6
Relapsed Disease
➤ Treatment for biochemically relapsed myeloma should be
individualized. Factors to consider include patient's tolerance of
prior treatment, rate of rise of myeloma markers, cytogenetic risk,
presence of comorbidities (i.e. renal insufficiency), frailty, and patient
preference. High-risk patients as defined by high-risk cytogenetics
and early relapse post-transplant/initial therapy should be treated
immediately. Close observation is appropriate for patients with slowly
progressive and asymptomatic relapse. (Moderate Recommendation;
IC/EB-I-B)
➤ All clinically relapsed patients with symptoms due to myeloma should
be treated immediately. (Strong Recommendation; EB-H-B)
➤ Triplet therapy should be administered on first relapse, though the
patient's tolerance for increased toxicity should be considered. A
triplet is defined as a regimen with two novel agents (proteasome
inhibitors, immunomodulatory drugs or monoclonal antibodies).
(Strong Recommendation; EB-H-B)
➤ Treatment of relapsed multiple myeloma may be continued until
disease progression. There is not enough data to recommend risk
based versus response-based duration of treatment (such as MRD).
(Moderate Recommendation; EB-I-B)
➤ Prior therapies should be taken into consideration when selecting the
treatment at first relapse. A monoclonal antibody-based regimen in
combination with an immunomodulatory drugs and/or proteasome
inhibitor should be considered. Triplet regimens are preferred based
on tolerability and comorbidities. (Moderate Recommendation; EB-L-B)
➤ Autologous stem cell transplantation, if not received after primary
induction therapy, should be offered to transplant eligible patients
with relapsed multiple myeloma. Repeat stem cell transplant may be
considered in relapsed multiple myeloma if PFS after first transplant
is 18 months or greater. (Weak Recommendation; EB-L-B)
➤ The risk status of the patients should be assessed using the Revised
ISS staging system for all patients at the time of diagnosis. (Strong
Recommendation; EB-H-B)
➤ Repeat risk assessment at the time of relapse should be performed
and should include bone marrow with FISH for myeloma abnormalities
seen with progression including, 17p and 1q abnormalities. FISH
for primary abnormalities (translocations and trisomies), if seen in
the initial diagnostic marrow, does not need to be repeated. (Strong
Recommendation; EB-H-B)
Treatment
