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Hughes D, Yong K, Ramasamy K, Stern S, Boyle E, Ashcroft J, Basheer F, Rabin N, Pratt G. Diagnosis and management of smouldering myeloma: A British Society for Haematology Good Practice Paper. Br J Haematol 2024; 204:1193-1206. [PMID: 38393718 DOI: 10.1111/bjh.19333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 01/20/2024] [Accepted: 01/28/2024] [Indexed: 02/25/2024]
Abstract
Multiple myeloma is a bone marrow-based plasma cell tumour that develops from asymptomatic pre-cursor conditions smouldering myeloma and monoclonal gammopathy of uncertain significance and all are characterised by the presence of a monoclonal protein in the blood. Diagnosis and distinction between these conditions is based on blood tests, the bone marrow biopsy and cross sectional imaging. There are various risk stratification models that group patients with smouldering myeloma into risk groups based on risk of progression to symptomatic disease. Management is mainly observational for patients with smouldering myeloma although clinical trials for high-risk disease may be available. Restaging is required if evidence for progression.
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Affiliation(s)
- Daniel Hughes
- UCL Cancer Institute, University College London, London, UK
| | - Kwee Yong
- UCL Cancer Institute, University College London, London, UK
| | - Karthik Ramasamy
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Oxford Translational Myeloma Centre, NDORMS, University of Oxford, Oxford, UK
| | - Simon Stern
- Epsom and St Helier University Hospitals NHS Trust, Sutton, UK
| | - Eileen Boyle
- UCL Cancer Institute, University College London, London, UK
| | - John Ashcroft
- The Mid Yorkshire Teaching Hospitals NHS Trust, Wakefield, UK
| | - Faisal Basheer
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Neil Rabin
- University College London Hospitals, London, UK
| | - Guy Pratt
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Lussier T, Schoebe N, Mai S. Risk Stratification and Treatment in Smoldering Multiple Myeloma. Cells 2021; 11:cells11010130. [PMID: 35011692 PMCID: PMC8750018 DOI: 10.3390/cells11010130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 12/20/2021] [Accepted: 12/28/2021] [Indexed: 11/30/2022] Open
Abstract
Smoldering multiple myeloma is a heterogeneous asymptomatic precursor to multiple myeloma. Since its identification in 1980, risk stratification models have been developed using two main stratification methods: clinical measurement-based and genetics-based. Clinical measurement models can be subdivided in three types: baseline measurements (performed at diagnosis), evolving measurements (performed over time during follow-up appointments), and imaging (for example, magnetic resonance imaging). Genetic approaches include gene expression profiling, DNA/RNA sequencing, and cytogenetics. It is important to accurately distinguish patients with indolent disease from those with aggressive disease, as clinical trials have shown that patients designated as “high-risk of progression” have improved outcomes when treated early. The risk stratification models, and clinical trials are discussed in this review.
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Affiliation(s)
- Tyler Lussier
- Department of Physiology and Pathophysiology, University of Manitoba, Cancer Care Manitoba Research Institute, Winnipeg, MB R3E 0V9, Canada; (T.L.); (N.S.)
- Faculté des Sciences, Université de Saint-Boniface, Winnipeg, MB R2H 0H7, Canada
| | - Natalie Schoebe
- Department of Physiology and Pathophysiology, University of Manitoba, Cancer Care Manitoba Research Institute, Winnipeg, MB R3E 0V9, Canada; (T.L.); (N.S.)
- Faculty of Biosciences, University of Heidelberg, 69117 Heidelberg, Germany
| | - Sabine Mai
- Department of Physiology and Pathophysiology, University of Manitoba, Cancer Care Manitoba Research Institute, Winnipeg, MB R3E 0V9, Canada; (T.L.); (N.S.)
- Correspondence: ; Tel.: +1-204-787-2135
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Visram A, Cook J, Warsame R. Smoldering multiple myeloma: evolving diagnostic criteria and treatment strategies. Hematology Am Soc Hematol Educ Program 2021; 2021:673-681. [PMID: 34889380 PMCID: PMC8791169 DOI: 10.1182/hematology.2021000304] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
The adage for smoldering myeloma (SMM) has been to observe without treatment, until criteria for active multiple myeloma were satisfied. Definitions and risk stratification models have become more sophisticated, with prognostication tailored to include high-risk cytogenetics as per the most recent International Myeloma Working Group 2020 risk model. Moreover, progress in defining genomic evolution and changes in the bone marrow microenvironment through the monoclonal continuum have given insight into the complexities underlying the different patterns of progression observed in SMM. Given recent data showing improved progression-free survival with early intervention in high-risk SMM, the current dilemma is focused on how these patients should be treated. This case-based article maps the significant advancements made in the diagnosis and risk stratification of SMM. Data from landmark clinical trials will also be discussed, and ongoing trials are summarized. Ultimately, we outline our approach to SMM and hope to impart to the reader a sound concept of the current clinical management of SMM.
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Affiliation(s)
- Alissa Visram
- Division of Hematology, The Ottawa Hospital, Ottawa, ON, Canada
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - Joselle Cook
- Division of Hematology, The Ottawa Hospital, Ottawa, ON, Canada
| | - Rahma Warsame
- Division of Hematology, The Ottawa Hospital, Ottawa, ON, Canada
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Landgren CO, Chari A, Cohen YC, Spencer A, Voorhees P, Estell JA, Sandhu I, Jenner MW, Williams C, Cavo M, van de Donk NWCJ, Beksac M, Moreau P, Goldschmidt H, Kuppens S, Bandekar R, Clemens PL, Neff T, Heuck C, Qi M, Hofmeister CC. Daratumumab monotherapy for patients with intermediate-risk or high-risk smoldering multiple myeloma: a randomized, open-label, multicenter, phase 2 study (CENTAURUS). Leukemia 2020; 34:1840-1852. [PMID: 32024950 PMCID: PMC7326703 DOI: 10.1038/s41375-020-0718-z] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 12/05/2019] [Accepted: 01/15/2020] [Indexed: 01/03/2023]
Abstract
Current guidelines for smoldering multiple myeloma (SMM) recommend active monitoring until the onset of multiple myeloma (MM) before initiating treatment or enrollment in a clinical trial. Earlier intervention may delay progression to MM. In CENTAURUS, 123 patients with intermediate-risk or high-risk SMM were randomly assigned to daratumumab 16 mg/kg intravenously on extended intense (intense), extended intermediate (intermediate), or short dosing schedules. At the prespecified primary analysis (15.8-month median follow-up), the complete response (CR) rates (co-primary endpoint) were 2.4%, 4.9%, and 0% for intense, intermediate, and short dosing, respectively; the co-primary endpoint of CR rate >15% was not met. Progressive disease (PD)/death rates (number of patients who progressed or died divided by total duration of progression-free survival [PFS] in patient-years; co-primary endpoint) for intense, intermediate, and short dosing were 0.055 (80% confidence interval [CI], 0.014-0.096), 0.102 (80% CI, 0.044-0.160), and 0.206 (80% CI, 0.118-0.295), respectively, translating to a median PFS ≥24 months in all arms (P < 0.0001, <0.0001, and =0.0213, respectively). With longer follow-up (median follow-up, 25.9 months), CR rates were 4.9%, 9.8%, and 0% for intense, intermediate, and short dosing, respectively. PD/death rates for intense, intermediate, and short dosing were 0.059 (80% CI, 0.025-0.092), 0.107 (80% CI, 0.058-0.155), and 0.150 (80% CI, 0.089-0.211), respectively, again translating to a median PFS ≥ 24 months in all arms (P < 0.0001 for all arms). Twenty-four-month PFS rates were 89.9% (90% CI, 78.5-95.4%), 82.0% (90% CI, 69.0-89.9%), and 75.3% (90% CI, 61.1-85.0%) for intense, intermediate, and short dosing, respectively. Pharmacokinetic analyses indicated that intense dosing maintained target-saturating trough concentrations in most patients throughout weekly, every-2-week, and every-4-week dosing periods. No new safety signals were observed. These data provide the basis for an ongoing phase 3 study of daratumumab in SMM.
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Affiliation(s)
- C Ola Landgren
- Department of Medicine, Myeloma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Ajai Chari
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Yael C Cohen
- Department of Hematology, Tel-Aviv Sourasky (Ichilov) Medical Center, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Andrew Spencer
- Malignant Haematology and Stem Cell Transplantation Service, Alfred Health-Monash University, Melbourne, VIC, Australia
| | - Peter Voorhees
- Levine Cancer Institute/Atrium Health, Charlotte, NC, USA
| | - Jane A Estell
- Haematology Department, Concord Cancer Centre, Concord Hospital, University of Sydney, Concord, NSW, Australia
| | - Irwindeep Sandhu
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | | | - Catherine Williams
- Department of Clinical Haematology, Nottingham University Hospitals, Nottinghamshire, UK
| | - Michele Cavo
- Department of Experimental, Diagnostic and Specialty Medicine, "Seràgnoli" Institute of Hematology, University of Bologna, Bologna, Italy
| | | | - Meral Beksac
- Department of Hematology, Ankara University, Ankara, Turkey
| | | | - Hartmut Goldschmidt
- University Hospital Heidelberg and National Center of Tumor Diseases (NCT), Heidelberg, Germany
| | | | | | | | - Tobias Neff
- Janssen Research & Development, LLC, Spring House, PA, USA
| | | | - Ming Qi
- Janssen Research & Development, LLC, Spring House, PA, USA
| | - Craig C Hofmeister
- Department of Hematology & Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA.
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Kunacheewa C, Manasanch EE. High-risk smoldering myeloma versus early detection of multiple myeloma: Current models, goals of therapy, and clinical implications. Best Pract Res Clin Haematol 2020; 33:101152. [PMID: 32139017 PMCID: PMC7069728 DOI: 10.1016/j.beha.2020.101152] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 01/23/2020] [Indexed: 10/25/2022]
Abstract
Multiple myeloma, a bone marrow cancer, is preceded by precursor stages called monoclonal gammopathy of unknown significance and smoldering multiple myeloma. Over the past few years, highly effective and safe therapies have been made available to treat multiple myeloma. This represents a major breakthrough and has major therapeutic implications. Treatment for multiple myeloma has evolved to include treatment of precursor stages (early treatment) as these therapies are shown to be safe and effective also in smoldering myeloma. Randomized studies have shown that early treatment can delay the onset of multiple myeloma and even improve overall survival compared to observation in smoldering myeloma. The best therapeutic course and selection of patients with smoldering myeloma to treat is still a matter of debate. In this manuscript, we review the definition, management, clinical implications of smoldering myeloma and early detection of myeloma in the current context and with up-to-date data.
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Affiliation(s)
- Chutima Kunacheewa
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elisabet E Manasanch
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Ulaner GA, Landgren CO. Current and potential applications of positron emission tomography for multiple myeloma and plasma cell disorders. Best Pract Res Clin Haematol 2020; 33:101148. [PMID: 32139013 DOI: 10.1016/j.beha.2020.101148] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 01/13/2020] [Indexed: 11/19/2022]
Abstract
Fluorine-18 (18F)-fluorodeoxyglucose (FDG) positron emission tomography (PET) allows evaluation of elevated glucose metabolism in malignancies. There has been increasing interest in FDG PET/CT for plasma cell disorders since the International Myeloma Working Group outlined multiple applications of this imaging modality, including distinguishing smoldering myeloma from active multiple myeloma, confirmation of solitary plasmacytoma, and multiple indications in patients with known multiple myeloma, including determining extent of initial disease, monitoring therapy response, and detection of residual disease following therapy. The field of molecular imaging is now shifting focus from evaluation of metabolism to targeted evaluation of specific tumor markers. Targeted PET imaging targeted of CXCR4 and CD38 has advanced into translational clinical trials, bringing us closer to powerful imaging options for myeloma. In this review we discuss the current applications of FDG PET/CT in plasma cell disorders, as well as advances in targeted PET imaging.
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Affiliation(s)
- Gary A Ulaner
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA; Weill Cornell Medical College, New York, NY, 10065, USA.
| | - C Ola Landgren
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA; Weill Cornell Medical College, New York, NY, 10065, USA.
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de Mello RB, do Vale ECS. Necrobiotic xanthogranuloma associated with smoldering multiple myeloma: satisfactory response to cyclophosphamide, dexamethasone, and thalidomide. An Bras Dermatol 2019; 94:337-340. [PMID: 31365665 PMCID: PMC6668937 DOI: 10.1590/abd1806-4841.20198500] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 11/22/2018] [Indexed: 11/25/2022] Open
Abstract
Necrobiotic xanthogranuloma is a rare chronic condition, belonging to the group C non-Langerhans cell histiocytoses, which is relevant due to the possibility of extracutaneous involvement and association with systemic diseases, particularly hematologic malignancies. The case reported here was only diagnosed after nine years of evolution and was associated with plasma cell dyscrasia. After treatment with cyclophosphamide, dexamethasone, and thalidomide, there was a reduction of cutaneous lesions and serum levels of monoclonal protein.
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Affiliation(s)
- Renan Bernardes de Mello
- Dermatology Service, Hospital das Clínicas, Universidade
Federal de Minas Gerais, Belo Horizonte, MG, Brazil
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Bolli N, Maura F, Minvielle S, Gloznik D, Szalat R, Fullam A, Martincorena I, Dawson KJ, Samur MK, Zamora J, Tarpey P, Davies H, Fulciniti M, Shammas MA, Tai YT, Magrangeas F, Moreau P, Corradini P, Anderson K, Alexandrov L, Wedge DC, Avet-Loiseau H, Campbell P, Munshi N. Genomic patterns of progression in smoldering multiple myeloma. Nat Commun 2018; 9:3363. [PMID: 30135448 PMCID: PMC6105687 DOI: 10.1038/s41467-018-05058-y] [Citation(s) in RCA: 144] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 06/06/2018] [Indexed: 12/21/2022] Open
Abstract
We analyzed whole genomes of unique paired samples from smoldering multiple myeloma (SMM) patients progressing to multiple myeloma (MM). We report that the genomic landscape, including mutational profile and structural rearrangements at the smoldering stage is very similar to MM. Paired sample analysis shows two different patterns of progression: a "static progression model", where the subclonal architecture is retained as the disease progressed to MM suggesting that progression solely reflects the time needed to accumulate a sufficient disease burden; and a "spontaneous evolution model", where a change in the subclonal composition is observed. We also observe that activation-induced cytidine deaminase plays a major role in shaping the mutational landscape of early subclinical phases, while progression is driven by APOBEC cytidine deaminases. These results provide a unique insight into myelomagenesis with potential implications for the definition of smoldering disease and timing of treatment initiation.
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Affiliation(s)
- Niccolò Bolli
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, 20122, Italy
- Department of Oncology and Hematology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, 20133, Italy
- Cancer Genome Project, Wellcome Trust Sanger Institute, Hinxton, Cambridgeshire, CB10 1SA, UK
| | - Francesco Maura
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, 20122, Italy
- Cancer Genome Project, Wellcome Trust Sanger Institute, Hinxton, Cambridgeshire, CB10 1SA, UK
| | - Stephane Minvielle
- CRCINA, INSERM, CNRS, Université de Nantes, Université d'Angers, Nantes, 44035, France
- CHU de Nantes, Nantes, 44093, France
| | - Dominik Gloznik
- Cancer Genome Project, Wellcome Trust Sanger Institute, Hinxton, Cambridgeshire, CB10 1SA, UK
| | - Raphael Szalat
- Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, 02215, MA, USA
| | - Anthony Fullam
- Cancer Genome Project, Wellcome Trust Sanger Institute, Hinxton, Cambridgeshire, CB10 1SA, UK
| | - Inigo Martincorena
- Cancer Genome Project, Wellcome Trust Sanger Institute, Hinxton, Cambridgeshire, CB10 1SA, UK
| | - Kevin J Dawson
- Cancer Genome Project, Wellcome Trust Sanger Institute, Hinxton, Cambridgeshire, CB10 1SA, UK
| | - Mehmet Kemal Samur
- Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, 02215, MA, USA
| | - Jorge Zamora
- Cancer Genome Project, Wellcome Trust Sanger Institute, Hinxton, Cambridgeshire, CB10 1SA, UK
| | - Patrick Tarpey
- Cancer Genome Project, Wellcome Trust Sanger Institute, Hinxton, Cambridgeshire, CB10 1SA, UK
| | - Helen Davies
- Cancer Genome Project, Wellcome Trust Sanger Institute, Hinxton, Cambridgeshire, CB10 1SA, UK
| | - Mariateresa Fulciniti
- Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, 02215, MA, USA
| | - Masood A Shammas
- Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, 02215, MA, USA
| | - Yu Tzu Tai
- Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, 02215, MA, USA
| | - Florence Magrangeas
- CRCINA, INSERM, CNRS, Université de Nantes, Université d'Angers, Nantes, 44035, France
- CHU de Nantes, Nantes, 44093, France
| | - Philippe Moreau
- CRCINA, INSERM, CNRS, Université de Nantes, Université d'Angers, Nantes, 44035, France
- CHU de Nantes, Nantes, 44093, France
| | - Paolo Corradini
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, 20122, Italy
- Department of Oncology and Hematology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, 20133, Italy
| | - Kenneth Anderson
- Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, 02215, MA, USA
| | - Ludmil Alexandrov
- Department of Cellular and Molecular Medicine and Department of Bioengineering and Moores Cancer Center, University of California, San Diego, La Jolla, CA, 92093, USA
| | - David C Wedge
- Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, OX3 7BN, UK
| | - Herve Avet-Loiseau
- Genomics of Myeloma Laboratory, L'Institut Universitaire du Cancer Oncopole, Toulouse, 31100, France.
| | - Peter Campbell
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, 20122, Italy.
| | - Nikhil Munshi
- Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, 02215, MA, USA.
- Veterans Administration Boston Healthcare System, West Roxbury, 02132, MA, USA.
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