COMMENTARY

In Conversation: Ola Landgren on the Updated Definition of Multiple Myeloma by the International Myeloma Working Group

Syed A. Abutalib, MD; Carl Ola Landgren, MD, PhD

Disclosures

June 22, 2015

In This Article

Editor's Note:
In November, the International Myeloma Working Group (IMWG) updated and clarified the criteria for the diagnosis of multiple myeloma,[1] a development that experts in the field recommend implementing in routine practice and in future clinical trials. In effect, the new criteria expand the pool of treatable patients by including those with early biomarkers suggesting the inevitable development of more typical features of multiple myeloma.

Specifically, in addition to the previously defined criteria for end-organ damage (the so-called CRAB criteria), the IMWG recently added the following criteria for the diagnosis of multiple myeloma requiring therapy: bone marrow plasma cells (BMPCs)≥ 60%; involved/uninvolved serum free light-chain ratio ≥ 100; and abnormal MRI with more than one focal lesion, with each lesion > 5 mm. Thus, the updated list of criteria includes seven variables. If a patient has one or more of these, per the 2014 IMWG criteria, he or she fulfills the definition of multiple myeloma requiring therapy.

The changes were based on two studies. First, a retrospective Mayo Clinic study[2] demonstrated that among 276 patients with smoldering myeloma, six (2%) had a BMPC percentage ≥ 60%. Four of these six patients progressed to symptomatic myeloma 3-9 months after the diagnosis of smoldering myeloma. The median progression-free survival of these six patients was 7.7 months. This observation prompted the Greek Myeloma Group to carry out another retrospective study.[3] On the basis of 96 patients, they made similar observations.

More recently, the IMWG issued a consensus statement[4] on the role of MRI, arguing that all patients with smoldering or asymptomatic myeloma should undergo whole-body MRI and that in cases of equivocal small lesions, a second MRI should be performed after 3-6 months.

In this article—the first in a new series, "In Conversation"—Syed A. Abutalib, MD, assistant director of Hematology and Hematopoietic Cell Transplant and the Cell Therapy Program at Cancer Treatment Centers of America in Zion, Illinois, interviews multiple myeloma expert Ola Landgren, MD, PhD, of Memorial Sloan Kettering Cancer Center in New York, who served as an author of the new guidelines, on what these changes mean for the community hematologist/oncologist.

Important Points for Patient Management
  • The International Myeloma Working Group added new criteria for the diagnosis of multiple myeloma.

  • The role of whole-body MRI in plasma cell disorders is more clearly defined in the new criteria for the diagnosis of multiple myeloma.

  • Clinical heterogeneity remains in terms of the risk of developing symptomatic disease in plasma cell disorders, specifically in persons with smoldering multiple myeloma.

  • Caution is advised in interpreting the free light-chain ratio.

  • Clinical trials should be done in a very responsible way, asking an important question that benefits the patient.

  • For us to move forward, we must proceed slowly but take the right approach, allowing patients the option of entering well-structured clinical trials.

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