多发性骨髓瘤2021.v5（英文）-NCCN肿瘤临床实践指南

NCCNClinicalPracticeGuidelinesinOncologyNCCNGuidelines®)MultipleMyelomarsionMarchNCCNGuidelinesforPatients®availableat/patientsVersion5.2022,03/09/22©2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon3/14/20227:04:15AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dex*ShajiK.Kumar,MD/Chair‡ξMayoClinicCancerCenter*NatalieS.Callander,MD/ViceChair‡ξUniversityofWisconsineCancerCenterKehindeAdekola,MD,MSCI‡†RobertH.LurieComprehensiveCancerCenterofNorthwesternUniversityLarryD.Anderson,Jr.,MD,PhD‡†UTSouthwesternSimmonsComprehensiveCancerCenterMuhamedBaljevic,MD†‡ÞξVanderbilt-IngramCancerCenterEricaCampagnaro,MD‡UniversityofMichiganRogelCancerCenterJorgeJ.Castillo,MD‡Dana-Farber/BrighamandWomen’sCancerCenter|MassachusettsGeneralHospitalCancerCenterCaitlinCostello,MD†‡ξUCSanDiegoMooresCancerCenterChristopherD'Angelo,MD†Fred&PamelaBuffettCancerCenterSrinivasDevarakonda,MD‡†TheOhioStateUniversityComprehensiveCancerCenter-JamesCancerHospitalandSoloveResearchInstituteNouraElsedawy,MD†St.JudeChildren'sResearchHospital/TheUniversityofTennesseeeCenteratthewFaimanMDMBArehensiveCancerCenteriversityHospitalsSeidmanCancerCenternstituteAlfredGarfall,MD‡AbramsonCancerCenterheUniversityofPennsylvaniaKellyGodby,MD†O'NealComprehensiveCancerCenteratUABJensHillengass,MD,PhD‡RoswellParkComprehensiveCancerCenterLeonaHolmberg,MD,PhDξ‡FredHutchinsonCancerResearchCenter/SeattleCancerCareAllianceMyoHtut,MD‡ÞCityofHopeNationalMedicalCenterCarolAnnHuff,MD†‡TheSidneyKimmelComprehensiveCancerCenteratJohnsHopkinsMalinHultcrantz,MD,PhD‡†MemorialSloanKetteringCancerCenterYubinKang,MD‡†ξDukeCancerInstituteSarahLarson,MD†UCLAJonssonComprehensiveCancerCenterMichaelaLiedtke,MD‡StanfordCancerInstituteThomasMartin,MD‡UCSFHelenDillerFamilyComprehensiveCancerCenterJamesOmelMD¥eDouglasSborov,MD,MSc†‡ÞξHuntsmanCancerInstituteattheUniversityofUtahKennethShain,MD,PhD†MoffittCancerCenterKeithStockerl-Goldstein,MD†ξSitemanCancerCenteratBarnes-JewishHospitalandWashingtonUniversitySchoolofMedicineDonnaWeber,MD†‡ÞTheUniversityofTexasdiMScesPanelDisclosuresξBonemarrowtransplantation†Medicaloncology‡Hematology¥PatientadvocacyeeÞInternalmedicine*DiscussionsectioneeVersion5.2022,03/09/22©2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.MyelomaPanelMembersryofGuidelinesUpdatesicWorkupandClinicalFindingsMYELSolitaryPlasmacytomaorSolitaryPlasmacytomawithMinimalMarrowInvolvement:PrimaryTreatmentandMyelomaPanelMembersryofGuidelinesUpdatesicWorkupandClinicalFindingsMYELSolitaryPlasmacytomaorSolitaryPlasmacytomawithMinimalMarrowInvolvement:PrimaryTreatmentandFollow-up/Surveillance(MYEL-2)SmolderingMyelomaAsymptomaticPrimaryTreatmentandFollowUpSurveillanceMYEL-3)MultipleMyelomaSymptomaticPrimaryTreatmentandFollowUpSurveillanceMYEL-4)MultipleMyelomaSymptomaticResponseAfterPrimaryTherapyandFollowUpSurveillanceMYEL)tmentPostAutologousHematopoieticCellTransplantMYELyelomaSymptomaticAdditionalTreatmentforRelapseorProgressiveDiseaseMYELStagingSystemsforMultipleMyeloma(MYEL-A)PrinciplesofImaging(MYEL-B)DefinitionsofSmolderingandMultipleMyeloma(MYEL-C)PrinciplesofRadiationTherapy(MYEL-D)ResponseCriteriaforMultipleMyeloma(MYEL-E)GeneralConsiderationsforMyelomaTherapy(MYEL-F)MyelomaTherapy(MYEL-G)SupportiveCareforMultipleMyeloma(MYEL-H)ManagementofVenousThromboembolism(VTE)inMultipleMyeloma(MYEL-I)ManagementofRenalDiseaseinMultipleMyeloma(MYEL-J)mmopathyofClinicalSignificance•MonoclonalGammopathyofRenalSignificance(MGRS-1)•MonoclonalGammopathyofNeurologicalSignificance(MGNS-1)POEMSPolyneuropathyOrganomegalyEndocrinopathyMonoclonalProtein,SkinChanges)(POEMS-1)dexClinicalTrials:NCCNbelievesthatthebestmanagementforanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.ernorgtutionsNCCNCategoriesofPreference:Allrecommendationsareconsideredappropriate.TheNCCNGuidelinesareastatementofevidenceandconsensusoftheauthorsregardingtheirviewsofcurrentlyacceptedapproachestotreatmentAnyclinicianseekingtoapplyorconsulttheNCCNGuidelinesisexpectedtouseindependentmedicaljudgmentinthecontextofindividualstancestodetermineanypatientscareortreatmentTheNationalComprehensiveCancerNetworkNCCNmakesnorepresentationsorwarrantiesofanykindregardingtheircontentuseorapplicationanddisclaimsanyresponsibilityfortheirapplicationoruseinanywayTheNCCNbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.©2021.Version5.2022,03/09/22©2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon3/14/20227:04:15AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexsionoftheNCCNGuidelinesforMultipleMyelomafromVersionincludeMYEL-G4of4•TherapyforPreviouslyTreatedMultipleMyelomapTherapiesforpatientswithLateRelapses(>3priortherapies):◊Ciltacabtageneautoleucelwasaddedasanoptionafteratleastfourpriortherapies,includingananti-CD38monoclonalantibody,aPI,andanIMiD.sionoftheNCCNGuidelinesforMultipleMyelomafromVersionincludeMYEL-G3of4•TherapyforPreviouslyTreatedMultipleMyeloma:pThefollowingregimenwasremovedfromOtherRecommendedRegimensforEarlyRelapse(1-3priortherapies):◊Panobinostat/bortezomib/dexamethasone(category1)MYEL-G4of4•TherapyforPreviouslyTreatedMultipleMyelomapUsefulinCertainCircumstancesforEarlyRelapses(1-3priortherapies):◊Thefollowingnewregimenwasadded:Selinexor/carfilzomib/dexamethasone◊Thefollowingwereremoved:–AftertwopriortherapiesincludingbortezomibandanIMiD:▪Panobinostat/carfilzomibinostatlenalidomidedexamethasoneNote:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.Version5.2022,03/09/22©2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.UPDATESPrintedbyMinTangon3/14/20227:04:15AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexUpdatesinVersion3.2022oftheNCCNGuidelinesforMultipleMyelomafromVersion2.2022include:MYEL-G4of4•TherapiesforLateRelapses(>3priortherapies)pTheregimenmelphalanflufenamide/dexamethasonewasremoved.sionoftheNCCNGuidelinesforMultipleMyelomafromVersionincludeMYEL-G1of4and2of4•MaintenanceTherapypOtherRecommendedRegimens◊Ixazomibwasmodifiedto:Ixazomib(category1category2B)•Footnoteiadded:ResultsfrominterimanalysesofTOURMALINEMM3andMM4trialsofixazomibinthemaintenancesettingsuggestsapotentialdecreaseinoverallsurvival.MYEL-G2of4•PrimaryTherapyforNon-TransplantCandidatespPreferredRegimens◊FootnotejremovedfromregimenBortezomib/lenalidomide/dexamethasone:Thisistheonlyregimenshowntohaveoverallsurvival.benefit.UpdatesinVersion1.2022oftheNCCNGuidelinesforMultipleMyelomafromVersion7.2021include:MYEL-2MYEL-3parameterflowcytometryasclinicallyparameterflowcytometryasclinically•Follow-UpSurveillancedicatedneededpSecondbulletadded:TestsdicatedneededThirdbulletrevisedWhole-bodyimagingwithMRIwithoutThirdbulletrevisedWhole-bodyimagingwithMRIwithoutcontrast,wdoseCTscanFDGPETCTannuallyorasclinicallyindicatedSPEP,withSIFEasneededneeded,ideallywiththesametechniqueusedatdiagnosis.MYEL-4needed,ideallywiththesametechniqueusedatdiagnosis.MYEL-4FootnotedaddedfromMYEL1:SkeletalsurveyisacceptableintaincircumstancesHoweveritissignificantlylesssensitivethanowdoseCTandFDGPETCTIfwholebodyFDGPETCTorlow-doseCThasbeenperformed,thenskeletalsurveyisnotneeded.◊Fourthsub-bulletrevised:SerumLDHandbeta-2microglobulinasclinicallyindicated◊Fifthsub-bulletrevised:Bonemarrowaspirateandbiopsyasclinicallyindicated◊Sixthsub-bulletadded:Allplasmacytomasshouldbeimagedyearly,preferablywiththesametechniqueusedatdiagnosis,foratleast5years.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.Version5.2022,03/09/22©2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.UPDATESPrintedbyMinTangon3/14/20227:04:15AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexsionoftheNCCNGuidelinesforMultipleMyelomafromVersioninclude•MultipleMyeloma(Symptomatic)pRevised:Tandemautologousorallogeneichematopoieticcelltransplant,undercertaincircumstances.•Follow-Up/SurveillancepThirdbulletrevised:24-hurinefortotalprotein,UPEP,andUIFEatbaselineandasclinicallyindicatedneededorifthereisasignificantchangeinFLClevelspFifthbulletrevised:Whole-bodyadvancedimagingwithFDGPET/CT,low-doseCTscan,MRIwithoutcontrastasclinicallyneeded,ideallywiththesametechniqueusedatpSixthbulletrevised:BonemarrowaspirateandbiopsywithmultiparameterflowcytometryasclinicallyindicatedneededMYEL-B1of2•ImagingforInitialDiagnosticWorkup(forpatientssuspectedofmyeloma/solitaryplasmacytoma)pFirstbulletrevisedbyaddingsentence:AsmallpercentageofpatientsmayhaveanegativePET/CTwithactiveMM.•ImagingforFollow-upofMMpFirstbulletrevised:Advancedwhole-bodyimaging(ie,FDGPET/CT,low-doseCTscan,whole-bodyMRIwithoutcontrast)isrecommendedasclinicallyindicatedneeded.MYEL-CFootnotebaddedBMPCs)>20%,M-protein>2g/dL,and(FLCr)arevariablesusedtoriskstratifypatientsatdiagnosis.PatientswithtwoormoreoftheseriskfactorsareconsideredtoighriskofprogressiontoMMLakshmanAetalBloodCancerJ2018;8:59.•SolitaryPlasmacytomapTreatmentInformation/Dosing:◊Firstbullet,firstsub-bulletrevised:RT(40–50Gyin1.8–2.0Gyfractions[20–25totalfractions])toinvolvedfield.•MultipleMyelomapPalliativeRTDosingforMM◊Firstbulletrevised:Low-doseRT(8Gyx1fractionor10–30Gyin2.0–3.0Gyfractions[5–10totalfractions])canbeusedaspalliativetreatmentforuncontrolledpain,forimpendingpathologicfracture,orforimpendingcordcompression.MYEL-F•Headinghasbeenrevised:PrinciplesofGeneralConsiderationsfor•GeneralPrinciplespFourthbulletadded:FortheMyelomaFrailtyScoreCalculatordevelopedbyInternationalMyelomaWorkingGroupfortheprognosisofelderlymyelomapatients,seehttp://www./pFifthbulletadded:Considerdosemodificationsbasedonfunctionalstatusandage.•DosingandAdministrationpFourthbulletwasmovedfromMYEL-G:Foranyregimenthatincludesdaratumumab,thiscouldbedaratumumabforintravenousinfusionordaratumumabandhyaluronidase-fihjforsubcutaneousinjection.Daratumumabandhyaluronidase-fihjforsubcutaneousinjectionhasdifferentdosingandadministrationinstructionscomparedtodaratumumabforintravenousinfusion.•Referenceadded:PalumboA,BringhenS,MateosMV,etal.Geriatricassessmentpredictssurvivalandtoxicitiesinelderlymyelomapatients:AnInternationalMyelomaWorkingGroupreport.Blood2015;125:2068-2074.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.Version5.2022,03/09/22©2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.UPDATESPrintedbyMinTangon3/14/20227:04:15AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexsionoftheNCCNGuidelinesforMultipleMyelomafromVersionincludeMYEL-G1of4•PrimaryTherapyforTransplantCandidatespThefollowingregimensweremovedfromPreferredRegimenstoUsefulinCertainCircumstances◊Bortezomib/cyclophosphamide/dexamethasonepThefollowingnewregimenwasaddedtoUsefulinCertainCircumstancesdexamethasone•MaintenanceTherapypUsefulinCertainCircumstances◊TheregimenBortezomib/lenalidomidewasrevisedtoBortezomib/lenalidomide±dexamethasone•FootnotefwasmovedtoGeneralConsiderationsforMyelomaTherapy.(AlsoforMYEL-G2of4)•Footnoteiadded:Dualmaintenancerecommendedforhigh-riskMM.MYEL-G2of4•PrimaryTherapyforNon-TransplantCandidatespThefollowingregimensweremovedfromPreferredRegimenstoUsefulinCertainCircumstances:◊Lenalidomide/low-dosedexamethasone(category1)◊Bortezomib/cyclophosphamide/dexamethasonepThefollowingnewregimenwasaddedtoUsefulinCertainCircumstances:◊Bortezomib/lenalidomide/dexamethasone(VRD-lite)forfrailPatients•MaintenanceTherapypThefollowingregimenwasaddedtoOtherRecommendedRegimens:◊Ixazomib(category1)MYEL-G3of4•Regimenswerereorganizedbyearly(1-3priortherapies)andlaterelapses(>3priortherapies).•EarlyRelapses:pThefollowingregimensweremovedfromOtherRecommendedtoPreferred:◊Isatuximab-irfc/carfilzomib/dexamethasone(category1)◊Daratumumab/pomalidomide/dexamethasone(category1)•Footnoteadded:Regimensincludedunder1-3priortherapiescanalsobeusedlaterinthediseasecourse/Attemptshouldbemadetousedrugs/drugclassesthepatientshavenotbeenexposedtoorexposedto>1lineprior.•Footnoteadded:Autologousstemcelltransplantshouldbeconsideredinaneligiblepatientwhohadnotpreviouslyreceivedtransplantorhadaprolongedresponsetoinitialtransplant.MYEL-G4of4pUsefulinCertainCircumstances:◊Fifthbulletrevised:High-doseorfractionatedcyclophosphamideMYEL-I1of3•Newsectionadded:ManagementofVenousThromboembolism(VTE)inMultipleMyelomaMGRS-1•InitialWorkuppRenalBiopsyrecommendedif:◊Secondbulletrevised:eGFR<60mL/minand>2ml/minperyeardeclinepConsiderrenalbiopsyif:◊Secondbulletrevised:eGFR<60mL/minand><2mL/minperyeardecline◊Thirdbulletremoved:Proteinuria◊FourthBulletrevised:Albumin:creatinine3-30mg/mmolorandGFR<60mL/minMGNS-1•InitialWorkuppFirstbullet,ninthsub-bulletrevised:Evaluationforlightchainamyloidosis,ifappropriate(SeeNCCNGuidelinesforSystemicLightChainAmyloidosis),WM(SeeNCCNGuidelinesforWM),orPOEMS(SeePOEMS-1),ifappropriate.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.Version5.2022,03/09/22©2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.UPDATESfunctiontests,albumin,bcalcium,serumuricacid,serumLDH,bandbeta-2microglobulinb•Creatinineclearance(calculatedormeasureddirectly)c•Serumquantitativeimmunoglobulins,serumproteinelectrophoresis(SPEP),serumimmunofixationelectrophoresis(SIFE)•24-hurinefortotalprotein,urineproteinelectrophoresis(UPEP),andurineimmunofixationelectrophoresisfunctiontests,albumin,bcalcium,serumuricacid,serumLDH,bandbeta-2microglobulinb•Creatinineclearance(calculatedormeasureddirectly)c•Serumquantitativeimmunoglobulins,serumproteinelectrophoresis(SPEP),serumimmunofixationelectrophoresis(SIFE)•24-hurinefortotalprotein,urineproteinelectrophoresis(UPEP),andurineimmunofixationelectrophoresis(UIFE)•Serumfreelightchain(FLC)assay•Whole-bodylow-doseCTscanorFDGPET/CTd,e•Unilateralbonemarrowaspirateandbiopsy,includingimmunohistochemistry(IHC)and/ormulti-parameterflowcytometry•Plasmacellfluorescenceinsituhybridization(FISH)bpanelonbonemarrowf[del13,del17p13,t(4;14),t(11;14),t(14;16),t(14:20),1q21gain/amplification,1pdeletion]generationsequencingNGSpanelonwf•Considerbaselinecloneidentificationandstorageofaspiratesampleforfutureminimalresidualdisease(MRD)testingbyNGS•Assessforcirculatingplasmacellsasclinicallyindicated•Historyandphysicalexam(H&P)•CBC,differential,plateletcount•Peripheralbloodsmear•SerumBUN/creatinine,electrolytes,liverryYELryYELingicgmacganceseelogicalanceseeesinicalficancedexINITIALDIAGNOSTICWORKUPaCLINICALFINDINGSinCircumstances•Ifwhole-bodylow-doseCTorFDGPET/CTisnegative,considerwhole-bodyMRIwithoutcontrasttodiscernsmolderingmyelomafromMM•Tissuebiopsytoconfirmsuspectedplasmacytoma•Plasmacellproliferation•Serumviscosity•HLAtyping•HepatitisBandHepatitisCtestingandHIVscreeningasrequired•Echocardiogram•Evaluationforlightchainamyloidosis,ifappropriate(SeeNCCNGuidelinesforryYELryYELarrayonbonemarrow,fand/arrayonbonemarrow,fand/ornext-aFrailtyassessmentshouldbeconsideredinolderadults.SeeNCCNGuidelinesforOlderAdultOncology.bThesetestsareessentialforR-ISSstaging.SeeStagingSystemsforMultipleMyeloma(MYEL-A).cSeeManagementofRenalDiseaseinMultipleMyeloma(MYEL-J).ebodydSkeletalsurveyisacceptableincertaincircumstances.However,ebodyFDGPET/CTorlow-doseCThasbeenperformed,thenskeletalsurveyisnotneeded.eSeePrinciplesofImaging(MYEL-B).fCD138positiveselectedsampleisstronglyrecommendedforoptimizedyield.gSeeDefinitionsofSmolderingandMultipleMyeloma(MYEL-C).Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.MYEL-1Version5.2022,03/09/22©2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.FOLLOW-UP/SURVEILLANCEPrintedbyMinTangon3/14/20227:04:15AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.FOLLOW-UP/SURVEILLANCEdexCLINICALFINDINGSPRIMARYTREATMENTSolitaryplasmacytomaorSolitaryplasmacytomawithminimaliijRTk±RTk±orConsideral•Follow-upinterval,every3–6mo:mpCBC,differential,plateletcountpSerumchemistryforcreatinine,albumin,andcorrectedcalcium•Testsasneeded:pSerumquantitativeimmunoglobulins,SPEP,withSIFEp24-hurinefortotalproteinandUPEPwithUIFEpSerumFLCassaypSerumLDHandbeta-2microglobulinpBonemarrowaspirateandbiopsypAllplasmacytomasshouldbeimagedyearly,agnosisforatleastyearseagnosisforatleastyearseh•SeeNCCNGuidelinesforSurvivorshipPrimaryprogressivenorResponsefollowedbyprogressionnithyelomaorkupSeeMultiplemyeloma(symptomatic)(MYEL-4)eSeePrinciplesofImaging(MYEL-B).hWhole-bodyMRI(orPET/CTifMRIisnotavailable)isthefirstchoiceforinitialevaluationofsolitaryosseousplasmacytoma(MRIofthespineandpelvis,whole-bodyPET/CT,orlow-dosewhole-bodyCTundercertaincircumstances).Whole-bodyPET/CTisthefirstchoiceforinitialevaluationofsolitaryextraosseousplasmacytoma.iAllcriteriamustbepresentforthediagnosis.Fordiagnosticcriteria,pleaserefertoRajkumarSV,etal.LancetOncol2014;15:e538-e548.jSolitaryplasmacytomawith10%ormoreclonalplasmacellsisregardedasactive(symptomatic)MMandsystemictherapyshouldbeconsidered.kSeePrinciplesofRadiationTherapy(MYEL-D).lConsidersurgeryifstructurallyunstableorifthereisneurologiccompromiseduetomasseffect.mPatientswithsofttissueandhead/neckplasmacytomacouldbefollowedlessfrequentlyafterinitial3-monthfollow-up.nSeeResponseCriteriaforMultipleMyeloma(MYEL-E).Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.Version5.2022,03/09/22©2021NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.MYEL-2FOLLOW-UP/SURVEILLANCEPrintedbyMinTangon3/14/20227:04:15AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright©2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.FOLLOW-UP/SURVEILLANCEdexCLINICALFINDINGSPRIMARYTREATMENTSmolderingicicgLowriskoHighrisko,qialpintervalsq(category1)Observeatintervalsq(category1)ialpObserveat3-mointervalsasLenalidomideinselectpatients(category2B)•Every3–6months:pCBC,differential,plateletcountpCreatinine,correctedcalciumpSerumquantitativeimmunoglobulins,SPEP,SIFEp24-hurinefortotalprotein,UPEP,andUIFEatbaselineandasclinicallyindicatedo