Time to redefine Myeloma

Abstract

Summary In November 2014 the International Myeloma Working Group (IMWG) revised the definition of multiple myeloma, such that asymptomatic patients with newly diagnosed multiple myeloma without any of the traditional ‘CRAB’ (hypercalcaemia, renal impairment, anaemia, bone disease) end organ damage criteria but with one of three new criteria would be recommended to start treatment. Previously, the standard of care for such patients was expectant management. These three new criteria are: greater than 60% clonal plasma cells on bone marrow biopsy, a serum free light chain (sFLC) ratio of >100 (the involved sFLC must be >100 mg/l) and greater than one unequivocal focal lesion on advanced imaging (low dose whole body computerized tomography, magnetic resonance imaging, 18F fluorodeoxyglucose positron emission tomography). Although this would appear to affect a small number of patients, the impact of these changes are broad, leading to an increased use of advanced imaging, a debate around the management of patients previously diagnosed with smouldering myeloma, changed terminology and clinical trial design and an extension of the use of biomarkers. For the first time the philosophy of treatment in myeloma will change from treatment initiation only being triggered by overt end organ damage to an era where sub clinical risk factors will also be taken into account.

Whole Body Low Dose Computed Tomography (WBLDCT) Can Be Comparable to Whole-Body Magnetic Resonance Imaging (WBMRI) in the Assessment of Multiple Myeloma

“…On WBLDCT, the diagnosis of osteolytic bone lesions was performed analyzing both axial and multiplanar reformatted (MPR) images: the typical, punched-out lytic lesions with a diameter of 5 mm or more were recorded as focal myeloma involvement, according to the recent guidelines [ 6 ]. The assessment of spinal involvement was performed using MPR images, especially on the sagittal plane.…”

“…The diagnosis of MM mainly relies on the demonstration of bone marrow plasmacytosis and/or presence of monoclonal proteins (M-proteins) in the serum or urine, and/or detection of end-organ damage (CRAB—hypercalcemia, renal failure, anemia, and bone disease), especially lytic bone lesions, based on the International Myeloma Working Group (IMWG) diagnostic criteria published in 2014 [ 1 , 4 , 5 , 6 ]. Indeed, at imaging assessment, the evidence of at least two 5-mm or larger focal lesions detected at magnetic resonance imaging (MRI) is considered to be a myeloma biomarker, while at least one 5-mm or larger osteolytic lesion at positron emission tomography (PET), whole-body low dose computed tomography (WBLDCT), or whole-skeletal x-ray is considered to be a CRAB feature [ 7 ].…”

Floccinaucinihilipilification: is there a continuing role for the radiographic skeletal survey?

“…It begs the question of what to do with diffuse marrow infiltration, something that is best seen with MRI but not currently regarded as a myeloma-defining event [22].…”

Prognostic Biomarkers in the Progression From MGUS to Multiple Myeloma: A Systematic Review

“…These new criteria are based on percentage clonal plasma cells on BM biopsy, serum free light chain (sFLC) ratio and amount of focal lesions on advanced imaging. (5) The genetic background and disease course are highly heterogeneous. Despite important progress in elucidating the molecular mechanism of MM, its pathogenesis is still unknown.…”