You Make the Call
TRAINING and EDUCATION
Each month in “ You Make the Call ,” we ’ ll pick a challenging clinical question submitted through the Consult-a-Colleague program and post the expert ’ s response . But , what would YOU do ? We ’ ll also pose a submitted question and ask you to send your responses . See how your answer matches up to the expert ’ s in the next print issue .
This month , Sagar Lonial , MD , addresses a question about duration of maintenance therapy in a patient diagnosed with multiple myeloma .
Clinical Dilemma :
I have a young patient who was diagnosed with IgG lambda multiple myeloma in 1997 . He was induced with vincristine , doxorubicin , and dexamethasone ( VAD ) followed by an autologous transplant in 1998 . He relapsed six years later . At this point ( in 2004 ) he was started on thalidomide and dexamethasone and intermittently switched to thalidomide alone . In 2013 , he was switched to lenalidomide ; he has been on 10 mg a day . His labs show no monoclonal protein . All of his other parameters suggest that he is in complete remission . How long should he continue taking lenalidomide ? If we decide to discontinue , what will guide us in decision making ?
Experts Make the Call
Sagar Lonial , MD Chair and Professor Department of Hematology and Medical Oncology Chief Medical Officer Winship Cancer Institute Emory University School of Medicine
All of the trials that give lenalidomide in the relapse setting continue until disease progression or there are signs of adverse events . If lenalidomide is well tolerated , I would continue as long as the two criteria above are met , that is , the patient tolerates treatment well and does not have signs of progression . If the patient is still on dexamethasone , I would definitely stop that , but continue the lenalidomide for as long as possible . While there are early signs that the use of minimal residual disease ( MRD ) testing with either next-generation sequencing or flow cytometry may be able to identify patients who are MRD-negative , there are no trials that incorporate these tests to decide when or if to stop treatment . Thus , current standard of care is to continue until progression .
DISCLAIMER : ASH does not recommend or endorse any specific tests , physicians , products , procedures , or opinions , and disclaims any representation , warranty , or guaranty as to the same . Reliance on any information provided in this article is solely at your own risk .
Consult a Colleague Through ASH
Consult a Colleague is a service for ASH members that helps facilitate the exchange of information between hematologists and their peers . ASH members can seek consultation on clinical cases from qualified experts in 11 categories :
• Anemias
• Hematopoietic cell transplantation
• Hemoglobinopathies
• Hemostasis / thrombosis
• Lymphomas
• Lymphoproliferative disorders
• Leukemias
• Multiple myeloma & Waldenström macroglobulinemia
• Myeloproliferative Disorders
• Myelodysplastic Syndromes
• Thrombocytopenias
Assigned volunteers (“ colleagues ”) will respond to inquiries within two business days ( either by email or phone ).
Have a puzzling clinical dilemma ? Submit a question , and read more about Consult-a-Colleague volunteers at hematology . org / Clinicians / Consult . aspx or scan the QR code .
* If you have a request related to a hematologic disorder not listed here , please email your recommendation to ashconsult @ hematology . org so it can be considered for addition in the future .
Next Month ’ s Clinical Dilemma :
I have a 6-year-old , Indian male patient with normal hemoglobin ( Hb ) and reticulocyte count but microcytosis ( 64 ). Results of Hb electrophoresis are as follows : Hb A 92.2 % ( low ), Hb A2 4.6 % ( high ), Hb F 3.2 % ( high ). Alpha thalassemia gene testing shows one alpha gene deletion . Does this child have both beta and alpha thalassemia trait ? How can I tell ?
How would you respond ? Email us at ashclinicalnews @ hematology . org .
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