Progress in the Front-line Treatment of Multiple Myeloma

Abstract

Multiple myeloma (MM) is a clonal plasma cell tumour that requires systemic treatment once disease-related symptoms arise. Symptomatic MM is defined by at least one of the following: hypercalcaemia, renal failure, anaemia and/or bone lesions. Several therapeutic milestones have been achieved during the last few decades, resulting in improved prognosis for affected subjects. The alkylator melphalan has been a backbone of MM treatment since its introduction in the 1960s. The compound is currently used at high doses followed by autologous stem cell transplantation (ASCT) in patients ≤65–70 years of age in conventional doses in conjunction with prednisone and either thalidomide (MPT) or the proteasome inhibitor bortezomib (VMP). Both regimens have proved superior to MP alone in randomised clinical trials. In patients eligible for ASCT, initial cytoreduction should be performed using one of the ‘novel’ compounds (thalidomide, bortezomib, lenalidomide) in combination with dexamethasone because of enhanced response both before and after ASCT compared with standard anthracycline/dexamethasone. However, it has not yet been determined which combination should best be used in a given patient. Whether up-front allogeneic transplantation may contribute to improved outcomes in younger patients depends on results from clinical trials that have been fully recruited, but longer follow-up is awaited in the near future.