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Jan 22 • 6 tweets • 5 min read
Four facts about MGUS that are under-appreciated or under-recognized.

An educational thread with references!

#mmsm

@rajshekharucms @AaronGoodman33 @HadidiSamer @Eddie_Cliff @RahulBanerjeeMD @HemOncFellows @HiraSMian @nihardesai7
1) The risk of MGUS progressing to MM remains fairly constant over time (i.e does not disappear/decrease after an initial time period).

This is different than smoldering myeloma, where highest risk is in first 2 years.

pubmed.ncbi.nlm.nih.gov/11856795/
2) MGUS defined today after exclusion of lytic lesions by advanced imaging and BM biopsy likely has an even lower risk of progression than cohort described by Kyle et al.

As BM biopsy and advanced imaging weren't done routinely in that cohort- some ppl may have had SMM/MM today!
3) The diagnosis of MGUS is often made when evaluating for conditions for which no firm biological association with MGUS exists, such as osteoporosis or auto-immune diseases, as the iSTOPMM study has shown!

ncbi.nlm.nih.gov/pmc/articles/P…

doi.org/10.1182/blood-…
4) The diagnosis of MGUS can result in considerable psychological distress, at times even approaching the level of distress seen with full blown-myeloma.

Important to consider this, especially when indication for testing is questionable.

ncbi.nlm.nih.gov/pmc/articles/P…

END.
Obviously- not everyone with MGUS needs advanced imaging or bone marrow biopsy- lest this tweet be perceived as such!

This tool from the @iStopMM can help you tell what your percentage chance of finding more than 10% plasma cells are:

istopmm.com/riskmodel/

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More from @ManniMD1

Manni Mohyuddin Profile picture
Jan 24
How much of precision medicine in myeloma is clever marketing, and how much is actual science?

We hear a lot about isatuximab for gain1q and selinexor for del17p!

We unpack all of this in our editorial just published- led by the great hem/onc fellow @OuchveridzeMD

#mmsm

🧵 ImageImageImage
Link to study:
sciencedirect.com/science/articl…

1) We start by describing how myeloma is incredibly heterogenous yet treated in a uniform fashion.

There indeed is ample opportunity to treat myeloma in a personalized fashion based on unique features!
Next, we talk about melflufen.

At a ODAC meeting, the sponsor of melflufen tried to tell us that for elderly patients (who represented a very small subset) of patients on the trial, melflufen was better than pomalidomide.

The FDA brilliant response 👇 Image
Read 12 tweets
Manni Mohyuddin Profile picture
Dec 23, 2022
As 2022 wraps up, it is time for a🧵 that highlights 10 pivotal trials that informed my practice and thinking in 2022. These are articles published in 2022 (although initial results/online pub maybe earlier)- abstracts from meetings covered elsewhere.

Myeloma 2022 Recap 👇
#mmsm
1. DETERMINATION (July 2022, NEJM)

pubmed.ncbi.nlm.nih.gov/35660812/

VRD>Auto>Len vs VRD>Len

Despite low cross-over to transplant in non transplant arm upon progression, (and higher MRD neg and PFS in transplant arm), there was no difference in overall survival at 7 yrs of follow-up.
2. MASTER (Sep 2022 (although appeared online in end December 2021- JCO)

Proof of concept that finite intensive therapy with quad and transplant followed by MRD guided discontinuation is feasible. Responses maintained upon updated follow-up.

pubmed.ncbi.nlm.nih.gov/34898239/
Read 12 tweets
Manni Mohyuddin Profile picture
Nov 24, 2022
An educational 🧵on looking beyond just response rates in a single arm Phase II trial and learning from the story of cilta-cel in CARTIFAN.

This trial has many golden lessons on critical appraisal/global disparity, and this🧵is for trainees/fellows/pharmacists

#mmsm

1/
Link to trial:

ascopubs.org/doi/pdf/10.120…
Cilta-cel is a chimeric antigen receptor cell therapy that is very promising, and targets BCMA on myeloma cells.

We have data from other trials (CARTITUDE-1), that cilta-cel is associated with a very high-response rate in those who are able to receive it.
Read 16 tweets
Manni Mohyuddin Profile picture
Nov 12, 2022
After ending two weeks on the BMT inpatient service, here is a 🧵 on my favorite BMT CTN trials that I teach to every new fellow/PA/NP/pharmacist/trainee on rounds.

I love these trials, and look forward to the ongoing ones!

(CAVEAT-trials simplified for purpose of 🧵)

#bmtsm
BMT CTN 0201

Peripheral blood VS bone marrow source for unrelated donor transplant for blood cancers

Primary Endpoint= 2 year OS was similar

⬆️chronic GVHD with peripheral blood
⬇️ long term QOL with peripheral blood

pubmed.ncbi.nlm.nih.gov/23075175/
BMT CTN 0102

Autotransplant followed by either non myeloablative allo transplant or a tandem auto for myeloma

Primary Endpoint=3 yr PFS, similar between both arms

⭐️Role for allogenic transplant limited- role of tandem limited now too (see next tweet)

pubmed.ncbi.nlm.nih.gov/21962393/
Read 7 tweets
Manni Mohyuddin Profile picture
Nov 9, 2022
I am excited to be on the @ASH_hematology News Daily editorial board, and will be covering/attending the meeting this year.

In this 🧵, I will highlight the top 10 myeloma abstracts that most influence my thought and practice from the #ASH22 meeting!

#mmsm
1. I will stop using restrictive neutropenic diets for patients who are undergoing transplant

as shown in this non-inferiority randomized trial. Patients are already going through a lot, lets not make it tougher for them by imposing dietary restrictions.

ash.confex.com/ash/2022/webpr…
2. I will have lower threshold for getting rid of dexamethasone early when I treat newly diagnosed myeloma in transplant ineligible patients

as shown in this trial of frail pts of dara/len compared to len/dex. No⬇️efficacy, but I want to see QOL data.

ash.confex.com/ash/2022/webpr…
Read 12 tweets
Manni Mohyuddin Profile picture
Aug 11, 2022
Just out in European Journal of Hematology, an in-depth patient level review of 456 deceased patients with myeloma, highlighting low palliative care involvement and⬆️transfusion usage, pain/anxiety, and hospitalizations at end of life.

#mmsm

A brief🧵

bit.ly/3pdhwD0
Can't give enough credit to Geoff McInturf, Kimberly Younger, @Aspenbaby and Charles Walde- all med students/residents at @KUcancercenter for diligently combing through hundreds of patient charts for this.

@KUcancercenter @KUIMchiefs
This project is close to their hearts, especially as some members of this team have seen close relatives endure blood cancers. To be able to mentor them and guide them through a project they found so much meaning in was so special! Thank you again.
Read 13 tweets

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