Book Review

Myeloma

N Engl J Med 2002; 347:1986-1987December 12, 2002

Article

Myeloma
Edited by Jayesh Mehta and Seema Singhal. 539 pp., illustrated. London, Martin Dunitz, 2002. $150. ISBN: 1-901865-50-9

Myeloma is a comprehensive overview of multiple myeloma and related plasma-cell disorders. Almost all the international experts in the field have contributed to this book. The numerous remarkable figures, schematic diagrams, photographs, and tables make the book a pleasure to read. The book is well organized, and each chapter contains a large and well-selected reference list.

Part 1 (chapters 1 through 8), which is devoted to the biology of monoclonal gammopathies, is exciting. The differentiation of B cells into plasma cells and the morphologic and immunophenotypic features of plasma cells are clearly presented. The immunophenotypic distinction between normal and malignant plasma cells is emphasized. The influence of cytokines on the development of plasma-cell dyscrasias, with emphasis on the pivotal role of interleukin-6, is nicely presented. The possible involvement of Kaposi's sarcoma herpesvirus (herpesvirus 8) in the pathogenesis of plasma-cell disorders is critically reviewed.

The presentation of the molecular biology of plasma-cell disorders is concise. It focuses on the multistep mechanisms by which dysregulated oncogenes contribute to the pathogenesis and progression of monoclonal gammopathies. The limitations of conventional cytogenetics are recognized, but the potential of fluorescence in situ hybridization, multicolor fluorescence in situ hybridization, multicolor spectral karyotyping, and comparative genomic hybridization is highlighted. The summary of practical applications of cytogenetic studies in plasma-cell dyscrasias is most helpful.

The pathophysiology of myeloma bone disease, the current ways of assessing skeletal involvement (namely, imaging techniques and assessment of bone-resorption markers), and the use of new bisphosphonates are extensively covered. The chapter on angiogenesis and antiangiogenic therapies is very good. The current and future roles of thalidomide in the treatment of myeloma are very well summarized. Apart from its activity in myeloma, thalidomide opens the door to innovative therapies targeting not only the plasma cell but also the microenvironment.

The clinical features of myeloma are well described. The fact that three different diagnostic criteria are discussed indicates that the current criteria are not entirely satisfactory. The prognostic relevance of serum levels of beta2-microglobulin and of cytogenetics is highlighted. The clinical picture and treatment of neuropathies associated with different plasma-cell disorders are nicely reviewed. The importance of treatment with chemotherapy, plasma exchange, and dialysis for patients with severe renal failure is emphasized. Perhaps the fact that the efficacy of plasma exchange is questionable in patients with renal failure severe enough to require dialysis (i.e., advanced myeloma kidney) should have been stressed. Part 3 of the book consists of three chapters in which the value of different laboratory tests is critically assessed. The chapter on imaging studies is well done, but new imaging techniques — particularly magnetic resonance imaging and positron-emission tomography — may be extremely useful in some instances. I believe that they cannot be routinely recommended in patients with monoclonal gammopathies.

Part 6 of the book covers treatment. The fact that combination chemotherapy is not superior to melphalan and prednisone in terms of survival is emphasized. The authors also make clear the importance of avoiding excessive use of melphalan in order not to preclude hematopoietic-cell harvest in patients in whom autologous transplantation is planned. Although autologous transplantation is safe and may be the best treatment for young patients, disease recurrence is the rule; approaches aimed at improving the complete remission rate and eliminating minimal residual disease after transplantation are highlighted. Tandem transplantation is not recommended in routine practice. In older patients and those with renal failure, autologous transplantation can be recommended only in selected cases, since the mortality and particularly the morbidity are higher. Although a fraction of patients with myeloma can be cured with allogeneic transplantation, the authors recognize the high transplantation-related mortality rate as a major obstacle. Interferon appears to be beneficial, particularly as maintenance therapy. However, its use is still controversial. Six chapters deal with plasma-cell disorders other than myeloma. The chapter on monoclonal gammopathies of undetermined significance, written by the physician who coined the term a quarter of a century ago and who is still personally following patients from his original series, first reported in 1978, is excellent. The importance of ruling out an early myeloma in solitary plasmacytoma is highlighted. The discussions of amyloidosis and Waldenström's macroglobulinemia are excellent, and the chapter on multicentric Castleman's disease is superb.

The fascinating field of monoclonal gammopathies is a challenge to clinicians and scientists. Myeloma offers solid, comprehensive coverage of these disorders by international experts. The book is very well written and the presentation is engaging. I am certain that it will be of interest to hematologists, oncologists, internists, and even generalists and that it will ultimately result in improved care for patients with multiple myeloma and related disorders.

Joan Bladé, M.D.
Hospital Clínic, 08036 Barcelona, Spain
jblade@clinic.ub.es