Dr C. Ola Landgren Discusses Identification of Smoldering Myeloma

The terminology for smoldering myeloma has been around for decades, but more discussion over what it means and who it really applies to is needed, said C. Ola Landgren, MD, PhD, professor of medicine and chief of the Myeloma Service at Memorial Sloan Kettering Cancer.

Transcript

How accurately can we identify patients with smoldering multiple myeloma at risk of developing multiple myeloma?

Smoldering myeloma is the terminology that goes back all the way to 1980. There was a case report in the New England Journal of Medicine based on 6 patients that did not fit into the criteria of monoclonal gammopathy, and they had not been sick from multiple myeloma. So, it was proposed that these patients potentially could be called smoldering myeloma.

Today, 40 years later, we still have these terminology. We know that patients that are labeled as smoldering myeloma based on the biological criteria that were used—the bone marrow having certain number of plasma cells, the monoclonal proteins being above certain on thresholds, and in the absence of myeloma criteria. There are many patients that actually do already have multiple myeloma, if you look a little bit closer; if you do advanced imaging with PET CTs or MRIs, you will see that at least a third or so of these patients actually have multiple myeloma. So, in my personal opinion, there are patients that have myeloma but have not yet been diagnosed.

Then there are patients that probably genomically are at the very high rate of the predisposition for developing multiple myeloma. If you plot these patients out graphically on a Kaplan Meier curve, you will see that most of these patients unfortunately developed myeloma in in the 5-year window. We can argue whether they have multiple myeloma or if there really is smoldering myeloma. I would argue that this is probably multiple myeloma also, it just has not clinically presented because myeloma still, to a high degree, is a clinical diagnosis.

Then you have a subset of the patients in the category of smoldering myeloma. As the current definition is written from 1980, that I don't think have that—they really have monoclonal gammopathy. When we follow patients over time in the clinic, some patients just remain stable and they will never develop multiple myeloma.

So, my overall assessment is that I think in the future, we will probably clean up a lot in the literature and the terminology. And I think there will be a few terminologies left; I think there will be the monoclonal gammopathy but is not a cancer. And then there is multiple myeloma, and if we detected early, or if we, unfortunately, find a patient presenting with symptoms, then we would treat them. So, I think that's probably where the field is going. But it's going to take some time and it has to be some agreements between the different groups.