Here’s how readers responded to a You Make the Call question about whether a mostly asymptomatic patient with amyloidosis should receive systemic therapy.
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I would treat the patient with daratumumab, bortezomib, cyclophosphamide, and dexamethasone induction for a period of time (as light chain ratio is greater than 100 mg/L, satisfying criteria for myeloma as well). I would also strongly consider consolidation with high dose melphalan and autologous hematopoietic cell transplantation (AHCT). I don’t feel that maintenance therapy is essential in this setting, but it would not be wrong to do.
Jason Valent, MD
The fact that the kappa/lambda ratio is more than 100 with plasma cell comprising more than 10% of the marrow, fits the definition of myeloma according to the new SLiM CRAB criteria and warrants treatment for myeloma. Kidney disease shouldn’t cause elevation of kappa/lambda ratio of more than 3. In the absence of other organ involvement by amyloidosis, a daratumumab-based regimen is not needed, but one could consider DVRd (daratumumab, bortezomib, lenalidomide, and dexamethasone) based on data from the GRIFFIN trial.
Yazhini Vallatharasu, MD
I would definitely treat this patient.
Laurie Adkins, BSc
North Chesterfield, VA
Yes, I would definitely treat this patient because free kappa light chain is high enough and it is a matter of time before more organs are involved.
Mixalis Mixail, MD
I would recommend erring on the side of treatment, as myeloma has given her a kappa-to-lambda ratio >100. Any degree of light chain dimerization does not change the fact that she has a very active ‘factory’ of amyloidogenic kappa proteins and a clear source within her marrow. Waiting until she develops proteinuria or true clinical sequelae of multiple myeloma would not be appropriate, given her young age and ostensible eligibility for AHCT.
Rahul Banerjee, MD
San Francisco, CA
What did the bone marrow biopsy show? And the bone imaging? The light chain ratio justifies treatment for myeloma if she meets marrow criteria.
Mark Hoffman, MD
Glen Falls, NY