International Myeloma Working Group (IMWG) Criteria for the Diagnosis of Multiple Myeloma

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The updated criteria for the diagnosis of myeloma represent a paradigm shift in the approach to myeloma and have considerable impact on the management of the disease. For decades the diagnosis of multiple myeloma required the presence of end-organ damage known as the CRAB criteria, including increased calcium level, renal dysfunction, anemia, and destructive bone lesions. The updated criteria allow for treatment of patients who are at such high risk of progression to symptomatic disease that it is clear they would benefit from therapy—and also potentially live longer—if they were treated before serious organ damage occurred. The revised IMWG criteria allow, in addition to the classic CRAB features, three “myeloma defining […]

IMWG Guidelines for the Management of Treatment-Emergent Peripheral Neuropathy in Multiple Myeloma (MM)

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The incidence, symptoms, reversibility, and predisposing factors of treatment-emergent peripheral neuropathy (PN) vary among myeloma therapies. PN incidence is affected by treatment dose and schedule, by combinations of potentially neurotoxic agents, and by patient characteristics. Strategies for managing PN include early and regular monitoring, dose modification, and treatment discontinuation. Because there is no cure for drug-induced PN, prevention is a key strategy for preserving quality of life and future treatment options. Following are evidence-based guidelines for preventing, assessing, and treating PN. PREVENTION OF PN The optimal prevention of treatment-induced PN in MM patients can be achieved with careful dose modification of the treatments that cause it, chiefly bortezomib and thalidomide. […]

IMWG Consensus Statement Regarding the Current Status of Allogeneic Stem Cell Transplantation for Multiple Myeloma

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There has been much controversy in over two decades about the role of allogeneic stem cell transplant in myeloma. Early studies conducted in Europe and at the Fred Hutchinson Cancer Center in Seattle, WA, consistently demonstrated high treatment-related mortality (TRM) of approximately 45% in heavily patients receiving full myeloablative allogeneic transplant (full allo). Overall survival rates in these studies were generally less than 30% at five years. Full allo in myeloma patients was therefore largely abandoned worldwide in the early 1990s. There were, however, some long-term remission durations among patients treated within one year of diagnosis, after a single line of therapy, and with chemotherapy-sensitive disease. In fact, there was […]

International Myeloma Working Group (IMWG) Guidelines for Serum Free Light Chain Analysis in Multiple Myeloma and Related Disorders

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For the more than 3% of myeloma patients who have non-secretory or oligosecretory disease, and for the majority of patients with AL amyloidosis (AL), the traditional methods of measuring circulating monoclonal immunoglobulins (electrophoresis, immunoelectrophoresis, immunofixation electrophoresis, and nephelometric measurement of immunoglobulin heavy chains of serum) are not adequate. The development of an assay that measures serum immunoglobulin-free light chains has demonstrated utility for monitoring these patients and for other specific indications, such as monitoring heavily-pretreated patients at relapse. The following guidelines from the International Myeloma Working Group describe the potential uses of the serum free light chain (SFLC) assay and distinguish which uses have proved their utility and which are […]

International Myeloma Working Group (IMWG) Molecular Classification of Multiple Myeloma

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The intent of this statement is to provide a biological classification of multiple myeloma and to establish the prognostic value of known genetic factors. Myeloma is divided at the highest genetic level into two subtypes: disease that is hyperdiploid (h-MM), and disease that is non-hyperdiploid (nh-MM). The non-hyperdiploid type is characterized by immunoglobulin heavy-chain (IgH) translocations and is generally associated with more aggressive disease and shorter survival. Accurate prognostic determination of disease course allows for a more rational selection and sequencing of therapy approaches and more direct discussion with the patient regarding disease threat. Risk stratification is essential for better understanding of the composition of patients in clinical trials, and […]

International Myeloma Working Group (IMWG) Uniform Response Criteria for Multiple Myeloma

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The International Myeloma Working Group established the below criteria in order to: facilitate precise comparisons of efficacy between new treatment strategies in trials incorporate the serum free light chain (FLC) assay to include assessment of patients with oligo-secretory and non-secretory disease provide stricter definitions for CR (complete response) provide classifications that would improve detail and correct inconsistencies in prior response criteria. The following criteria reconcile various previously used systems for assessing response and have been universally adopted. Response IMWG criteria sCR CR as defined below plus normal FLC ratio and absence of clonal cells in bone marrow3 by immunohistochemistry or immunofluorescence4 CR Negative immunofixation on the serum and urine and […]

IMWG Guidelines for the Prevention of Thalidomide- and Lenalidomide-Associated Thrombosis in Myeloma

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The risk of VTE in cancer patients is greater than 7%; those with myeloma have the highest risk of thrombosis.2 The oral immunomodulatory drugs, thalidomide and lenalidomide, further increase that risk. The following guidelines from the International Myeloma Working Group recommend a prophylaxis strategy based upon a risk assessment model. The recommendations have been made in the absence of clear data from randomized studies, and are therefore based on common sense and on data extrapolated from many studies not specifically designed to answer these questions. Treatment decisions must be based on the type of therapy and the patient’s individual risk factors. Risk factors for venous thromboembolism (VTE) in myeloma patients […]

IMWG consensus statement on the role of vertebral augmentation in multiple myeloma

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Following are the recommendations of the IMWG on role of minimally invasive percutaneous injection of polymethyl methacrylate (PMMA), first developed as “vertebroplasty” in France in the late 1980s, as treatment for painful vertebral compression fractures (VCFs). Consequences of VCF-related kyphosis Compression of abdominal contents Anorexia, weight loss Decreased lung capacity Limited exercise tolerance/physical activity Anterior loading of spine Subsequent fractures Increasing kyphosis and deformity Types of vertebral augmentation Vertebroplasty: fractured bone fragments are stabilized and strengthened by percutaneous injection of PMMA. Kyphoplasty:  inflation of a balloon in the vertebral body prior to PMMA injection can restore vertebral height and reduce kyphotic deformity in addition to stabilizing the fractured vertebral body. […]

IMWG Guidelines for Facilities and Services for the Management of Myeloma Patients

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The following guidelines are excerpted from Palumbo et al, International Myeloma Working Group Guidelines for the Management of Multiple Myeloma Patients Ineligible for Standard High-Dose Chemotherapy with Autologous Stem Cell Transplantation, Leukemia (2009), 1-15. The most important feature of any clinical unit established to care for myeloma patients is the training and expertise of the medical staff.   Below are the diagnostic and specialty services required to support treatment decision-making and patient management.  Patient support services, though desirable hallmarks of a good specialty center, are not absolutely essential. Facilities It is recommended that a special clinical unit be developed devoted to the treatment of MM, with clear policies and protocols for […]

IMWG Guidelines on Imaging Techniques in the Diagnosis and Monitoring of Multiple Myeloma

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Up to 90% of myeloma patients develop osteolytic lesions, a major cause of morbidity and mortality, during the course of their disease. 2  Appropriate use of imaging techniques is essential to identify and characterize skeletal complications resulting from MM, to determine the extent of intramedullary and extramedullary foci, and to evaluate disease progression. Several imaging techniques are used to clarify bone and soft tissue disease in the diagnosis and management of myeloma: conventional radiography, computed tomography (CT), magnetic resonance imaging (MRI), and nuclear medicine imaging. The following International Myeloma Working Group (IMWG) guidelines provide recommendations for the use of each of the technologies. The appropriate use of these various technologies […]