My husband was diagnosed in March 2014 with IgG kappa multiple myeloma. His first (and really only) symptom was a compression fracture in a lumbar vertebra. He has been through two rounds of Velcade/dex/Revlimid [VRD] and is starting round 3.
Labs after round two rounds showed his IgG went from 4250 to 1503; his M Spike from 2.9 to 0.8; Kappa free light chains from 78.23 to 20.99, and kappa/lambda free light chain ratio from 9.71 to 1.38. His plasma cell percentage from a bone marrow biopsy before treatment started was 20% and he has a 1q21 abnormality. The beta microglobulin was 2.8 before treatment and we don't have the new number yet.
He's been told that if he was in remission (this was before the M-spike number was in) he would have a choice between harvesting and storing, or harvesting and going ahead with stem cell transplant, but that if he isn't in remission, going ahead with SCT would be recommended.
Obviously, the m-spike isn't zero, but it has gone down over 70% after just two rounds. The IgG and kappa/lamba ratio are now in normal limits, and the latest kappa number (20.99), just not far over normal (19.40 is the high end of the normal range).
I know we have to wait for all the numbers and of course I will ask the doctors all these questions, but what is the chance they will let him continue induction to see if he can get to remission levels within a short period (given the excellent response after 2 rounds) so that he can choose to wait on the SCT, which is the way he is leaning if in remission?
The plan is to do two more rounds anyway. Won't they look at the numbers again after round 4?
He's had no bad effects from the treatment so far so seems like, if it's working and not killing him, why not keep doing it a little longer?
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Re: Why not continue treatment to deepen response?
One thing I have learned from researching the types of questions that you and your husband are confronting now is that both doctors and patients have differing opinions. You will have to gather information, perhaps seek more than one opinion, and make your own choices.
In my own case, and I think it is typical with VRD as initial treatment, the numbers dropped very quickly at the outset. For example, my M-spike went from 5.9 at diagnosis to 0.5 after two cycles, and to 0.1 after three cycles, where it has remained through six cycles and and a stem cell transplant. My serum kappa/lambda ratio reached normal levels after two cycles and has remained there.
Most doctors who favor transplant will tell you that getting the deepest response possible prior to transplant is preferable. Whether to proceed immediately to transplant after 4-6 cycles of VRD is a question on which there are many threads in these forums.
I struggled with the decision, and for my own reasons decided to go forward with the transplant. Studies are ongoing in an attempt to answer the question.
In my own case, and I think it is typical with VRD as initial treatment, the numbers dropped very quickly at the outset. For example, my M-spike went from 5.9 at diagnosis to 0.5 after two cycles, and to 0.1 after three cycles, where it has remained through six cycles and and a stem cell transplant. My serum kappa/lambda ratio reached normal levels after two cycles and has remained there.
Most doctors who favor transplant will tell you that getting the deepest response possible prior to transplant is preferable. Whether to proceed immediately to transplant after 4-6 cycles of VRD is a question on which there are many threads in these forums.
I struggled with the decision, and for my own reasons decided to go forward with the transplant. Studies are ongoing in an attempt to answer the question.
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goldmine848 - Name: Andrew
- When were you/they diagnosed?: June 2013
- Age at diagnosis: 60
Re: Why not continue treatment to deepen response?
CMD5 Hello,
I just wanted to add a reply on your thoughts about harvesting and storing. I was diagnosed at the end of January and started Revlimid / dexamethasone in February. Like your husband, I have had next to no issues. The only thing i had was a rash on my neck and that was stopped with Aveeno healing ointment. My oncologist has been saying that I should possibly try to get my levels as low as we can and do a harvest and storage in the near future.
I am between a rock and a hard place because I have no sick time or vacation time left and have been on disability since February due to multiple broken ribs. One rib is a real mess and is slow to heal. But I am scheduled to go back to work July 14th if my next X-ray looks good.
Being that said, I would possibly lose my job if I take off more time within the next year (same job for 22 years). Almost near retirement but still 3 or 4 year away. If I had an office type job I think that I would be able to have a harvest and transplant done without losing too much time away from work. But I work on heavy equipment and there is no light duty or office work. So many things to think about and everyone's situation is a little different.
I also wanted to ask a question about the IgA numbers. i have been looking at my lab results and after my last lab work it shows IgA at 365 and the range is 73 to 347. The other one is the bamma globulin protein spike. this shows a 6.3% compared to 7.6% last month. Are there different tests that your husband is getting? I am not up on all these numbers. My oncologist just let me know that there is another test that I will fall into once my numbers come down some more.
I just wanted to add a reply on your thoughts about harvesting and storing. I was diagnosed at the end of January and started Revlimid / dexamethasone in February. Like your husband, I have had next to no issues. The only thing i had was a rash on my neck and that was stopped with Aveeno healing ointment. My oncologist has been saying that I should possibly try to get my levels as low as we can and do a harvest and storage in the near future.
I am between a rock and a hard place because I have no sick time or vacation time left and have been on disability since February due to multiple broken ribs. One rib is a real mess and is slow to heal. But I am scheduled to go back to work July 14th if my next X-ray looks good.
Being that said, I would possibly lose my job if I take off more time within the next year (same job for 22 years). Almost near retirement but still 3 or 4 year away. If I had an office type job I think that I would be able to have a harvest and transplant done without losing too much time away from work. But I work on heavy equipment and there is no light duty or office work. So many things to think about and everyone's situation is a little different.
I also wanted to ask a question about the IgA numbers. i have been looking at my lab results and after my last lab work it shows IgA at 365 and the range is 73 to 347. The other one is the bamma globulin protein spike. this shows a 6.3% compared to 7.6% last month. Are there different tests that your husband is getting? I am not up on all these numbers. My oncologist just let me know that there is another test that I will fall into once my numbers come down some more.
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Castaway - Name: George
- Who do you know with myeloma?: just myself
- When were you/they diagnosed?: 1/24/14
- Age at diagnosis: 62
Re: Why not continue treatment to deepen response?
Hello from sunny (for the next minute or two anyway) Seattle,
An important reason to collect stem cells early (after 4-6 cycles of induction chemotherapy) is that myeloma treatment can limit the stem cell yield. This is especially true for patients on Revlimid, which is well know to negatively affect collection in some patients. Because of this, virtually all transplant centers recommend collection early (4-6 cycles ) rather than later.
In addition, most of the response that will be seen to any given induction treatment regimen (e.g. RVD, CyBorD, Revlimid and dexamethasone, etc) is seen in the first 4-6 cycles, so waiting for a big change in the response to occur after already getting months of treatment is usually not beneficial. It is true that response deepens in some patients as they get more and more therapy, but in general this does not have enough of an impact to delay collection until later.
You certainly could collect the stem cells early (as described) and wait for another few cycles before you decided for/against early transplant though.
An important reason to collect stem cells early (after 4-6 cycles of induction chemotherapy) is that myeloma treatment can limit the stem cell yield. This is especially true for patients on Revlimid, which is well know to negatively affect collection in some patients. Because of this, virtually all transplant centers recommend collection early (4-6 cycles ) rather than later.
In addition, most of the response that will be seen to any given induction treatment regimen (e.g. RVD, CyBorD, Revlimid and dexamethasone, etc) is seen in the first 4-6 cycles, so waiting for a big change in the response to occur after already getting months of treatment is usually not beneficial. It is true that response deepens in some patients as they get more and more therapy, but in general this does not have enough of an impact to delay collection until later.
You certainly could collect the stem cells early (as described) and wait for another few cycles before you decided for/against early transplant though.
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Dr. Edward Libby - Name: Edward Libby, M.D.
Beacon Medical Advisor
Re: Why not continue treatment to deepen response?
Thanks, Dr. Libby, for the response.
I guess the real question is, would they wait at least until 4 or 6 rounds of treatment to see if there is a remission, so that the decision on when to do the transplant itself could wait?
It just seems like, with all the other numbers getting either normal or close to it, it would be worth waiting to see what the 0.8 m-spike does. I don't know the odds of that getting to zero in the next 2 (or 4) cycles -- I suppose it's like everything else -- maybe, maybe not, or it depends. I know they would want to do a harvest relatively early, but since the transplant decision seems to hinge on a remission or not, it would be nice to have the option ...
Castaway,
He gets a bunch of blood tests, but the m-spike number is found on the Serum Protein Electrophoresis (SPEP) test. It seems like a different lab that did the first test called it something other than m-spike. The IgG number (as well as IgA), and the kappa lambda numbers are on a test listed as Immunoglobins. I hope you are able to do what needs to be done and keep your job.
I guess the real question is, would they wait at least until 4 or 6 rounds of treatment to see if there is a remission, so that the decision on when to do the transplant itself could wait?
It just seems like, with all the other numbers getting either normal or close to it, it would be worth waiting to see what the 0.8 m-spike does. I don't know the odds of that getting to zero in the next 2 (or 4) cycles -- I suppose it's like everything else -- maybe, maybe not, or it depends. I know they would want to do a harvest relatively early, but since the transplant decision seems to hinge on a remission or not, it would be nice to have the option ...
Castaway,
He gets a bunch of blood tests, but the m-spike number is found on the Serum Protein Electrophoresis (SPEP) test. It seems like a different lab that did the first test called it something other than m-spike. The IgG number (as well as IgA), and the kappa lambda numbers are on a test listed as Immunoglobins. I hope you are able to do what needs to be done and keep your job.
Re: Why not continue treatment to deepen response?
Good morning !
You certainly can ask your oncologist to wait until your husband has had 4-6 cycles of treatment and postpone the transplant decision until that time. I strongly believe that the patient and their family are integral parts of the health care and decision making team.
Every transplant center has slightly different approaches to the questions you pose. The is no single right answer. Best of luck to you and your husband.
You certainly can ask your oncologist to wait until your husband has had 4-6 cycles of treatment and postpone the transplant decision until that time. I strongly believe that the patient and their family are integral parts of the health care and decision making team.
Every transplant center has slightly different approaches to the questions you pose. The is no single right answer. Best of luck to you and your husband.
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Dr. Edward Libby - Name: Edward Libby, M.D.
Beacon Medical Advisor
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