How is smoldering multiple myeloma monitored? What testing should be done and how often?

How is smoldering multiple myeloma monitored?

What testing should be done and how often?

Do you repeat imaging and bone marrow biopsies on smoldering myeloma patients?

Once you are diagnosed with smoldering multiple myeloma, then that's where assessing the risk of your smoldering myeloma comes in handy.

That it is dependent on how much of your bone marrow is involved by myeloma cells.

That is dependent on how much protein you have in your bloodstream.

That is also assessed by your serum free light chain assay and the ratios involved.

And there are different there's at least three established ways to try and assess the risk for myeloma that the goal of it is to determine whether you have high risk myeloma or not.

If you have high risk myeloma, your risk of becoming active in the next two years is 50%.

And so if you fit that category, you should be watched much more closely.

Usually you want to have your blood test repeated at least the first three months to assess how quickly those blood tests may be changing.

After that, you may be able to go to every six months, but it shouldn't go beyond six months in terms of following your disease.

If you do not meet the criteria for high risk disease, you can definitely start at six months and possibly go up to even a year in terms of when you repeat your blood test again.

But regardless of what your doctor and you choose, if you develop any new symptoms, you need to immediately go see your doctor to make sure that is not your disease changing.

Smoldering myeloma. We manage it or we observe it exactly the same way, like myeloma.

So we look at the m-spike, the light chain ratio. We look at if they have anemia or not, they have high calcium or not renal failure.

So we look at all those markers and then in certain patients, we want to make sure we have a bone marrow biopsy and we looked at cytogenetics and FISH.

At least dose, if not next generation sequencing.

And we want to do imaging because many people their first presentation is little lesions and we want to make sure we do an MRI or a PET CT scan or a low dose CT scan because skeletal surveys are not good enough for us.

Do you repeat imaging and bone marrow biopsies on smoldering myeloma patients?

I don't usually repeat bone marrow biopsies on smoldering myeloma patients unless they have become active.

There is no data to show that the change in the percentage of plasma cells from the original bone marrow will determine how aggressive or how quickly this would change.

The other thing is that when we do a bone marrow biopsy, we're doing a blind biopsy.

And so the if I do a bone marrow biopsy today in one spot and then do the same biopsy just a week later in a different spot, I make it a very different percentage of involvement of your plasma cells.

There's patchy involvement, so it's very difficult to interpret just the bone marrow by itself in terms of if you see 10% one day versus 20% another day where there's a treat change or not.

So unless there's some new reason or new symptom or we're moving to therapy, there's no reason to repeat the bone marrow biopsy in my opinion.

In terms of imaging, I think the imaging is something that probably should be considered at least yearly, at least in the first two years from diagnosis.

Because again, you want to determine we're not great at putting everyone in that bucket of high risk.

And so if you happen to be put in a bucket of not high risk, but you carry a mutation that perhaps makes you higher risk than we just didn't realize that you may be at risk of transforming in those two years.

And so I recommend imaging once a year.