What are the recommended monitoring exams and treatment options for patients with multiple myeloma?

Recommended Monitoring Exams and Treatment Options for Multiple Myeloma

For patients with multiple myeloma, regular monitoring should include blood tests every 3-6 months (CBC, serum chemistry, quantitative immunoglobulins, SPEP/SIFE, and serum free light chain assay), annual bone imaging, and bone marrow assessment as clinically indicated. 1

Laboratory Monitoring

Blood Tests (Every 3-6 Months)

• Complete blood count (CBC) to monitor for anemia, leukopenia, and thrombocytopenia 1, 2
• Serum chemistry including creatinine, albumin, calcium, LDH, and β2-microglobulin 1, 2
• Serum quantitative immunoglobulins to track disease burden 1, 2
• Serum protein electrophoresis (SPEP) and serum immunofixation electrophoresis (SIFE) to detect and quantify monoclonal proteins 1, 2
• Serum free light chain (FLC) assay with kappa/lambda ratio 1, 2

Urine Tests (Every 3-6 Months)

• 24-hour urine collection for total protein 2, 3
• Urine protein electrophoresis (UPEP) and urine immunofixation electrophoresis (UIFE) 2, 3

Imaging Studies

• Annual bone survey or as clinically indicated 1, 2
• Whole-body low-dose CT scan is preferred over traditional skeletal survey for bone surveillance 2
• MRI and/or CT and/or PET/CT as clinically indicated, particularly for:
  • Evaluation of suspected disease progression 1, 2
  • Assessment of bone lesions 2
  • Detection of extramedullary disease 1, 2

Bone Marrow Assessment

• Bone marrow aspirate and biopsy should be performed:
  • When clinically indicated (e.g., suspicion of disease progression) 2
  • To establish complete response 2
  • When hyposecretory myeloma progression is suspected 2

Follow-Up Frequency Based on Disease Status

Smoldering (Asymptomatic) Myeloma

• Initial observation at 3-6 month intervals 2
• Laboratory tests every 3-6 months 1, 2
• Annual bone survey or as clinically indicated 1, 2
• MRI should be considered as it can detect occult lesions and predict progression to symptomatic myeloma 2

Active Myeloma in Remission

• Follow-up every 3-6 months with laboratory tests 1, 2
• Imaging studies annually or as clinically indicated 1
• No need to repeat bone marrow examination to assess response if the myeloma can be monitored with serum and urine studies 2
• No need to repeat skeletal survey in patients responding to treatment unless new bone symptoms develop 2

Progressive or Relapsed Disease

• More frequent monitoring (every 4 weeks initially) 1, 2
• Comprehensive reassessment including:
  • Bone marrow examination 2
  • Cytogenetic or FISH analyses (if not performed at baseline) 2
  • Imaging studies with MRI and/or CT and/or PET/CT 2, 1
  • Serum LDH (predictive of poor prognosis at relapse) 2

Treatment Options

Newly Diagnosed Multiple Myeloma

Transplant-Eligible Patients

• Induction therapy with a combination of:
  • Proteasome inhibitor (e.g., bortezomib) 4, 5
  • Immunomodulatory agent (e.g., lenalidomide) 5
  • Dexamethasone 5
• Followed by autologous stem cell transplantation 5
• Maintenance therapy with lenalidomide 2, 5

Transplant-Ineligible Patients

• Triplet therapies including:
  • Bortezomib, lenalidomide, and dexamethasone 2
  • Daratumumab plus bortezomib plus melphalan plus prednisone 2, 6
• Continuous therapy is preferred over fixed-duration therapy 2

Relapsed/Refractory Multiple Myeloma

• Options include:
  • Daratumumab-based regimens 6
  • Bortezomib-based combinations 4
  • Carfilzomib and dexamethasone 6
  • Pomalidomide and dexamethasone 6

Common Pitfalls in Multiple Myeloma Monitoring

• Failure to obtain 24-hour urine collections (random samples are insufficient) 1, 3
• Missing extramedullary disease progression by not utilizing appropriate imaging 1, 2
• Overlooking early signs of disease progression such as rising free light chain levels 1
• Using the same monitoring method throughout follow-up is important for consistency 2
• For IgA or IgD myeloma, nephelometric quantitation of serum immunoglobulin is necessary 2
• For nonsecretory or oligosecretory myeloma, free light chains should be serially assessed 2

Special Considerations

• Multiparameter flow cytometry may help individualize follow-up strategy for smoldering myeloma patients, but should only be performed in laboratories with experience 1, 2
• MRI of spine and pelvis is mandatory for patients with presumed solitary plasmacytoma 2
• PET imaging can reliably predict active myeloma through FDG uptake; smoldering myeloma is typically negative on PET scan 2
• Mass spectrometry is emerging as a more sensitive method than immunofixation for monitoring treatment response 7