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Multiple myeloma

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 Canadian Myeloma Research Group Consensus Guideline Consortium (CMRG-CGC 2023), the United Kingdom Myeloma Society (UKMS/BSH 2021), the European Hematology Association (EHA/ESMO 2021), the Cancer Care Ontario Foundation (CCO/ASCO 2019), and the American Society of Clinical Oncology (ASCO 2018).
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Guidelines

1.Classification and risk stratification

Risk assessment
As per BSH 2021 guidelines:
Use the 2014 International Myeloma Working Group 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

2.Diagnostic investigations

Laboratory tests: 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

3.Diagnostic procedures

Bone marrow examination: perform bone marrow aspirate and trephine biopsy with plasma cell phenotyping to establish the diagnosis of MM.
B
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  • Renal biopsy

4.Medical management

General principles: discuss all cases of newly diagnosed MM at a multidisciplinary meeting.
B
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  • Watchful waiting

  • Induction therapy (transplant eligible)

  • Induction therapy (transplant ineligible)

  • Consolidation therapy

  • Maintenance therapy

  • Bone-modifying agents (initiation)

  • Bone-modifying agents (monitoring)

5.Therapeutic procedures

Stem cell transplantation, indications, ESMO/EHA
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)

6.Follow-up and surveillance

Assessment of treatment response, transplant eligible: 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)