LWBK1006-34 LWW-Govindan-Review November 24, 2011 11:25
468 DeVita, Hellman, and Rosenberg’s CANCER: Principles and Practice of Oncology ReviewANSWERS
Answer 34.1. The answer is B.
The choice of initial therapy for elderly patients with multiple myeloma
has been a subject of several clinical trials. There have been three ran-
domized controlled trials (IFM 99-06: Facon T, Mary JY, Hulin C, et al.
Lancet. 2007;370[9594]:1209–1218; IFM 01-01: Hulin C, Virion J,
Leleu X, et al. Am J Clin Oncol. 2007;25[18S]:8001; GIMEMA: Palumbo
A, Bringhen S, Caravita T, et al. Lancet. 2006;367[9513]:825–831.) com-
paring MPT and MP regimens. All three studies showed superiority of
MPT over MP on the basis of response including complete remission
(13% to 16% vs. 2% to 2.4%) and progression-free survival (24 to
27.5 months vs. 17.8 to 19 months). In the IFM studies, the improved
response rate of MPT over MP translated into improved OS (45 to
50 months vs. 27 to 33 months). The VISTA trial (San Miguel, et al. Blood
[ASH Annual Meeting Abstracts] 2007;110[11]:2712) recently showed
the melphalan, prednisone, and bortezomib (MPV) combination to be
superior to MP (CR rate: 35% vs. 5%, 2-year OS: 83% vs. 70%). There
is no study comparing MPV with MPT. The combination of TD has been
compared with MP (Ludwig H, et al. Hematologica. 2007;92[10]:1411–
1414). Although TD showed a better response rate (CR/near CR: 30% vs.
14%), it resulted in inferior survival (OS: 44.6 vs. 57.9 months) secondary
to its toxicity. HDCT with melphalan 200 mg/m^2 has emerged as standard
of care for transplant-eligible patients. However, patients aged more than
75 years are usually not considered for transplantation because of the tox-
icity of the treatment in this group. In the IFM 99-06 study, patients who
received MPT showed a superior survival compared with reduced-dose
melphalan 100 mg/m^2 followed by autologous stem cell transplantation
(OS: 51.6 vs. 38.3 months). Thus, the MPT regimen would be the most
appropriate for this patient.Answer 34.2. The answer is D.
The choice of the optimal induction therapy before autologous stem cell
transplantation for patients with multiple myeloma has been the subject
of several randomized clinical trials. VAD chemotherapy had been the
most popular induction chemotherapy regimen in the United States until
the 1990s. Several randomized trials have recently compared various reg-
imens for induction therapy before transplantation. Marco et al. (Blood
[ASH Annual Abstracts] 2007;110[11]) compared TD with VAD as induc-
tion regimen before HDCT and reported a good partial response (VGPR)
with TD compared with VAD before transplant (35% vs. 12%). However,
there was no difference in VGPR at 6 months post-HDCT (44% vs. 41%).
Horousseau et al. (Blood [AHS Annual Abstracts] 2007;110[11]) reported
a higher CR+near CR postautologous transplantation with VD as induc-
tion therapy compared with VAD as induction therapy (41% vs. 29%).
In a phase 3 study, Carvo et al. (ASH 2007) reported that VTD induction
therapy resulted in higher CR+near CR postautologous transplantation