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Blood Tests May Be Sufficient To Monitor For Relapse Or Progression Of Multiple Myeloma After Stem Cell Transplantation

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Published: Sep 14, 2012 12:12 pm

Results from a recent retrospective study suggest that blood tests may be sufficient, and that urine tests and skeletal surveys may not be necessary, to detect most cases of relapse or disease progression after stem cell transplantation for multiple myeloma.

However, the investigators point out that patients who show clinical signs of relapse/progression, such as such kidney problems or bone lesions, after stem cell transplantation may need additional types of testing, since they tend to have poorer prognoses.

The investigators note that their findings could be used to strengthen current guidelines for monitoring myeloma patients after stem cell transplantation.

Dr. Hani Hassoun, a hematologist/oncologist at the Memorial Sloan-Kettering Cancer Center, and lead investigator of the study, pointed out that he and his colleagues are seeking to confirm their findings in a larger study.

“We are currently looking at a larger population to confirm the findings that we have described in the current study,” he said.

“We […] need to validate these observations using prospective studies or populations of patients that have been treated and followed in a very homogeneous way,” said Dr. Hassoun.

However, Dr. Sagar Lonial from the Winship Cancer Institute at Emory University, who was not involved in the study, does not feel that monitoring of patients after stem cell transplantation should change based on the results of the study because it is a very preliminary analysis.

“I think this study in its current form does not have implications yet about how we should follow patients, but it does raise some very important issues about how we follow patients over time,” said Dr. Lonial. “These results stress the importance of continued follow-up with a myeloma center post [transplantation] as they are likely to do a very comprehensive workup at regular intervals to detect subtle changes in disease status,” he added.

Autologous stem cell transplants are commonly used as a part of first-line therapy following initial treatment for multiple myeloma. In this process, stem cells from the patients are harvested, after which high-dose chemotherapy is used to kill most cells in the bone marrow including cancerous plasma cells. The previously harvested stem cells are then re-infused into the patient to repopulate the bone marrow.

Previous studies have shown that most patients eventually relapse or show disease progression after stem cell transplantation.

According to the study investigators, detecting patterns of relapse/progression could help design effective surveillance approaches for patients who undergo stem cell transplantation. They added that previous studies on this subject did not clearly define relapse/progression and were performed before the era of novel drugs.

In the current study, the researchers compared the effectiveness of different monitoring methods after transplantation so that they could generate evidence-based recommendations for monitoring myeloma patients after stem cell transplantation.

They retrospectively analyzed data from 273 patients who received stem cell transplants at the Memorial Sloan-Kettering Cancer Center between 2001 and 2009 as a part of first-line therapy against multiple myeloma.

The mean age at diagnosis was 57 years, and about 14 percent of patients carried high-risk chromosomal abnormalities. All patients had received initial treatment based on Revlimid (lenalidomide), Velcade (bortezomib), thalidomide (Thalomid), or a combination of these. In addition, all patients included in the analysis received stem cell transplants within a year of diagnosis.

The researchers first reviewed blood test data to check for relapse/progression based on criteria defined by the International Myeloma Working Group.

Among the 273 patients, about 63 percent showed signs of relapse/progression based on blood tests (also called serological relapse/progression); the remaining 37 percent of patients showed no evidence of relapse/progression based on blood tests.

The researchers found that only 2 percent of all patients showed clinical signs of relapse/progression, such kidney problems or bone lesions, without evidence of relapse/progression in the blood.

Among the patients who showed signs of relapse/progression in the blood, 85 percent did not show any clinical symptoms. Such patients were defined as having ‘asymptomatic relapse/progression.’

The researchers found that the remaining 15 percent who showed both clinical and serological signs of relapse/progression were younger, had high-risk chromosomal abnormalities, and had a shorter time between stem cell transplantation and relapse. Risk of death in this subset of patients was about 3.4 times higher than in those who had asymptomatic relapse/progression.

Only 3 percent of patients who showed signs of relapse/progression based on blood tests also had lesions detected by skeletal surveys (series of X-rays of all bones in the body) within a year before relapse, suggesting that skeletal surveys may not be of high predictive value.

However, imaging data revealed that about 40 percent of patients who experienced asymptomatic relapse/progression showed bone lesions within four weeks of relapse. The researchers therefore suggested that imaging be recommended to all patients who show relapse/progression according to blood tests in order to find such hidden bone lesions.

A recent study has shown that MRI, which detects bone lesions, may also be helpful for detecting relapse (see related Beacon news).

The researchers found that urine testing had limited value in predicting relapse/progression, as only about 9 percent of patients who had achieved a complete response after stem cell transplantation showed monoclonal protein in the urine within three months before relapse/progression according to blood tests.

For further information, please see the study in Bone Marrow Transplantation (abstract).

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2 Comments »

  • Jan Stafl MD said:

    Thank you for a good review of this study, which further elucidates indicated follow up after ASCT, which I underwent in February. While I agree that serum M protein levels are sufficient to detect most relapses, in oligosecretory or high risk karyotypic patients, serum free light chain follow up may not be sufficient. MRI's (rather that PET/CT scans) may be quite useful (every 6 to 12 months?) to detect bone lesions before they become symptomatic. I have not seen any studies looking at this particular question. Are you aware of any? The Myeloma Beacon's combination of clinical study summaries interspersed with quite profound personal essays is very much appreciated.

  • Richard Anter said:

    I have been through exactly what you describe - rev, velcade and Dex. After stem cell transplant in March, 2012 I am doing great. My question is that you give no timeframe for a relapse. In your study, what period of time passes until a relapse became detectable?

    Respectfully,
    Richard Anter