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Therapeutic Strategies in Myeloma

CE / CME

Therapeutic Strategies in Multiple Myeloma: Overview of Current and Emerging Treatment Options

Pharmacists: 1.00 contact hour (0.1 CEUs)

Physicians: Maximum of 1.00 AMA PRA Category 1 Credit™

Nurses: 1.00 Nursing contact hour

Released: April 26, 2023

Expiration: April 25, 2024

Shaji K. Kumar
Shaji K. Kumar, MD
CME/CE Information

Activity

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IMWG Criteria for Diagnosis of MM

When discussing the treatment of active MM, it is important to distinguish between the precursor conditions. This includes MGUS as well as within SMM—standard-risk or low-risk SMM—who do not need an intervention outside of clinical trials vs those with active disease.

The definition of active or symptomatic MM has undergone transition over the past few years. The new definition incorporates the SLiM criteria, which is the clonal bone marrow plasma cell percentage, the serum FLC ratio, and presence of abnormalities on MRI, in addition to the traditional CRAB criteria. Once patients meet these criteria, therapy for newly diagnosed MM should be initiated.7

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Current Role for Imaging in MM

One of the key components of the revised diagnostic criteria is the more uniform utilization of sensitive imaging studies, particularly the use of whole body, low dose CT scan. This can detect lytic lesions in almost a quarter more patients than a traditional skeletal survey. Ongoing studies are looking at whole body MRI as well as FDG PET to determine the benefit of these imaging modalities over a whole-body, low-dose CT scan (NCT05381077, NCT03891914).25,26

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Defining High Risk

Once a diagnosis of active MM is made, the prognostication of these patients is extremely important. Multiple variables have been used to define high-risk MM. These include cytogenetic abnormalities, laboratory characteristics such as LDH and albumin, and presence of circulating plasma cells and extramedullary disease. Once patients initiate therapy, patients who relapse early (within 18 months of diagnosis) are often considered to have functional high-risk disease.27-29

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Revised ISS Staging System

Now, the goal is to devise models that will allow us to incorporate these various characteristics into a single staging system. The Revised International Staging System (R-ISS) has been used for some time that incorporates the serum albumin and the beta 2 microglobulin in addition to some of the more common cytogenetic abnormalities.27

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Second Revision of R-ISS (R2-ISS)

More recently, a second revision of the RISS, called the R2ISS, incorporates and gives a weight to individual risk characteristics such as the ISS stage, del(17p), high risk translocation, high LDH and 1q abnormalities.30

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Additive Impact of HR Abnormalities

A similar model, the Mayo Additive Staging System, was developed by the Mayo group and looks at the additive impact of these high-risk abnormalities. Like the original ISS, patients can be categorized into 3 equal groups by presence of ≥1 of these abnormalities. Irrespective of which staging system is used, patients with high-risk abnormalities need to be identified so we can alter therapy for them and definitively prognosticate them in a more specific manner.31

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Key Points for Clinical Practice: Risk Assessment in Newly Diagnosed MM

  • Once criteria for active MM is met, patients should be initiated on optimal therapy based on patient and disease characteristics.
  • After diagnosis of active MM, cytogenetics, disease, and lab variables should be used to categorize patients into various risk groups to aid in treatment selection and determine prognosis.

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