Case Study 4 - Question 2 | FocusOn Oncology

Question 2

Patient history: Luis, an 81-year-old man, returns for a consultation 16 months after receiving a diagnosis of multiple myeloma, with a 17p gene deletion.

Treatment regimen and response: Luis achieved VGPR after 6 cycles of DRd. Dexamethasone was discontinued after 9 months to reduce the risk of neuropsychiatric toxicity. He continued daratumumab, with adjustment of the lenalidomide dose (5 mg/day). Zoledronic acid was discontinued 12 months after diagnosis, because the patient maintained VGPR and did not develop new osteolytic lesions.
Current presentation: Luis presents with worsening symptoms, including fatigue, weakness, back pain, and body aches. His family reports that Luis has limited mobility and requires assistance with basic daily activities. The initial ECOG performance status score of 2 remains unchanged.
Current laboratory results are suggestive of disease progression: IgG M-protein levels (4.0 g/dL); free light chain (FLC) levels and ratio: Kappa FLC: 600 mg/L, Lambda FLC: 20 mg/L, Kappa/Lambda FLCr: 30.0. The creatinine clearance rate has not decreased significantly since the last evaluation (80 mL/min). Serum creatinine and calcium levels are within the normal ranges. Hematology tests indicate anemia (Hb: 9.0 g/dL) and moderate thrombocytopenia (75,000/mcL). A repeat bone marrow biopsy shows 65% plasma cells. Positron emission tomography detects new osteolytic lesions.
Challenge: Luis has experienced relapse despite adequate adherence and good initial response to the treatment regimen. His symptom burden has increased, resulting in limited mobility and functional impairment.

Choose your next step:

a. Switch to pomalidomide (4 mg/day) plus dexamethasone (40 mg/week)

b. Increase lenalidomide dose to 15 mg daily, add dexamethasone (20 mg/week)

c. Add bortezomib and dexamethasone (40 mg/week)

d. Switch to pomalidomide plus bortezomib and low-dose dexamethasone (20 mg/week)

e. Recommend T-cell therapy (Ciltacabtagene autoleucel)

Question 2

Question 2

Choose your next step:

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