Department of Internal Medicine, Howard University Hospital, Washington, DC.
Clive O Callender, MD Howard-Harvard Outcome Research Center, Howard University College of Medicine, Washington, DC.
Clin Lymphoma Myeloma Leuk. 2023 Jan;23(1):e27-e40. doi: 10.1016/j.clml.2022.10.009. Epub 2022 Oct 23.
A subset of individuals with smoldering myeloma (SMM) are at a high risk of progression to symptomatic myeloma. Current efforts are focused on identifying this high-risk group and intercepting the disease process before its progression. There is no consensus on what the goal of an intervention should be, whether to aim for a cure through a high-intensity intervention or pursue immunologic disease control using the least intense approach. This systematic review summarized current evidence in support of the optimum approach. A database search of Medline/PubMed, Scopus, EMBASE, Web of Science, CINAHL, Wiley Cochrane Library, clinicaltrials.gov, and conference proceedings of ASH, EHA, ASCO, ESMO was performed. Results were presented using narrative synthesis of quantitative data. Of the 2088 identified records, a total of 10 eligible studies made up of 6 minimal-intensity clinical trials, 3 moderate-intensity trials, and 1 high-intensity trial were included in this review with a total demographic population of 588 high-risk SMM patients. Minimal intensity lenalidomide-based regimen demonstrated clinical effectiveness in delaying disease progression and improving overall survival in high-risk SMM. The single-agent monoclonal antibodies did not have any major impact on improving overall survival, although the studies were not powered to do so. There is a marked increase in the depth of response as the intensity of treatment increases without a proportional improvement in overall survival. Moderate- and high-intensity interventions yielded similar minimal residual disease negativity rates and overall survival. The minimal, moderate, and high-intensity approaches all demonstrated clinical benefits in delaying disease progression and improving overall survival in patients with high-risk SMM and increasing intensity of intervention does not necessarily translate to improved overall survival.
有一小部分冒烟型骨髓瘤（SMM）患者存在进展为有症状骨髓瘤的高风险。目前的努力重点是识别这一高风险群体，并在疾病进展之前阻断其进程。对于干预的目标应该是什么，是通过高强度干预达到治愈目的，还是采用最温和的方法追求免疫性疾病控制，尚无共识。本系统综述总结了目前支持最佳方法的证据。对 Medline/PubMed、Scopus、EMBASE、Web of Science、CINAHL、Wiley Cochrane Library、clinicaltrials.gov 和 ASH、EHA、ASCO、ESMO 会议记录进行了数据库检索。结果采用定量数据的叙述性综合呈现。在 2088 条确定的记录中，共有 10 项符合条件的研究纳入了本综述，其中包括 6 项最低强度临床试验、3 项中等强度试验和 1 项高强度试验，共有 588 名高危 SMM 患者的总人群。低强度来那度胺为基础的方案在延缓高危 SMM 疾病进展和改善总生存率方面显示出临床疗效。单克隆抗体在改善总生存率方面没有任何重大影响，尽管这些研究没有能力做到这一点。随着治疗强度的增加，反应深度明显增加，但总生存率没有相应提高。中等强度和高强度干预均产生了类似的微小残留病阴性率和总生存率。低强度、中强度和高强度方法均在延缓高危 SMM 患者疾病进展和改善总生存率方面显示出临床获益，增加干预强度不一定转化为改善总生存率。
