EBMT 2026 | Using MRD in routine practice in myeloma to monitor response and drive treatment decisions

I think it’s important to consider that MRD meets the key requirement to be an endpoint for survival and treatment monitoring. And the reason is because it supersedes CR, it’s more potent than CR to predict survival, predict in newly diagnosed transplant and non-transplant eligible patients, as well as in relapsed patients. It has been conferred by two different techniques, NGS and NGF, across the world in many different labs. It predicts the outcome upon different MRD rates. In other words, the lowest the level of residual disease, the longest the survival, 10 to the minus 6 is better than 10 to minus 5, minus 4, minus 3. It has an impact both in standard and in high-risk patients to predict outcome and on top of this is a relatively cheap technique if you compare with the cost of any treatment and the reason for this is because you can use this technique to try to adapt the treatment. In other words, for treatment monitoring. That was exactly your question. 

I mean, if I have convinced you that MRD is the most relevant parameter for prognostication and to evaluate response to therapy, why not use it to drive therapy? And the potential uses are, first of all, to compare two treatment approaches, you compare one quadruplet versus a triplet, and you can see that the quadruplet is superior to the triplet in terms of progression for survival. And you ask why? And it’s because of the depth of response. There is a very beautiful correlation between the MRD rate achieved by the quadruplet higher than with the triplet, and this translates into longer progression of survival. In other words, you can compare early on which one of the two approaches is more efficient, CAR-T versus transplant, for instance. 

Second, to adapt treatment therapy according to the MRD follow-up. And you have already the MIDAS trial, in which you have also the UK Myeloma trial, in which they stratify the patients, not according to cytogenetics, but according to the MRD. And they consider in the MIDAS, standard risk the patients that achieves MRD negativity and high risk, the MRD positivity. And in the negative ones, they have compared to continue the same treatment with a quadruple versus one transplant. And the MRD positive patients, they are comparing one versus two transplants. In other words, you can adapt therapy according to the MRD.

On top of this, you can adapt the duration of treatment and the intensity during the maintenance. And there are plenty of evidence coming from Luciano Costa, from my own group, and several ones in which we have decided to stop maintenance at a time that the patient has been on sustained MRD negativity for a period of more than two years, providing that the patient was not high-risk, or also providing that the patient achieved the MRD negative rate very early on the treatment after induction or after transplant. In other words, you can use the MRD to try to adapt the duration of maintenance. 

Also, another possibility in terms of practical use is to introduce early rescue intervention. Nowadays, we treat our patients as soon as they develop biochemical relapse. We don’t wait until the patient has a new fracture or renal insufficiency. As soon as the patient has a biochemical relapse, we treat immediately. Why not treat as soon as the patient has an MRD conversion? Okay. 

And last but not least, to adapt therapy in our current clinical practice, in my current clinical practice, outside of clinical trials, when I have a patient that has persistent MRD-positivity after the autologous transplant, I try to modify the consolidation in order to eradicate the disease. Last but not least, although my goal is to achieve MRD-negativity, my driver is MRD-positivity. In my current practice, the decisions that I take are usually based on the MRD positivity. When it’s positive, I change the treatment.

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