The International Myeloma Workshop 2017 in New Delhi Begins and Consensus in the Management of Multiple Myeloma in India
The International Myeloma Workshop begins today at New Delhi, India. It is very exciting to have the entire Who’s Who of myeloma on a single platform. Following all the great insights and discussion on myeloma research and treatment.
While we have almost the entire myeloma fraternity in India, a look at myeloma treatment here:
The management of multiple myeloma is far from uniform among Indian physicians. Of course, there are aspects which are unique to Indian patients making it difficult for a consensus in the treatment of myeloma in India. While researching myeloma treatment options in India, we spoke to some of the greatest in the field both in India as well as outside and was surprised at the difference in treatment modalities and availability of therapies in India.
Even though some of the factors continue to inhabit the field, things have changed.
We now have a consensus in the management of multiple myeloma in India spearheaded by the Indian Academic Groupe (IMAGE). The group was formally launched in October 2016 and consists of national experts on the subject who have finally put down details on how myeloma can be treated and managed in India. The consensus was presented at the Myeloma State of the Art 2016 Conference and will be discussed extensively at the ongoing Myeloma International Workshop 2017 in New Delhi.
Let’s take a look at the consensus in detail:
Labs for Newly Diagnosed Myeloma Patient and Disease Monitoring
There are quite a few constraints that physicians in India come up against during initial lab work such as,
- Availability of laboratory infrastructure in the form of equipment and expertise
- Quality assurance
- Financial affordability of patient and travel to health facility
Working within these limitations, the consensus recommends the following:
Plasma Cell Percentage
In ideal conditions, 1000 cell mononuclear cell count is required for estimating plasma cell percentage but this is rarely done in laboratories in India due to lack of expert pathologists and workload. Another hindrance, is non-availability of immunohistochemistry on bone marrow biopsy and aspirate. Even in places where this is done, plasma cell percentage is rarely reported. Flow cytometry can be used at centers where this is available. It is advised that a combination of bone marrow aspirate, bone marrow biopsy and flow cytometry should be checked where patient presents with abnormal plasma cell numbers and the highest measurement should be considered for calculation of plasma cells.
The consensus recommends that wherever possible FISH should be the preferred investigation test. Metaphase cytogenetic testing is not standardised and rarely available in India and where available the hurdles of this labor intensive procedure like timely transportation of sample, separation and isolation of plasma cells make it economically non viable for labs.
Evaluation of M Protein
Quantiﬁcation of M band, serum immunoﬁxation and urine protein electrophoresis (UPEP) should be performed at diagnosis. Most experts felt that it is important to do UPEP, urine immunoﬁxation (UIFE), and Bence Jones Protein on 24 hour urinary collection rather than the spot urine in patients with MM.
UPEP is not performed routinely in most centers (even academic). The evaluation of BJP or spot urine by dipsticks cannot be an alternative for 24 h UP or prelude to the UPEP. A qualitative UPEP may diagnose free light chain myeloma in cases where sFLC is not done. The reasons for not routinely doing UPEP include lack of education of the physicians and hematologists/oncologists, cost constraints and difﬁculty in collecting 24-h urine. Also, it is important to compare the extent of proteinuria at baseline to that on follow up. The possibility of bisphosphonate-induced proteinuria must be entertained in patients who develop increasing proteinuria while showing a response to therapy as assessed by other disease parameters. The 24 h UP estimation is particularly useful in suspected cases of light chain amyloidosis. For BJP testing early morning 150 mL urine can be substituted for 24 h urinary collection to avoid difﬁculties in the urine collected. Although the necessity of UPEP, UIFE and BJP is questionable in patients who undergo SFLC estimation, however, these parameters continue to be a part of response criteria and are thus required on follow-up. Secondly, some patients with free light chain escape can be picked up using UPEP who have increased excretion of the FLC with normal serum FLC. Also, the availability of the SFLC at different places in India is scarce.
In patients presenting with plasmacytoma or extramedullary disease, a PET/CT scan can be recommended. However, in patients with lytic lesions PET/CT has limited role. Availability and cost continue to be issues.
sFLC (Serum Free Light Chain measurement)
SFLC can be avoided if the SIFE and SPEP can identify the type of heavy and light chain at the diagnosis if cost is an issue.
The standardization of the platform for SFLC is not present in India. The difference between light chain assay and the free light chain assay was emphasized by the experts. It is mandatory to do free light chain assay at diagnosis.
Immunoglobulin levels (Ig) in Monitoring
Ig levels have a role in the monitoring of IgA or IgD myeloma. In patients with frequent infections, Ig levels can be used to monitor immune paresis (reduction of immunoglobulin levels).
Investigation for the cause of Anemia
In a developing country like India, anemia may be multifactorial in origin so a relevant minimal set of investigations (iron proﬁle, RBC indices, peripheral blood smear) for diagnosing the etiology of anemia are required before attributing it solely to multiple myeloma.
Evaluation for associated plasma cell disorders
It is important to keep in mind that monoclonal gammopathies represent a wide spectrum of disorders. Amyloidosis and LCDD should be considered in the differential when patients have signiﬁcant proteinuria.
We will be looking at myeloma treatment and maintenance in India in details in the next write up. Stay tuned.