Table 5.
Our Approach to Monitoring and Assessing Disease
| Stage of Treatment | Assessment Goals | Intervention | Timing |
|---|---|---|---|
| During treatment | Treatment tolerance Treatment response |
Physical and neurological examination Neurological outcome measures |
3 mo and if any new clinical symptoms reported |
| Toxicity (infections, neuropathy, organ function | FBC, SPEP ± SFLC (if informative) | With each treatment cycle | |
| Anticoagulation plan | Review anticoagulation and antiplatelet therapy | With each treatment cycle and adjust according to VEGF reduction/ platelet count | |
| Endocrinopathy | Renal, liver and bone profile. Hepatitis B DNA PCR if prior exposure | With each treatment cycle | |
| Ongoing response assessment | Endocrine profilea | Adjust steroid replacement (Hydrocortisone) dose for hypoadrenalism according to concurrent therapeutic steroids (dexamethasone) Tailor to individual requirement (3–6 mo) |
|
| VEGF | With each treatment cycle | ||
| Imaging | Not routinely indicated for treatment surveillance; consider appropriate imaging for new symptoms Consider DEXA scan for bone density if hypogonadal or hypoadrenal, on long-term steroids or severe impaired mobility |
||
| Categorical response assessment | Overall assessment of treatment response (3–6 mo following frontline therapy) | Physical and neurological examination (including appropriate neurological outcome measure testing) | |
| FBC, SPEP, SFLC, serum immunoglobulins, renal, liver and bone profile | |||
| Endocrine profilea | |||
| VEGF | |||
| Pulmonary function tests, echocardiogram | If significant cardiopulmonary dysfunction before treatment or ongoing | ||
| Nerve conduction studies/EMG | If evidence of further neurological deterioration on assessment | ||
| Imaging (PET-CT/MRI) | Depending on clinical circumstances (FDG-avidity may persist months to years) | ||
| Bone marrow biopsy | If previous positive findings AND ambiguity about categorical response | ||
| Posttreatment | Monitor for disease relapse Monitoring of late effects/ treatment toxicity: skeletal, infections, secondary malignancy (particularly post-ASCT) Neuropathy Endocrinopathy Health education (diet, physical activity, weight control) |
||
| Physical and neurological examination Neurological outcome measures |
CR: 6–12 mo <CR: 3–6 mo |
||
| FBC, SPEP, SFLC, Serum immunoglobulins, Renal, liver and bone profile | |||
| Endocrine profilea | |||
| VEGF | |||
| Pulmonary function tests, echocardiogram | Consider annually | ||
| Nerve conduction studies/EMG | Depending on clinical symptoms | ||
| Imaging (PET-CT/MRI) | Low threshold for reimaging if new clinical symptoms arise | ||
| Imaging (DEXA) | Consider as per osteoporosis guidelines if hypogonadal or prolonged corticosteroid exposure | ||
| Bone marrow biopsy | Before any new treatment consideration | ||
a
Endocrine profile: testosterone, estradiol; fasting glucose, glycosylated hemoglobin; thyroid-stimulating hormone, parathyroid hormone; luteinizing hormone, follicle-stimulating hormone, and adrenocorticotrophic hormone.
ASCT = autologous stem cell transplantation; DEXA = dual-energy x-ray absorptiometry; EMG = electromypgraphy; FBC = full blood count; MRI = magnetic resonance imaging; PET = positron emission tomography; SFLC = serum-free light chains; SPEP = serum protein electrophoresis; VEGF = vascular endothelial growth factor.