In this episode of #AskDrDurie, IMF Chairman Dr. Brian Durie discusses treatment options available for those myeloma patients with the t(4;14) abnormality, including IMiDs, next-generation proteasome inhibitors, novel combination therapies, and autologous stem cell transplants.

DR. DURIE: This week’s #AskDrDurie question is from a patient who has the translocation 4;14 abnormality. So this means that when the bone marrow was done, most likely at the time of diagnosis, FISH testing showed a problem with chromosome four and 14, with a switching of these two types of chromosomes. This is a type of abnormality that is called an intermediate risk, so this means that many treatments will work well in this situation, but oftentimes the length of the remission of the response is shorter than average. And so, this particular patient asks, ‘What treatment should I use now? I had a very excellent response with Velcade upfront, but now the myeloma has relapsed, and so what are the additional options and therapy that could be considered?’

The good news in this situation is that there are in fact several options. The first option that had been offered to the patient is a use of an IMiD. First of all, Revlimid or possibly pomalidomide, the most recent IMiD approved by the FDA. Of these two IMiDs, the data would suggest that perhaps pomalidomide is perhaps more effective and could give a better and more sustained benefit.

The next option is to consider another drug like Velcade. Velcade is a proteasome inhibitor, and so we are fortunate enough to have available to us next generation proteasome inhibitor called carfilzomib, commercial name Kyprolis®. And so, this type of drug—a proteasome inhibitor—is likely to be quite active in this setting of the t(4;14) abnormality. And so, this should definitely be strongly considered.

In the relapse setting, many times the relapse can be quite aggressive and these days we often consider not just a single drug but perhaps a combination to achieve a deeper and a more sustained benefit. And so, in this situation, a combination to consider would be carfilzomib combined with pomalidomide and dexamethasone, this three-drug regimen.

A follow up question that the patient had was, ‘Well, what about the role of stem cell transplant?’ This patient had not received a stem cell transplant, and the important thing to remember is that in this setting, a stem cell transplant—an autologous stem cell transplant (ASCT)—can still be beneficial. And so, this would definitely be one of the things that would be on the list of options.

And so, this is a situation where these various pros and cons of various situations need to be discussed carefully with the treating physician. As I said at the beginning, the good news is that there are several options, but these need to be reviewed and considered in terms of the benefit and possible side effects and impact on work and all kinds of issues that could be personally important. And so, discuss with the doctor and come up with what could be one of several options that could work well in this situation.

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