A 68-year-old man with multiple myeloma has received lenalidomide + bortezomib + dexamethasone (RVD) induction with excellent response. He is ineligible for autologous stem cell transplantation (ASCT) due to age and comorbidities. Which maintenance strategy has been shown to prolong progression-free survival in transplant-ineligible myeloma?
- A Thalidomide maintenance 200 mg/day indefinitely
- B Bortezomib monthly maintenance for 2 years
- C Lenalidomide continuous maintenance therapy ✓
- D No maintenance; observe until relapse
Explanation
Multiple large phase III trials (FIRST/MM-020, MYELOMA XI, IFM 2009 in transplant-ineligible patients) have demonstrated that continuous lenalidomide maintenance significantly prolongs progression-free and overall survival in newly diagnosed multiple myeloma, including in transplant-ineligible patients. Lenalidomide is given until disease progression or intolerance. Thalidomide maintenance is now largely abandoned due to excess peripheral neuropathy and thrombosis. Bortezomib subcutaneous maintenance for 2 years also showed benefit but lenalidomide is preferred. Observation without maintenance is associated with significantly shorter PFS.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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