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9 augustus 2011: Bron: N Engl J Med 2011; 365:474-475

Mensen waarvan het beenmerg meer dan 60% plasma cellen bevat hebben een veel grotere kans op het ontwikkelen van botkanker, Multiple Myeloma - Kahler dan mensen die weinig tot geen plasma cellen in het beenmerg hebben. Dit blijkt uit een gerandomiseerde fase III studie bij 655 patienten die Multiple Myeloma bleken te hebben ontwikkeld in de periode van 1996 tot 2010. Het verschil tussen de mensen die weinig tot geen plasmacellen hadden was in vergelijking met degenen die 60 procent of meer plasma cellen hadden in het beenmerg significant in het nadeel van degenen die 60% of meer plasmacellen in het beenmerg hadden (P<0.001) in relatie tot ziektevrije tijd en mediane overlevingstijd. Hier het abstract van de studie die werd gepubliceerd in de New England Journal of Medicin - NEMJ.

Bone marrow involvement predicts progression to symptomatic myeloma

Bron: N Engl J Med 2011; 365:474-475

In 2007, we reported in the Journal the diagnosis, natural history, and progression of smoldering multiple myeloma (SMM).1 Consistent with the accepted definition of this disease,2 patients with bone marrow containing 10% or more plasma cells and no evidence of end-organ damage attributable to the plasma-cell disorder were considered to have SMM; however, no upper limit of bone marrow involvement was defined. Since then, major advances in the field have led to evolving definitions of SMM, along with changes in therapy.3 Accordingly, the natural history described in our paper may not apply to patients with marked bone marrow infiltration. In order to define an upper limit of bone marrow involvement for SMM, we reassessed the cohort described in our original publication and found that only 6 of 276 patients (2%) had bone marrow containing 60% or more plasma cells. Furthermore, 4 of these 6 patients progressed to symptomatic myeloma 3 to 9 months after the diagnosis of SMM, and 1 of these patients died 13.5 months after the diagnosis, with no information available about whether or not the disease had progressed. In the 1 remaining patient, SMM progressed to myeloma 50 months after the diagnosis, which resulted in death within 2 years of that date. The median progression-free survival of these 6 patients was 7.7 months (95% confidence interval , 0.4 to 14.9); 83% had progression or died by 14 months after the diagnosis.

We then studied all patients diagnosed with SMM at the Mayo Clinic from January 1996 through June 2010. This group comprised 655 patients who underwent a baseline bone marrow evaluation at the time of diagnosis; in 21 of these patients (3.2%), the percentage of bone marrow plasma cells was at least 60%. The median time to progression to symptomatic myeloma was significantly shorter among the patients with 60% or more bone marrow involvement, as compared with those having less than 60% involvement (P<0.001) (Figure 1Figure 1Time to Progression of Disease in Patients Diagnosed with Smoldering Multiple Myeloma, as Stratified According to the Percentage of Plasma Cells in the Bone Marrow (BMPC) at Baseline.). Progression to myeloma occurred within 2 years of the diagnosis in 95% of the patients with 60% or more bone marrow plasma cells, with a median time to progression of 7 months (95% CI, 1.0 to 12.9). We conclude that the natural history of SMM is based almost exclusively on data from patients in whom the number of bone marrow plasma cells is less than 60%. In patients without end-organ damage at diagnosis but with 60% or greater bone marrow involvement, the clinical course is characterized by progression to symptomatic myeloma within 2 years. Such patients should be considered to have myeloma that requires therapy at the time of diagnosis.

S. Vincent Rajkumar, M.D.
Dirk Larson, M.S.
Robert A. Kyle, M.D.
Mayo Clinic, Rochester, MN

Disclosure forms provided by the authors are available with full text of this letter at NEJM.org.

3 References

  1. 1

    Kyle RA, Remstein ED, Therneau TM, et al. Clinical course and prognosis of smoldering (asymptomatic) multiple myeloma. N Engl J Med 2007;356:2582-2590
    Full Text | Web of Science | Medline

  2. 2

    The International Myeloma Working Group. Criteria for the classification of monoclonal gammopathies, multiple myeloma and related disorders: a report of the International Myeloma Working Group. Br J Haematol 2003;121:749-757
    CrossRef | Web of Science | Medline

  3. 3

    Kyle RA, Rajkumar SV. Criteria for diagnosis, staging, risk stratification and response assessment of multiple myeloma. Leukemia 2009;23:3-9
    CrossRef | Web of Science | Medline

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