Page 165 - Hospital Authority Convention 2018

Masterclasses

M11.1 Advances in Medicine 10:45 Convention Hall C

Update on Management of Idiopathic Thrombocytopenic Purpura
Wong RSM
Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong
Immune thrombocytopenia (ITP) is an immune-mediated acquired disease of adults and children characterised by a low HOSPITAL AUTHORITY CONVENTION 2018
platelet count (<100 x 109/L, transient or persistent) and an increased risk of bleeding. In the last decade, changes in our
understanding of pathophysiology of the disorder have led to the publication of new guidelines for diagnosis and management
of ITP and standards for terminology. Majority of patients may have the diagnosis of ITP established with a careful history and
physical examination as well as review of the peripheral blood smear and minimal further testing. Corticosteroids, intravenous
immunoglobulin and anti-D immunoglobulin have been the standard first-line treatment for many years and remain the
recommended initial treatment for ITP in current practice guidelines but only a few patients have sustained response after
cessation of treatment.

Splenectomy, other immunosuppressive agents (e.g. azathioprine, cyclosporin A, mycophenolate mofetil, rituximab) as well
as thrombopoietin-receptor agonists (TPO-RAs) have been recommended for second-line treatment of patients with ITP.
Splenectomy was the treatment of choice for decades, but the risk of infection and other post-operative complications should
not be neglected. Rituximab has been used as an alternative to splenectomy but despite an initial response rates of about
40-60%, the long-term response rates have been limited. Long-term follow-up data on TPO-RAs have demonstrated good
efficacy and safety in both adults and children.

M11.2 Advances in Medicine 10:45 Convention Hall C

Multiple Myeloma: The Past, the Present and the Future
Chim CS
Department of Medicine, The University of Hong Kong, Hong Kong

Multiple myeloma (MM) arises from neoplastic proliferation of plasma cells, and presents with hypercalcemia (C), renal failure
(R), anaemia (A) and bone pain (B) or fractures (CRAB), hence a miserable disease. MM may be preceded by an asymptomatic
stage, monoclonal gammopathy of unknown origin (MGUS). However, apart from MM, differential diagnoses of MGUS include
solitary plasmacytoma, chronic lymphocytic leukaemia, lymphoproliferative disease and light chain amyloidosis, all of which
carries different prognosis and requires different treatments.
The incidence of MM in Hong Kong is rising with >300 new cases/100,000/year. Transplant-eligible myeloma patients will Tuesday, 8 May 2018
receive induction, followed by autologous stem cell transplantation (ASCT), and then maintenance therapy. A decade ago,
MM patients received induction with conventional chemotherapy, followed by ASCT with complete remission (CR) rate of 5%
after chemotherapy induction, and 20% after ASCT. In the recent decade, major advances emerged with the advent of novel
agents including proteasome inhibitor (PI) and immunomodulatory agent (IMiD). Induction with novel agent-based regimen
generally comprises a triplet with a proteasome inhibitor (PI), an immunomodulatory agent (IMiD), and dexamethasone
that results in a much higher CR rate of about 25% after induction, and up to 60-70% after ASCT. Moreover, the increase
in CR rates translates into improvement of survival with median survival of about 10 years, compared with two to three
years using conventional chemotherapy. However, despite a high CR rate, most patients eventually relapse. Active salvage
therapy includes triplets composed of next generation PIs (carfilzomib or ixazomib), IMiD (lenalidomide or pomalidomide)
and dexamethasone. On the other hand, monoclonal antibodies including daratumumab and elotuzumab are important
breakthroughs in the treatment of relapsed MM. Besides, BCL2 inhibitors and exportin-1 inhibitor are promising new drugs.
Furthermore, antibody conjugate (ADC) and bispecific antigen engager (BiTE) are also undergoing clinical trials. In addition,
CAR-T cell has also been shown effective in advanced, refractory MM. Finally, minimal residual disease (MRD), a low level
of cancer cells that escapes detection by conventional serological techniques, is being extensively studied for informing
treatment strategies, or as a prognostic factor for survival. Therefore, with the advent of novel agents, antibodies, and cell
therapy, MM is making great strides and the future is promising.

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