[Thalidomide as a new treatment option in patients with multiple myeloma]

Thalidomide as a new treatment option in patients with multiple myeloma. HISTORYAND ADMISSION FINDINGS: In a 56 year old woman the diagnosis of multiple myeloma of subtype IgG kappa led to the performance of an autologous stem cell transplantation. After initial partial remission the disease became refractory to standard chemotherapy requiring repeated plasmaphereses due to hyperproteinemia. INVESTIGATIONS: Before application of thalidomide the patient had a serum protein of 12 g/dl and a paraprotein of 4.4 g/dl. Bone marrow histology revealed a 40 % infiltration of the marrow by differentiated plasma cells. On neurologic examination a slightly diminished nerve conduction speed of the right median nerve due to carpal tunnel syndrome was diagnosed. TREATMENT AND COURSE: Treatment with thalidomide in a dosage of 400 mg p. o. was initiated and led to a partial remission with a > 50 % reduction of the paraprotein within four weeks. Due to a neuropathy (WHO grade 1) a dose reduction to 200 mg per day was performed after seven weeks of treatment. 48 weeks after initiation of treatment the patient remains in a stable partial remission with a paraprotein of 1.4 g/dl. After 20 weeks of treatment 5 % of the bone marrow remained infiltrated by monoclonal plasma cells. CONCLUSION: Monotherapy with thalidomide led to a stable partial remission in a patient with refractory multiple myeloma. In vitro thalidomide is a potent inhibitor of angiogenesis. Besides, a reduction of TNFalpha as well as an inhibition of cytokines have been described. The exact mechanism of the drug in multiple myeloma remains elusive. However several phase II trials have demonstrated a beneficial effect in relapsed or refractory disease. The optimal dosage and timing have to be studied in further trials.