are usually collected during cycle 1--cycle 2 PBSC collection is done if needed--with a median CD34 count of 29 x 106/kg. 87% of collections yielded at least 20 x 106/kg.

Duration of each cycle not specified; 2 cycles total are given, no more than 8 weeks apart

During the interim period between cycle 1 and cycle 2, as well as after cycle 2 and prior to transplant, this is given once platelets have recovered to at least 50 x 109/L:

21-day cycles, given between induction cycles and transplant

In other words, the initial therapy consists of: Induction therapy cycle 1, dexamethasone & thalidomide, induction therapy cycle 2, dexamethasone & thalidomide, then transplant.

Supportive medications

  • As described in Barlogie et al. 2006, which Barlogie et al. 2007 refers to. Note: Barlogie et al. 2007 lists an incorrect title for the reference. See below for the the correct full reference.
  • Filgrastim (Neupogen) "was administered to support induction and consolidation chemotherapy regimens"
  • "Prophylactic antibiotics, histamine H2 blockers, and recombinant erythropoietin" were given as needed
  • Low molecular weight heparin (LMWH) prophylaxis was used for all patients receiving thalidomide

Chemotherapy, autologous hematopoietic cell transplant

Full details were not provided in Barlogie et al. 2007. Tandem autologous transplants were done between 2 to 6 months apart.

During the interim period after transplant 1 and transplant 2, patients receive:

21-day cycles, given in the time between and after each transplant; if platelets less than 50 x 109/L, proceed to year 1 of maintenance therapy. Otherwise, if platelets are at least 50 x 109/L, proceed to consolidation therapy.

Chemotherapy, consolidation (VTD-PACE)

VTD-PACE: Velcade (Bortezomib), Thalidomide, Dexamethasone, Platinum (Cisplatin), Adriamycin (Doxorubicin), Cyclophosphamide, Etoposide

Cycle 1 of consolidation starts 1.5 to 4 months after the last transplant. Cycle 2 of consolidation starts 2 to 4 months after cycle 1 of consolidation.

2 cycles total are given according to the interval specified above, with the interim therapy below used

During the interim period between cycle 1 and cycle 2, as well as after cycle 2 and prior to maintenance therapy, this is given once platelets have recovered to at least 50 x 109/L:

21-day cycles, given between consolidation cycles and maintenance

In other words, consolidation therapy consists of: Consolidation therapy cycle 1, dexamethasone & thalidomide, consolidation therapy cycle 2, dexamethasone & thalidomide, then maintenance therapy.

Supportive medications

  • As described in Barlogie et al. 2006, which Barlogie et al. 2007 refers to. Note: Barlogie et al. 2007 lists an incorrect title for the reference. See below for the the correct full reference.
  • Filgrastim (Neupogen) "was administered to support induction and consolidation chemotherapy regimens"
  • "Prophylactic antibiotics, histamine H2 blockers, and recombinant erythropoietin" were given as needed
  • Low molecular weight heparin (LMWH) prophylaxis was used for all patients receiving thalidomide

Chemotherapy, maintenance year 1 (VTD)

VTD: Velcade (Bortezomib), Thalidomide, Dexamethasone

Year 1 of maintenance therapy starts 1 to 4 months after consolidation cycle 2.

28-day cycle for 1 year, then proceed to maintenance therapy years 2 to 3

Chemotherapy, maintenance years 2 & 3 (TD)

TD: Thalidomide, Dexamethasone

28-day cycle for 2 years

References

  1. Total Therapy 1: Barlogie B, Jagannath S, Vesole DH, Naucke S, Cheson B, Mattox S, Bracy D, Salmon S, Jacobson J, Crowley J, Tricot G. Superiority of tandem autologous transplantation over standard therapy for previously untreated multiple myeloma. Blood. 1997 Feb 1;89(3):789-93. link to original article PubMed
    1. Update: Barlogie B, Jagannath S, Desikan KR, Mattox S, Vesole D, Siegel D, Tricot G, Munshi N, Fassas A, Singhal S, Mehta J, Anaissie E, Dhodapkar D, Naucke S, Cromer J, Sawyer J, Epstein J, Spoon D, Ayers D, Cheson B, Crowley J. Total therapy with tandem transplants for newly diagnosed multiple myeloma. Blood. 1999 Jan 1;93(1):55-65. link to original article contains verified protocol PubMed
    2. Pooled update: Barlogie B, Attal M, Crowley J, van Rhee F, Szymonifka J, Moreau P, Durie BG, Harousseau JL. Long-term follow-up of autotransplantation trials for multiple myeloma: update of protocols conducted by the Intergroupe Francophone du Myelome, Southwest Oncology Group, and University of Arkansas for Medical Sciences. J Clin Oncol. 2010 Mar 1;28(7):1209-14. Epub 2010 Jan 19. Erratum in: J Clin Oncol. 2010 Jul 20;28(21):3543. link to original article link to PMC article PubMed
  2. Total Therapy 2: Barlogie B, Tricot G, Anaissie E, Shaughnessy J, Rasmussen E, van Rhee F, Fassas A, Zangari M, Hollmig K, Pineda-Roman M, Lee C, Talamo G, Thertulien R, Kiwan E, Krishna S, Fox M, Crowley J. Thalidomide and hematopoietic-cell transplantation for multiple myeloma. N Engl J Med. 2006 Mar 9;354(10):1021-30. link to original article supportive medication details PubMed
    1. Update: Zangari M, van Rhee F, Anaissie E, Pineda-Roman M, Haessler J, Crowley J, Barlogie B. Eight-year median survival in multiple myeloma after total therapy 2: roles of thalidomide and consolidation chemotherapy in the context of Total Therapy 1. Br J Haematol. 2008 May;141(4):433-44. Epub 2008 Mar 26. link to original article link to PMC article PubMed
    2. Subgroup analysis: Barlogie B, Pineda-Roman M, van Rhee F, Haessler J, Anaissie E, Hollmig K, Alsayed Y, Waheed S, Petty N, Epstein J, Shaughnessy JD Jr, Tricot G, Zangari M, Zeldis J, Barer S, Crowley J. Thalidomide arm of Total Therapy 2 improves complete remission duration and survival in myeloma patients with metaphase cytogenetic abnormalities. Blood. 2008 Oct 15;112(8):3115-21. Epub 2008 May 20. link to original article link to PMC article PubMed
    3. Pooled update: Barlogie B, Attal M, Crowley J, van Rhee F, Szymonifka J, Moreau P, Durie BG, Harousseau JL. Long-term follow-up of autotransplantation trials for multiple myeloma: update of protocols conducted by the Intergroupe Francophone du Myelome, Southwest Oncology Group, and University of Arkansas for Medical Sciences. J Clin Oncol. 2010 Mar 1;28(7):1209-14. Epub 2010 Jan 19. Erratum in: J Clin Oncol. 2010 Jul 20;28(21):3543. link to original article link to PMC article PubMed
  3. Total Therapy 3: Barlogie B, Anaissie E, van Rhee F, Haessler J, Hollmig K, Pineda-Roman M, Cottler-Fox M, Mohiuddin A, Alsayed Y, Tricot G, Bolejack V, Zangari M, Epstein J, Petty N, Steward D, Jenkins B, Gurley J, Sullivan E, Crowley J, Shaughnessy JD Jr. Incorporating bortezomib into upfront treatment for multiple myeloma: early results of Total Therapy 3. Br J Haematol. 2007 Jul;138(2):176-85. link to original article contains verified protocol PubMed
    1. Update: Pineda-Roman M, Zangari M, Haessler J, Anaissie E, Tricot G, van Rhee F, Crowley J, Shaughnessy JD Jr, Barlogie B. Sustained complete remissions in multiple myeloma linked to bortezomib in total therapy 3: comparison with total therapy 2. Br J Haematol. 2008 Mar;140(6):625-34. link to original article link to PMC article PubMed
    2. Pooled update: Barlogie B, Attal M, Crowley J, van Rhee F, Szymonifka J, Moreau P, Durie BG, Harousseau JL. Long-term follow-up of autotransplantation trials for multiple myeloma: update of protocols conducted by the Intergroupe Francophone du Myelome, Southwest Oncology Group, and University of Arkansas for Medical Sciences. J Clin Oncol. 2010 Mar 1;28(7):1209-14. Epub 2010 Jan 19. Erratum in: J Clin Oncol. 2010 Jul 20;28(21):3543. link to original article link to PMC article PubMed

VP

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VP: Velcade (Bortezomib) & Prednisone

Regimen

Study Evidence
Larocca et al. 2016 Phase II

Chemotherapy

28-day cycle for 9 cycles

Subsequent treatment

References

  1. Larocca A, Bringhen S, Petrucci MT, Oliva S, Falcone AP, Caravita T, Villani O, Benevolo G, Liberati AM, Morabito F, Montefusco V, Passera R, De Rosa L, Omedé P, Vincelli ID, Spada S, Carella AM, Ponticelli E, Derudas D, Genuardi M, Guglielmelli T, Nozzoli C, Aghemo E, De Paoli L, Conticello C, Musolino C, Offidani M, Boccadoro M, Sonneveld P, Palumbo A. A phase 2 study of three low-dose intensity subcutaneous bortezomib regimens in elderly frail patients with untreated multiple myeloma. Leukemia. 2016 Jun;30(6):1320-6. link to original article contains verified protocol PubMed

VTD-PACE

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VTD-PACE: Velcade (Bortezomib), Thalidomide, Dexamethasone, Platinum (Cisplatin), Adriamycin (Doxorubicin), Cyclophosphamide, Etoposide

Regimen

Study Evidence
Barlogie et al. 2007 (Total Therapy 3) Prospective

Note: this is the induction therapy used in Total Therapy 3. We are not aware of other sources prospectively describing VTD-PACE.

Chemotherapy

Duration of each cycle not specified; 2 cycles total are given, no more than 8 weeks apart

References

  1. Total Therapy 3: Barlogie B, Anaissie E, van Rhee F, Haessler J, Hollmig K, Pineda-Roman M, Cottler-Fox M, Mohiuddin A, Alsayed Y, Tricot G, Bolejack V, Zangari M, Epstein J, Petty N, Steward D, Jenkins B, Gurley J, Sullivan E, Crowley J, Shaughnessy JD Jr. Incorporating bortezomib into upfront treatment for multiple myeloma: early results of Total Therapy 3. Br J Haematol. 2007 Jul;138(2):176-85. link to original article contains verified protocol PubMed

Investigational agents

These are drugs under study with at least some promising results for this disease.

Response criteria

Prognosis

Durie-Salmon Staging System - 1975

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Composed of four factors with a modifier based on renal function

  • Serum levels of monoclonal protein (only defined for IgM, IgA, and Bence-Jones)
  • Number of lytic bone lesions
  • Hemoglobin
  • Serum calcium level

Risk stratification

  • Stage I: (must meet ALL criteria)
    • Hemoglobin greater than 10 g/dL
    • Calcium normal or less than or equal to 12 mg/dL
    • Skeletal survey with normal bone structure (scale 0) or solitary bone plasmacytoma only
    • Monoclonal protein relatively small (IgG M-spike value less than 5 g/dL OR IgA M-spike value less than 3 g/dL OR urine light chain protein less than 4 g/24 hr)
  • Stage II: not stage I or stage III
  • Stage III: (if meets ANY of the criteria)
    • Hemoglobin less than 8.5 g/dL
    • Calcium greater than 12 mg/dL
    • Skeletal survey with extensive skeletal destruction and major fractures
    • Monoclonal protein relatively large (IgG M-spike value greater than 7 g/dL OR IgA M-spike value greater than 5 g/dL OR urine light chain protein greater than 12 g/24 hr)

Modifier

  • A: relatively normal creatinine (less than 2 mg/dL)
  • B: creatinine greater than or equal to 2 mg/dL

References

  1. Durie BG, Salmon SE. A clinical staging system for multiple myeloma. Correlation of measured myeloma cell mass with presenting clinical features, response to treatment, and survival. Cancer. 1975 Sep;36(3):842-54. link to original article PubMed

International Staging System (ISS) - 2005

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Composed of two factors

  • Serum albumin level
  • Serum beta-2 microglobulin level

Risk stratification

  • Stage I: Median survival of 62 months
    • Beta-2 microglobulin less than 3.5 mg/l
    • Albumin greater than or equal to 3.5 g/dl
  • Stage II: Median survival of 44 months
    • Not meeting stage I or stage III criteria
  • Stage III: Median survival of 29 months
    • Beta-2 microglobulin greater than or equal to 5.5 mg/l

References

  1. Greipp PR, San Miguel J, Durie BG, Crowley JJ, Barlogie B, Bladé J, Boccadoro M, Child JA, Avet-Loiseau H, Kyle RA, Lahuerta JJ, Ludwig H, Morgan G, Powles R, Shimizu K, Shustik C, Sonneveld P, Tosi P, Turesson I, Westin J. International staging system for multiple myeloma. J Clin Oncol. 2005 May 20;23(15):3412-20. Epub 2005 Apr 4. link to original article PubMed
  2. Kyle RA, Rajkumar SV. Criteria for diagnosis, staging, risk stratification and response assessment of multiple myeloma. Leukemia. 2009 Jan;23(1):3-9. Epub 2008 Oct 30. link to PMC article PubMed

IMWG consensus on risk stratification - 2013

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Composed of four factors

  • Serum albumin level
  • Serum beta-2 microglobulin level
  • Age
  • Chromosomal abnormalities detected by interphase fluorescent in situ hybridization (FISH)

Risk stratification

  • Low risk: (must meet all criteria) Median survival of greater than 10 years
    • ISS Stage I or II
    • Age less than 55 years
    • Absence of the following: del(17p13), t(4;14), +1q21
  • Standard risk: Median survival of 7 years
    • Not meeting low risk or high risk criteria
  • High risk: (if meets both criteria) Median survival of 2 years
    • ISS Stage II or III
    • Either of the following: del(17p13) or t(4;14)

References

  1. Chng WJ, Dispenzieri A, Chim CS, Fonseca R, Goldschmidt H, Lentzsch S, Munshi N, Palumbo A, San Miguel J, Sonneveld P, Cavo M, Usmani S, Durie BG, Avet-Loiseau H; International Myeloma Working Group. IMWG consensus on risk stratification in multiple myeloma. Leukemia. 2014 Feb;28(2):269-77. Epub 2013 Aug 26. link to original article PubMed

Revised International Staging System (R-ISS) - 2015

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Composed of four factors

  • Serum albumin level
  • Serum beta-2 microglobulin level
  • Serum LDH
  • Chromosomal abnormalities detected by interphase fluorescent in situ hybridization (FISH)

Risk stratification

  • Low risk: 5-year overall survival = 82%
    • Beta-2 microglobulin less than 3.5 mg/l
    • Albumin less than or equal to 3.5 g/dl
    • LDH less than the upper limit of normal range
    • Absence of the following: del(17p), t(4;14), t(14;16)
  • Intermediate risk: 5-year overall survival = 62%
    • Not meeting low risk or high risk criteria
  • High risk: (if meets ANY of the criteria) 5-year overall survival = 40%
    • Beta-2 microglobulin greater than or equal to 5.5 mg/l
    • LDH greater than the upper limit of normal range
    • Any of the following: del(17p), t(4;14), t(14;16)

References

  1. Palumbo A, Avet-Loiseau H, Oliva S, Lokhorst HM, Goldschmidt H, Rosinol L, Richardson P, Caltagirone S, Lahuerta JJ, Facon T, Bringhen S, Gay F, Attal M, Passera R, Spencer A, Offidani M, Kumar S, Musto P, Lonial S, Petrucci MT, Orlowski RZ, Zamagni E, Morgan G, Dimopoulos MA, Durie BG, Anderson KC, Sonneveld P, San Miguel J, Cavo M, Rajkumar SV, Moreau P. Revised International Staging System for multiple myeloma: a report from International Myeloma Working Group. J Clin Oncol. 2015 Sep 10;33(26):2863-9. Epub 2015 Aug 3. link to original article link to PMC article

Miscellaneous

  1. Avet-Loiseau H, Attal M, Moreau P, Charbonnel C, Garban F, Hulin C, Leyvraz S, Michallet M, Yakoub-Agha I, Garderet L, Marit G, Michaux L, Voillat L, Renaud M, Grosbois B, Guillerm G, Benboubker L, Monconduit M, Thieblemont C, Casassus P, Caillot D, Stoppa AM, Sotto JJ, Wetterwald M, Dumontet C, Fuzibet JG, Azais I, Dorvaux V, Zandecki M, Bataille R, Minvielle S, Harousseau JL, Facon T, Mathiot C. Genetic abnormalities and survival in multiple myeloma: the experience of the Intergroupe Francophone du Myélome. Blood. 2007 Apr 15;109(8):3489-95. Epub 2007 Jan 5. link to original article PubMed
  2. Avet-Loiseau H, Hulin C, Campion L, Rodon P, Marit G, Attal M, Royer B, Dib M, Voillat L, Bouscary D, Caillot D, Wetterwald M, Pegourie B, Lepeu G, Corront B, Karlin L, Stoppa AM, Fuzibet JG, Delbrel X, Guilhot F, Kolb B, Decaux O, Lamy T, Garderet L, Allangba O, Lifermann F, Anglaret B, Moreau P, Harousseau JL, Facon T. Chromosomal abnormalities are major prognostic factors in elderly patients with multiple myeloma: the Intergroupe Francophone du Myélome experience. J Clin Oncol. 2013 Aug 1;31(22):2806-9. Epub 2013 Jun 24. link to original article link to PMC article PubMed

External links

References