Treating High-Risk Multiple Myeloma - Episode 5
Ajai Chari, MD:The follow-up for multiple myeloma is pretty well standardized. First, we look for serologic remission with the SPEP (serum protein electrophoresis), the immunofixation, the free light chains, and those patients who have urine protein. So, once we see that the serologies are all converting to negative, ideally, the next thing that should also be considered is imaging, because for the patient who may have presented with a lot of bone disease, we want to make sure that the bone disease is all resolved. And so, this is where PET scans and MRIs are much more useful than X-ray, because once the bone is damaged on plain X-ray, even if the disease is in remission, it may not completely normalize and typically does notwhereas PET scans will go from FDG-avid to FDG-not avid or MRI lesions can improve with treatment.
So, if a patient has serologic remission, radiologic remission, then a bone marrow could be done to determine if a patient is minimal residual diseasenegative. And I mention the imaging because the bone marrow is just a random sample, and if you get an MRD-negative result but then the patient still has radiologic disease, that is not the same as somebody who has negative imaging and is MRD-negative. And with the second patient, we’re much more confident that we really achieved a good remission.
So, in the ALCYONE study, it’s impressive because even in an elderly population, almost one-quarter of patients attained MRD negativity. The use of MRD is really important in this type of setting because there’s no need for MRD in a penta-refractory patient who’s heavily pretreated, because you want to see that the overall survival is better, and the progression-free survival should speak for itself. As you move up into these newly diagnosed settingsbecause myeloma patients are living longer and longer—the follow-up for showing that somebody is MRD-negative, a particular arm is better than another and would be really prohibitively long. And so, MRD can be used as a surrogate endpoint specifically in this kind of newly diagnosed setting or in a maintenance setting, where this is the earliest sign that we’re really going to have impact on long-term outcomes.
Transcript edited for clarity.