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Diagnosing and Treating AML: What Testing Is Essential?

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Diagnosing and Treating AML: What Testing Is Essential? from Patient Empowerment Network on Vimeo.

How do test results affect the diagnosis and care of patients with acute myeloid leukemia (AML)? Dr. Farhad Ravandi-Kashani reviews essential testing for AML patients, including molecular testing and what these test results might reveal about the disease.

Dr. Farhad Ravandi-Kashani is professor of medicine and Chief of the Section of Developmental Therapeutics in the Department of Leukemia at The University of Texas MD Anderson Cancer Center in Houston, TX. Learn more about Dr. Ravandi-Kashani.

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Transcript:

Laura Beth:

Dr. Ravandi, can you define molecular testing for AML patients?  

Dr. Ravandi:

We have progressed on our understanding of cancer, in general. And we have progressed in our technology, so we know that various cancers are likely caused by a number of molecular events, and this is best characterized in leukemias because we have been doing this in leukemia for many years now, simply because leukemias are much more accessible than other cancers. Leukemic cells are in blood and easily obtained and even in bone marrow, are much easier obtained than other solid tumor cancers.  

And so, we’ve been able to identify a number of gene and chromosome changes that we have discovered to be prognostic, but also, have become the targets for developing effective drugs.  

Laura Beth:

Beyond molecular testing, what other testing should take place following an AML diagnosis?  

Dr. Ravandi:

I mean, the classical patient presents because there is something in their blood counts, so they usually have had a blood count testing done. And, of course, you need to do a number of other tests, for example, the chemistry profile, because that can show us some of the problems that can be caused by leukemia.  

And the most important thing is bone marrow aspiration and biopsy, which is still, unfortunately, absolutely necessary, first to make the diagnosis, and second, to obtain the specimens for those biomarker testing that you mentioned.  

Laura Beth:

If a patient relapses, does all of this testing need to be repeated?  

Dr. Ravandi:

Unfortunately, yes. And so, when you said all of these testing, actually, again, compared to some other cancers, this is limited testing. Taking blood for the blood tests, and even doing a bone marrow is generally much easier than taking tissue in a colonoscopy for a colon cancer, or doing a biopsy, a lung biopsy in lung cancer, etc.  

But yes, they all need to be tested, and actually, we do like to repeat the genetic testing because leukemias are dynamic, and after initial therapy, they may change in ways. They may develop new targets or new molecular changes that may be potentially amenable to new targeted therapies.  

Laura Beth:

And is it common for a mutation to appear at a relapse?  

Dr. Ravandi:

It is, yes. I mean, I would say it’s – I wouldn’t say it’s common, but it is frequent.  

What Tests Are Essential Before Choosing a Myeloma Treatment Approach?

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What Tests Are Essential Before Choosing a Myeloma Treatment Approach? from Patient Empowerment Network on Vimeo.

Dr. Abdullah Khan, a myeloma specialist, discusses the types of tests that myeloma patients should undergo before choosing therapy, at diagnosis, and if they relapse.

Dr. Abdullah Khan is a hematologist specializing in multiple myeloma and plasma cell disorders at the Ohio State University Comprehensive Cancer Center – The James. Dr. Khan is also an assistant professor in the Division of Hematology at The Ohio State University. Learn more about Dr. Khan.

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How Do Test Results Impact Myeloma Treatment Options?

Transcript:

Katherine:

What testing should take place before choosing a myeloma treatment?  

Dr. Khan:

I thought I could answer this question in an indirect way first.  

Katherine:

Okay.  

Dr. Khan:

I just wanted to let the audience know that anyone, including those that are not in the medical field, can create an account with the nccn.org. That’s the National Comprehensive Cancer Network’s website.  

And from there they can download the myeloma guidelines, which are available to all myeloma providers as well. And in the guidelines, there are sections for workup, treatment, how to follow patients with myeloma, and many other things.   

So, going back to the question, the first patient encounter will likely include a thorough history and physical exam. Initial lab work includes blood counts, the serum chemistries so we know about the liver and kidney function, multiple myeloma markers. And patients about get very familiar with monoclonal protein, the serum immunoglobulins, and the serum-free light chains. 

These are used as the surrogates for responses when you’re undergoing treatment for the myeloma. We will also at the first visit probably also do a 24-hour urine collection, and that’s looking for the abnormal protein in the urine.  

There’s imaging. In the past, we used to do x-rays head to toe. That’s sometimes called the myeloma survey or the skeletal survey. But the new recommendations are actually looking for something a bit more sensitive.  

So, at our practice, what we do is a PET scan.  

So, that includes functional information as well the images themselves. And some institutions may do a PET scan head to toe using low-dose radiation. The final test we will do in patients with newly diagnosed myeloma is a bone marrow biopsy and an aspirate. 

So, the biopsy’s looking at the bone itself and the architecture. And the aspirate, you take the liquid part of the bone marrow, and you can ascertain a lot of information including the burden of myeloma when the patient’s newly diagnosed.  

Katherine:

What do you mean by “burden”?   

Dr. Khan:

You can quantify the number of cancerous plasma cells in the bone marrow. So, some of the information says you have a healthy amount of good bone marrow cells, 50 percent, 60 percent, for example, but of that 50 percent, 60 percent, maybe 80 percent is taken over by myeloma. So, you will get burden of myeloma information from there.  

Katherine:

What additional testing should take place following a relapse?  

Dr. Khan:

I’ll start that response by first talking about the types of relapses, and there are two broad categories. If we see the myeloma coming back as just the monoclonal protein going back up from its lowest, or maybe the serum-free light chain going up – and there are very specific criteria for what defiance a relapse. But if it’s just a number, we call it a biochemical relapse.  

On the other side, there’s a clinical relapse. And at that point, there might be new end organ damage. We’ve heard of the acronym CRAB when we’re describing myeloma. That stands for hypercalcemia, renal or kidney insufficiency, anemia, and bone disease. So, these are end organ damage directly from the multiple myeloma. 

So, typically, we’ll try to change the management at biochemical relapse, because a new organ injury may contribute to the patient’s frailty, or it might even limit the treatment options. The testing out of relapse is pretty similar to the first diagnosis. We’ll repeat the history and the physical example, the labs, imaging. And more often than not, I’ll also recommend a bone marrow biopsy to see is that myeloma changing genetically, and does it help me kind of determine new treatment options.  

What Key Tests Should Follow a Myeloma Diagnosis?

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What Key Tests Should Follow a Myeloma Diagnosis? from Patient Empowerment Network on Vimeo.

What are the key tests that should take place following a multiple myeloma diagnosis? Dr. Peter Forsberg details the appropriate tests, including imaging and blood tests, that may aid in assessing the risk and informing treatment options.

Dr. Peter Forsberg is assistant professor of medicine at the University of Colorado School of Medicine and is a specialist in multiple myeloma. More about Dr. Forsberg here.

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How Do Myeloma Test Results Guide Prognosis and Treatment?

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What Are Key Factors in Myeloma Treatment Decisions?

Transcript:

Katherine:                  

What testing should take place following a myeloma diagnosis?

Dr. Forsberg:             

So, after a patient is diagnosed with myeloma, or with suspected myeloma, a number of tests take place to both understand the myeloma. Get some sense for how aggressive the myeloma might be and understand what may be being caused by the myeloma at any given time. So, that involves a number of blood tests. It involves checking urine, doing at least one 24-hour collection of urine. Doing imaging, tests to look at the skeleton or different areas of the body for myeloma involvement.

And a bone marrow biopsy and what’s called an aspirate.

So, all those tests together are used to help confirm myeloma, to understand what’s going on with it and then to understand some of the characteristics of it that might be important over time.

Some of the more complicated tests when people are initially diagnosed with myeloma to get their head around are some pretty important blood tests that we monitor pretty closely.

Things called the serum protein electrophoresis and serum light chain assays. And basically, those are tools that help us measure antibodies. Myeloma is a disease; it comes from cells that make antibodies or fragments of antibodies. And by measuring those, we can understand the myeloma, we can give it some names. And then we can also measure it over time. So, those can seem a little bit impenetrable to patients when they’re first diagnosed, but they’re pretty important for patients and for people treating the myeloma to understand where the myeloma stands and how things are going.

Katherine:                  

What about genetic testing?

Dr. Forsberg:             

So, the main way that we use genetic testing in multiple myeloma is through something called, cytogenetics. And cytogenetics is a way for us to evaluate chromosomes. Chromosomes are in cells and that’s where genetic material is contained. And in myeloma, some of the main vents that drive myeloma cells to change from normal plasma cells come through changes in chromosomes.

And so, those chromosome changes that can be detected with different tests, sometimes they’re called karyotyping or what’s called FISH can give us a sense for some of the changes that may drive the myeloma or have driven it in the first place.