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Multiple myeloma

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Updated 2024 BSH guidelines for the diagnosis and management of smoldering multiple myeloma.

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of multiple myeloma are prepared by our editorial team based on guidelines from the British Society for Haematology (BSH 2024), the Canadian Myeloma Research Group Consensus Guideline Consortium (CMRG-CGC 2023), the European Hematology Association (EHA/ESMO 2021), the United Kingdom Myeloma Society (UKMS/BSH 2021), the Cancer Care Ontario Foundation (CCO/ASCO 2019), and ...
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Classification and risk stratification

Risk assessment
As per BSH/UKMS 2021 guidelines:
Use the 2014 IMWG diagnostic criteria for staging MM.
A
Use the revised International Staging System in all patients with newly diagnosed MM.
A
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  • Frailty assessment

  • Eligibility for HSCT

Diagnostic investigations

Laboratory tests: as per BSH/UKMS 2021 guidelines, obtain the following laboratory tests in patients with suspected or confirmed MM:
Situation
Guidance
Screening tests
CBC
Urea and creatinine
Calcium, immunoglobulins and serum electrophoresis
SFLC
Diagnostic tests
Immunofixation of serum
Tests to estimate tumor burden and prognosis
Β-2 microglobulin
LDH
Albumin
B
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  • Diagnostic imaging

Diagnostic procedures

Bone marrow examination: as per BSH/UKMS 2021 guidelines, perform bone marrow aspirate and trephine biopsy with plasma cell phenotyping to establish the diagnosis of MM.
B
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  • Renal biopsy

Medical management

General principles: as per BSH/UKMS 2021 guidelines, discuss all cases of newly diagnosed MM at a multidisciplinary meeting.
B
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  • Induction therapy (transplant eligible)

  • Induction therapy (transplant ineligible)

  • Consolidation therapy

  • Maintenance therapy

  • Bone-modifying agents (initiation)

  • Bone-modifying agents (monitoring)

Therapeutic procedures

Stem cell transplantation, indications
As per EHA/ESMO 2021 guidelines:
Offer tandem ASCT in patients with genetically defined high-risk disease as well as in all patients received bortezomib, cyclophosphamide, and dexamethasone induction.
B
Do not offer allo-SCT following ASCT, as it does not improve overall survival compared with tandem ASCT, even in high-risk disease.

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  • Stem cell transplantation (conditioning)

Specific circumstances

Patients with smoldering myeloma, indications for screening: as per BSH 2024 guidelines, do not obtain screening for MGUS or smoldering MM outside of clinical trials.
D

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  • Patients with smoldering myeloma (diagnostic criteria)

  • Patients with smoldering myeloma (laboratory evaluation)

  • Patients with smoldering myeloma (diagnostic imaging)

  • Patients with smoldering myeloma (renal biopsy)

  • Patients with smoldering myeloma (cytogenetic analysis)

  • Patients with smoldering myeloma (risk stratification)

  • Patients with smoldering myeloma (thromboprophylaxis)

  • Patients with smoldering myeloma (antibiotic prophylaxis)

  • Patients with smoldering myeloma (routine immunizations)

  • Patients with smoldering myeloma (immunoglobulin replacement therapy)

  • Patients with smoldering myeloma (watchful waiting)

  • Patients with smoldering myeloma (general counseling)

  • Patients with smoldering myeloma (bisphosphonates)

  • Patients with smoldering myeloma (monitoring)

Follow-up and surveillance

Assessment of treatment response, transplant eligible: as per ASCO/CCO 2019 guidelines, set the achievement of the best depth of remission as the goal of initial therapy in transplant-eligible patients.
B
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  • Assessment of treatment response (transplant ineligible)

  • Management of relapsed/refractory disease (risk assessment)

  • Management of relapsed/refractory disease (general principles)

  • Management of relapsed/refractory disease (systemic therapy)

  • Management of relapsed/refractory disease (stem cell transplantation)

  • Management of relapsed/refractory disease (assessment of response)

  • Management of treatment-related adverse events (neuropathy)

  • Management of treatment-related adverse events (infections)

  • Management of treatment-related adverse events (gastrointestinal disturbances)

  • Management of treatment-related adverse events (fatigue)

  • Management of treatment-related adverse events (cytopenias)

  • Management of treatment-related adverse events (thrombosis)