What are the recommended screening tests for disease progression in patients with multiple myeloma?

Recommended Screening Tests for Multiple Myeloma Disease Progression

Regular laboratory monitoring every 3-6 months is the cornerstone of screening for disease progression in multiple myeloma patients, including complete blood count, serum chemistry, quantitative immunoglobulins, serum protein electrophoresis with immunofixation, and serum free light chain assay. 1, 2

Laboratory Monitoring (Every 3-6 Months)

• Complete blood count (CBC) to monitor for anemia, leukopenia, and thrombocytopenia 1
• Serum chemistry including creatinine, albumin, calcium, LDH, and β2-microglobulin 1, 2
• Serum quantitative immunoglobulins to track disease burden 1
• Serum protein electrophoresis (SPEP) and serum immunofixation electrophoresis (SIFE) to detect and quantify monoclonal proteins 1, 3
• Serum free light chain (FLC) assay with kappa/lambda ratio 1, 3
• 24-hour urine collection for protein electrophoresis and immunofixation (random samples are insufficient) 3, 2

Imaging Studies

• Annual skeletal 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
  • Assessment of bone lesions 1, 2
  • Detection of extramedullary disease 1, 2

Bone Marrow Assessment

• Bone marrow aspirate and biopsy should be performed:
  • When disease progression is suspected 1
  • To establish complete response 2
  • When hyposecretory myeloma progression is suspected 2

Follow-Up Frequency Based on Disease Status

• For active myeloma in remission:
  • Laboratory tests every 3-6 months 1, 2
  • Imaging studies annually or as clinically indicated 1, 2
• For progressive or relapsed disease:
  • More frequent monitoring (every 4 weeks initially) 1, 2
  • Comprehensive reassessment including bone marrow examination, cytogenetic or FISH analyses, and imaging studies 1, 2

Special Circumstances Requiring Additional Testing

• Lumbar puncture (cell counts, chemistry, cytology, immunophenotyping) when leptomeningeal involvement is suspected 3
• MRI for evaluation of cord compression or painful areas of the skeleton 3
• CT, MRI, or PET/CT for suspected extramedullary plasmacytomas 3
• Evaluation for AL amyloidosis when clinically indicated 3
• Bleeding time, APTT, PT when bleeding disorders are suspected 3
• Cryoglobulins, Coombs test for suspected cold autoantibody 3
• Serological tests for hepatitis C virus in type II cryoglobulinemia 3
• IgM anti-myelin-associated glycoprotein activity for peripheral neuropathy 3
• Serum viscosity and fundoscopy for symptoms of hyperviscosity 3

Common Pitfalls in Multiple Myeloma Monitoring

• Failure to obtain 24-hour urine collections (random samples are insufficient) 1, 2
• 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, 2
• Using the same monitoring method throughout follow-up instead of adapting to disease characteristics 2
• Relying solely on funduscopic examination rather than laboratory testing for hyperviscosity 3

Cytogenetic Testing for Disease Progression

• FISH analysis should be performed on purified tumor cells or with simultaneous staining of cytoplasmic immunoglobulins (cIg-FISH) 3
• Standard metaphase cytogenetics provides prognostic information by separating hyperdiploid from nonhyperdiploid patients 3
• FISH should include probes for chromosome 17p13, t(4;14), and t(14;16) 3, 2