OpenOnco Handbook

Multiple myeloma: first-line risk and fitness reasoning

draft hcp_learner en

Deterministic learning chapter over OpenOnco KB entities, synthetic cases, and source records.

Learning objectives

  1. Use cytogenetic risk, ISS/R-ISS features, renal function, frailty, and transplant eligibility as separate first-line MM reasoning axes.
  2. Explain why VRd and D-VRd appear as standard and alternative first-line tracks in the OpenOnco model.
  3. Recognize myeloma emergencies and supportive-care obligations that run beside induction selection.

At a glance

  • First-line MM reasoning is risk-stratified rather than purely stage-driven.
  • High-risk cytogenetics and aggressive biology route toward D-VRd in the OpenOnco model.
  • Frailty and renal dysfunction often affect dosing and safety planning rather than simply changing the disease indication.
  • Bone disease, hypercalcemia, renal impairment, infection risk, and cord compression are core safety checks.
  • The chapter is OpenOnco-authored educational content, not official ESMO or CME material.

Risk-stratified induction

The MM first-line chapter separates induction choice from downstream transplant and maintenance decisions. High-risk cytogenetics and aggressive biology move the learner toward the D-VRd track in the OpenOnco model.

Linked entities

ALGO-MM-1LALGO-MM-1LalgorithmsRF-MM-HIGH-RISK-CYTOGENETICSMultiple myeloma high-risk cytogenetics: any of t(4;14), t(14;16), t(14;20), del(17p)/TP53 loss, gain or amplification of 1q21 by interphase FISH on CD138-enriched plasma cellsredflagsIND-MM-1L-DVRDIND-MM-1L-DVRDindications

Section sources

  • SRC-NCCN-MM-2025 NCCN Clinical Practice Guidelines in Oncology: Multiple Myeloma
  • SRC-ESMO-MM-2023 ESMO Clinical Practice Guideline on Multiple Myeloma
  • SRC-PERSEUS-SONNEVELD-2024 Daratumumab, Bortezomib, Lenalidomide, and Dexamethasone for Multiple Myeloma

Standard-risk and access-aware reasoning

VRd remains the standard track in OpenOnco when high-risk triggers are absent or when quadruplet access is not feasible. The handbook frames this as educational reasoning, not a patient-specific prescription.

Linked entities

IND-MM-1L-VRDIND-MM-1L-VRDindicationsREG-VRDBortezomib + Lenalidomide + Dexamethasone (VRd), 4-6 induction cyclesregimens

Section sources

  • SRC-NCCN-MM-2025 NCCN Clinical Practice Guidelines in Oncology: Multiple Myeloma
  • SRC-ESMO-MM-2023 ESMO Clinical Practice Guideline on Multiple Myeloma

Common traps

Renal dysfunction, hypercalcemia, cord compression, infection screening, pregnancy prevention for lenalidomide, and severe neuropathy risk are parallel obligations. They may change dosing, sequencing, urgency, or supportive care.

Linked entities

RF-MM-RENAL-DYSFUNCTIONMultiple myeloma with significant renal dysfunction: CrCl <60 mL/min or serum creatinine >177 µmol/L (>2 mg/dL) attributable to myeloma kidneyredflagsRF-MM-HYPERCALCEMIAMultiple myeloma with hypercalcemia (corrected serum calcium ≥11 mg/dL or symptomatic): part of CRAB criteria; emergency when ≥14 mg/dL or symptomatic (altered mentation, AKI, arrhythmia)redflagsRF-MM-CORD-COMPRESSIONMultiple myeloma with malignant epidural spinal cord compression: new motor deficit, sensory level, severe back pain with vertebral plasmacytoma / lytic lesion + canal invasion — MM is a leading hematologic cause of MESCCredflagsRF-MM-INFECTION-SCREENINGActive or latent infection requiring resolution / prophylaxis before initiating MM induction (VRd, D-VRd): HBsAg+ or anti-HBc+ (HBV reactivation risk on dexamethasone + anti-CD38 in D-VRd; reactivation rate ≈8-15% on daratumumab without prophylaxis), HIV+, or active TB. redflags

Section sources

  • SRC-NCCN-MM-2025 NCCN Clinical Practice Guidelines in Oncology: Multiple Myeloma
  • SRC-ESMO-MM-2023 ESMO Clinical Practice Guideline on Multiple Myeloma

Worked synthetic cases

  • patient_mm_standard_risk Standard-risk newly diagnosed myeloma - VRd standard track, risk stratification examples/patient_mm_standard_risk.json
  • patient_mm_high_risk High-risk newly diagnosed myeloma - D-VRd alternative track, high-risk cytogenetics examples/patient_mm_high_risk.json

Practice questions

0 of 3 answered · 0 correct

Answers, score, and reasoning tags are kept in your browser session only and clear when you close this tab. Multi-select questions require every correct option (and no extras) for a credit.

Question 1 type_a intro HQ-MM-1L-001

In the OpenOnco first-line myeloma learning model, which factor most directly pushes toward D-VRd reasoning?

Question 2 type_a intermediate HQ-MM-1L-002

Which issue is a parallel urgent/safety problem in newly diagnosed myeloma rather than just a routine induction-regimen preference?

Question 3 type_k intermediate HQ-MM-1L-003

Which statements are true for the OpenOnco first-line MM chapter?