Multiple myeloma: modern treatment and the place of transplant

Multiple myeloma is a cancer of plasma cells, the bone marrow cells that normally make antibodies. A single abnormal clone expands and produces large amounts of one antibody fragment, the M-protein, which can be measured in blood and urine.

The disease shows itself through its effects. Doctors summarise them as CRAB: high calcium, kidney damage, anemia and bone lesions.

Diagnosis and Staging

Blood and urine tests measure the M-protein and free light chains, a bone marrow biopsy shows the proportion of plasma cells and their genetic changes, and low-dose whole-body CT, PET-CT or MRI looks for bone lesions.

Not every patient with an M-protein needs treatment. Precursor states such as MGUS and smouldering myeloma are followed, and treatment starts when there are signs of active disease or a high risk of progression.

Treatment Combinations

First-line treatment usually combines three or four drugs: a proteasome inhibitor such as bortezomib, an immunomodulatory drug, a steroid, and increasingly an anti-CD38 antibody. These combinations produce deep responses in most patients.

Kidney involvement is common in myeloma and needs prompt treatment. Dr. Uzay's early published work examined bortezomib in patients with renal impairment — one of the reasons it became a cornerstone for this group.

Autologous Transplant

For fit patients, induction treatment is followed by collection of the patient's own stem cells and high-dose melphalan with an autologous transplant. It deepens the response and lengthens remission, and it is followed by maintenance treatment.

When the disease returns, newer options — further antibody combinations, bispecific antibodies and CAR-T cell therapy — mean that relapse is managed rather than accepted.