High-risk Smoldering Multiple Myeloma Patients Research Articles

Three-dimensional telomere profiling predicts risk of progression in smoldering multiple myeloma.

Smoldering multiple myeloma (SMM) is a precursor stage that precedes multiple myeloma (MM). SMM is heterogenous with nearly 40% of patients progressing to MM in the first 5 years. The high rate of progression of SMM patients highlights the need for early intervention, which underscores the importance of identifying SMM patients with the highest risk of progression. Several risk stratification models showed utility in identifying high-risk SMM patients; however, these systems showed limited sensitivity. To date, identifying high-risk SMM patients remains an important clinical need. In this study, we present the 3-dimensional telomere profiling as a structural biomarker capable of stratifying SMM patients as a function of genomic instability. Quantifying telomere dysfunction using the TeloView technology showed utility in risk stratification of cancer patients, particularly hematological malignancies. In this study, we analyzed 168 SMM patients. We report an AUC in ROC analysis of 0.8 using a subset of the patients as a training dataset. We then conducted a blind validation on a different cohort and demonstrated a positive predictive value of 85% and negative predictive value of 73%, with sensitivity and specificity of 83% and 76%, respectively. We examined the correlation between the TeloView prediction and the 20-2-20 scoring system, and cytogenetic abnormalities. We report a correlation of 53% with the 20-2-20 scores and over 60% correlation with cytogenetic abnormalities. The result of this study presents the telomere profiling as an effective biomarker able to stratify SMM patients to their respective risk groups with high sensitivity and specificity.

The 3D- Telomere Profiling Assay Identifies High Risk Smoldering Multiple Myeloma Patients with High Precision

Smoldering multiple myeloma (SMM) is an asymptomatic precursor stage of multiple myeloma (MM). According to the international Myeloma Working Group data (Blood Cancer J. 2020 Oct 16;10(10):102) the probability of progression to MM is 22% at 2 years, and 42% and 64% at 5 and 10 years, respectively. Thus, identification of patients with high risk of early progression to MM is crucial for optimal treatment management. Genomic instability is a sensitive indicator of disease progression in cancer. Telomere dysfunction is an early event in genomic instability. The 3-dimensional (3D) spatial profiling of telomeres using TeloView technology allows for quantification of telomere dysfunction and was shown to be instrumental in risk stratification of cancer patients generally, but particularly in selected hematological malignancies. Importantly, the utility of the 3D-telomere profiling was recently demonstrated in 2 clinical studies validating the utility of 3D telomere profiling as a structural biomarker to identify high risk SMM patients. The two studies achieved accuracy of >80% and specificity and sensitivity of over 80% & 76% respectively in a training dataset study followed by a blind validation (Kumar S.et al 2023. J Clin Oncol). To present the 3D telomere profiling assay as a reliable prognostic tool in the clinic, capable to precisely identify high risk SMM patients, it is important to demonstrate the repeatability and accuracy of the assay. In this study, we conducted a retrospective analytical validation including samples of 20 SMM patients with known progression outcome. The samples of each patient were blindly processed in triplets using the 3D-telomere assay, followed by the TeloView analysis. To eliminate any validation-bias the validation was conducted with uncontrolled variables. Samples were processed blindly by different operators on different dates using different instrumentation. We interrogated the repeatability and precision of the results of each patient analyzed on 2 levels. First, we calculated coefficient of variation (CV) of telomere predictors of each patient across the three runs; and secondly, we interrogated the repeatability of patient outcome using the scoring model developed and validated in (Kumar et al. 2023, J Clin Oncol) across the three runs of each patient. We set the acceptable concordance to 80% for CVs (CV <20%) and the acceptable repeatability of patient-outcome as predicted by the scoring model to 80% of the patients included in the study. We report CVs across all the telomere predictors, across the 3 runs of all patients ranging between 2.3 - 17.8. Furthermore, patient outcome as high/low risk of progression was consistent in 17 out of the 20 patients in all 3 runs (85%). The results of this study demonstrate the 3D-telomere profiling as an accurate and prognostic structural biomarker. The assay shows high level of precision, repeatability, and reliability, and presents a viable solution to accurately identify high risk SMM patients. This will potentially allow the treating physicians to make confident treatment decisions for high risk SMM patients based on the results of the 3D Telomere profiling assay.

Single-Cell RNA Sequencing of Circulating Tumor Cells in Precursor Myeloma Patients Reveals Mechanisms of Disease Dissemination

Introduction Multiple Myeloma (MM) is preceded by the precursors Monoclonal Gammopathy of Undetermined Significance (MGUS) and Smoldering Multiple Myeloma (SMM), where some patients with precursor disease progress to active MM faster than others. BM biopsies are useful to monitor disease progression, however, they cannot be repeated often for continuous monitoring of tumor burden especially in the precursor disease management setting. Numerous studies have identified circulating tumor cell (CTC) levels in peripheral blood (PB) are a powerful biomarker of disease aggressiveness; CTC levels have associated with disease stage, PFS and OS in various trials and even outperformed BM to assess tumor burden in the SMM setting. Genomic profiling also demonstrated CTCs harbor the same copy number abnormalities, translocations and mutations as BM tumor cells, and CTCs can be serially monitored to detect the emergence of high-risk subclones in the blood. Further investigations of the molecular profile of both normal plasma cells (NPCs) and CTCs are needed to improve our understanding of myeloma pathogenesis and mechanisms of CTC dissemination across the MM disease continuum. Methods A cohort of 309 samples including CD138-enriched paired PB and BM aspirates and matched CD138- BM aspirates were collected from 103 individuals, including patients with MGUS (n=11), SMM (n=46), NDMM (n=17) and healthy donors (n=29). Malignant PCs from BM and PB underwent 5' single-cell RNA sequencing (scRNA-seq) and single-cell B-cell receptor sequencing (scBCR-seq) (10x Genomics), and CD138- BM immune cells underwent 5' scRNA-seq and single-cell T-cell receptor sequencing (scTCR-seq) to study immune alterations related the tumors' ability to circulate. To differentiate malignant from normal PCs, we used clonal V(D)J rearrangements. Differential expression (DE) and composition analyses were conducted using Wilcoxon's rank-sum tests. Results We successfully captured and profiled 774,647 BM tumor cells and 93,878 CTCs from the PB. The percent malignant plasma cells within the PB increased with disease stage, where NDMM patients had significantly more CTCs compared to MGUS patients (p=0.017) and low-risk SMM patients (p=0.0052). A median of 13.51%, 15.53%, and 18.34% CTCs were present from low (n=20), intermediate (n=10), and high-risk (n=16) SMM patients as defined by the International Myeloma Working Group's 2/20/20 criteria, suggesting sequencing-based CTC enumeration captures prognostically relevant differences in tumor burden. High expression of driver genes upregulated in patients with translocations, including CCND1, NSD2, and MAF, were detected in both BM tumor cells and CTCs in patients with t(11;14), t(4;14), and t(14;16) as identified by fluorescence in situ hybridization (FISH). In 5 patients with normal or inconclusive FISH results, we observed high levels of CCND2 and MAF in both BM and CTCs, indicating scRNA-seq can detect missed prognostically relevant cytogenetic abnormalities. A cytogenetic classifier model was developed to determine the accuracy of translocation calling using minimal numbers of CTCs, where the classifier's performance was able to consistently identify translocations downsampled to 50 CTCs. DE analysis of CTCs vs. BM tumor cells highlighted transcriptional similarity between BM and CTCs, validating their utility as a surrogate for analyzing BM tumor cells. DE analysis also revealed 8 genes significantly upregulated and 3 genes significantly downregulated in CTCs compared to BM tumor cells, providing novel insights into genes involved in PC circulatory potential. Pathway enrichment analysis revealed genes upregulated in CTCs were associated with epithelial mesenchymal transition, interferon response, and inflammation, consistent with CTC studies on MM patients, suggesting these pathways are dysregulated earlier in the disease continuum. Conclusions In the largest scRNA-seq study on CTCs to date, we demonstrate the utility of CTC-based molecular profiling for prognostication of patients with early-stage disease and provide novel insights into PC circulatory potential. Additional analyses are ongoing to gain further insight into intra-patient CTC heterogeneity and define high-risk disease CTC signatures that emerge throughout the MM disease continuum.

Three-dimensional telomere profiling to predict risk of progression in smoldering multiple myeloma.

8056 Background: Multiple myeloma (MM) is preceded by monoclonal gammopathy of undetermined significance (MGUS). A transitional stage of smoldering multiple myeloma (SMM) can be identified between MGUS and MM. While MGUS carries a steady risk of progression of 1% per year, SMM is more heterogenous with nearly 40% of patients progressing in the first 5 years, 15% in the next 5 years, reaching the same low risk as MGUS after 10 years. SMM with its high risk of progression in the initial years after diagnosis presents a viable opportunity for early intervention. For implementing early intervention, the ability to identify SMM patients at the highest risk of progression is critical. This has led to the development of several risk stratification systems. Using these systems high risk SMM patients studied in phase 3 trials demonstrated delayed progression to MM and improved overall survival with early initiation of therapy. However, these approaches showed limited specificity exposing patients at lower risk of progression to therapy. To date, identifying high risk SMM patients and confirming disease stability in low risk SMM patients remain an important clinical need. Genomic instability has been shown to be a sensitive indicator of disease progression in cancer. Telomere dysfunction is an early event in genomic instability. The 3-dimensional spatial profiling of telomeres using TeloView technology allows for quantification of telomere dysfunction, and was shown to be instrumental in risk stratification of cancer patients generally, but particularly in selected hematological malignancies. Importantly, in a previous SMM proof-of-concept study telomeric parameters measured by TeloView technology was found to be significantly different between SMM patients who progressed to active MM within 2 years and those who remained stable for over 5 years. Methods: We analyzed a total of 162 SMM patients using TeloView technology. 88 patients were employed as training dataset in Receiver Operating Curve (ROC) modeling to develop a scoring model that stratifies individual SMM patients based on risk of progression to full stage MM. An additional cohort of 74 SMM patients was used for blind validation of the developed scoring model. Results: We report area-under-the-curve (AUC) in the ROC analysis of 0.8 (accuracy 80%) achieved by the scoring model developed using the training dataset. Furthermore, the independent blind validation achieved positive predictive value of 83% and negative predictive value of 71%, with sensitivity and specificity of 80% and 76% respectively. Conclusions: The result of this study supports presenting TeloView as an accurate prognostic biomarker which appears able to stratify SMM patients into their respective risk groups with high sensitivity and specificity. This will potentially allow for evidence-based treatment decisions for high risk SMM patients and confident monitoring of stable patients.

ISAMAR: Multicenter phase II single arm trial of isatuximab (ISA) with/without lenalidomide (LEN) in pts with high risk smoldering multiple myeloma (HRSMM).

8046 Background: HRSMM patients (pts) have a median time to progression of < 2 years. ISA is a monoclonal antibody that binds to highly expressed CD38 on myeloma cells and is approved in RRMM. We designed a phase II study to test the efficacy of ISA +/- LEN in HRSMM (NCT02960555). Methods: The primary endpoint of the study was the overall response rate (ORR) after 6 months of ISA 20 mg/kg IV days 1, 8, 15, 22 cycle 1; days 1, 15 cycles 2-6; day 1 cycles 7-30 monotherapy (stage 1, n = 25) or with LEN 25 mg po daily on days 1-21 every 28 days, cycles 1-6 (stage 2, n = 36). Secondary endpoints are progression free survival (PFS), overall survival (OS) while exploratory endpoints included quality of life (QoL), flow and sequencing. Results: 61 HRSMM pts (+immunoparesis and ≥95%abnormal plasma cells in bone marrow) (stage 1 n = 25; stage 2 n = 36) were accrued 02/2017-10/2022. The study met its primary endpoint of ORR ≥ 70% after 6 cycles of therapy [Stage 2 ORR (89%) = VGPR 9 (25%), PR 23 (64%), MR 3(8%), PD 1(3%)]. Median time to response was 1 cycle. In stage 2, 17/36 (47%) patients had grade 3 treatment related adverse events (AEs): 1 pt related to ISA (myalgia, 3%) and 16 pts related to LEN (44%) [ANC decrease (36%), skin rash (8%), ALC decrease (11%), WBC decrease (8%), fatigue (6%)] and 1/36 pts a grade 4 (related to LEN) [ANC decrease 3%]. Most common grade 1-2 AEs: WBC decrease (53%), ANC decrease (56%), skin rash (28%), fatigue (39%), ALC decrease (42%), thrombocytopenia (28%), diarrhea (39%), constipation (28%). There were no grade 5 AEs. No patients discontinued treatment due to AEs. There were 3 deaths in stage 1 unrelated to therapy: 1 patient progressed to and died while on systemic AL amyloidosis therapy, one patient (with COPD) died of COVID19 while in sustained PR, one heavy smoker died of squamous cell cancer of the tongue. Pre- and post- treatment BM flow showed that ISA/LEN increased CD4+/CD8+ and effector memory cytotoxic T cells. QoL measures (n = 32; 15 in stage 1, 17 in stage 2 and 21 with both BL/after 6 months data) showed that ISA+/- LEN resulted in decreased cancer worry/anxiety and improved future perspective at 6 months compared to BL in both stages. QoL was favorable and conserved throughout treatment, suggesting minimal effects of treatment on patient assessment of well-being. For stage 1, median PFS was 49.3 months (95% CI:40.8~NA months); median OS not reached at a median f/u of 49 months (range 6.3-68 months). Stage 2 median PFS/OS is not reached. Conclusions: ISA/LEN results in high ORR without decrease in patient well-being. ISA monotherapy also results in prolonged PFS when compared to historical data. ISA/LEN therapy remodels the BM TME with increase in memory cytotoxic T cells. The results of this study give rationale for the ongoing phase 3 ITHACA evaluating ISA +/- LEN/DEX with the potential to change the standard of care in HRSMM (NCT04270409). RO and OL have equal contribution. Clinical trial information: NCT02960555 .

A systematic review on smoldering multiple myeloma: Whether treatment is beneficial.

e20029 Background: Smoldering multiple myeloma (SMM) is an asymptomatic proliferative disorder of plasma cells. There are multiple early intervention strategies investigated in the last ten years, including single v/s combination therapy, which can either delay progression or be used as an aggressive therapy to cure SMM. This study aims to summarize the reported outcomes of interventions in SMM within the past decade. Methods: We performed a literature search following PRISMA guidelines and used the following bibliographic databases: PUBMED, EMBASE, Cochrane Library, Web of Science, and clinical trials.gov. A total of 1474 articles were found from the above-mentioned databases and a total of seven articles were included in the final analysis. Results: Seven clinical trials were finalized, which included 599 patients, gender was specified in five studies and constituted 51 percent female patients, and the remaining were males. The median age of patients ranges from 61 (21-89) years. In progression evaluation, four studies, 440 patients were considered. However, significant heterogeneity existed with treatments and the survival analysis hence cumulative PFS was not obtained. PFS greater than 90% was obtained in two studies; 95.5% was obtained with Carfilzomib (K), lenalidomide (R), and dexamethasone(d) regimen after a follow-up period of 31.9 months. PFS of 91% was obtained with Lenalidomide alone for a follow-up of 35 months. Three studies, including 200 patients, were evaluated for response rate. MRD negative CR of 70.4% was obtained with the use of the KRd regimen. Overall response (ORR) of intense and intermediate use of Daratumumab showed a rate of 56.7% and 53.1%, while the complete response in the respective arms was 4.9% and 9.8%. CR, stringent CR of 17.4% and 4.3% was obtained with the use of Isatuximab with Lenalidomide. Conclusions: No definite conclusion can be made due to variability in the data. However, based on the data analyzed from the seven clinical trials, we advocate for early therapeutic intervention in high-risk SMM patients. There are multiple ongoing clinical trials to answer whether we should treat SMM or not.[Table: see text]

A Machine Learning Model Based on Tumor and Immune Biomarkers to Predict Undetectable Measurable Residual Disease (MRD) in Transplant-Eligible Multiple Myeloma (MM)

A Machine Learning Model Based on Tumor and Immune Biomarkers to Predict Undetectable Measurable Residual Disease (MRD) in Transplant-Eligible Multiple Myeloma (MM)

OAB-056: A machine learning model based on tumor and immune biomarkers to predict undetectable measurable residual disease (MRD) in transplant-eligible multiple myeloma (MM)

<h3>Background</h3> There is expectation of using biomarkers to personalize treatment. Yet, a successful treatment selection cannot be confirmed before 5 or 10 years of progression-free survival (PFS). Treatment individualization based on the probability of an individual patient to achieve undetectable MRD with a singular regimen, could represent a new model towards personalized treatment with fast assessment of its success. This idea has not been investigated previously. <h3>Methods</h3> We sought to define a machine learning model to predict undetectable MRD in newly-diagnosed transplant-eligible MM patients (n=278). The training (n=152) and internal validation cohort (n=60) consisted of 212 active MM patients enrolled in the GEM2012MENOS65 clinical trial. The external validation cohort was defined by 66 high-risk smoldering MM patients enrolled in the GEM-CESAR clinical trial, which treatment differed only by the substitution of bortezomib by carfilzomib during induction and consolidation. Patients were included in the study based on data availability of 17 parameters (p≤.05) associated with MRD outcomes. <h3>Results</h3> We started by investigating patients' MRD status after VRD induction, HDT/ASCT and VRD consolidation (GEM2012MENOS65) according to their ISS and Revised-ISS, LDH levels, and cytogenetic alterations. High LDH levels and del(17p13), two features relatively infrequent at diagnosis, were the only parameters associated with lower rates of undetectable MRD. The ISS and R-ISS were not predictive. Therefore, we aimed to evaluate other disease features associated with MRD outcomes and develop more effective models based on machine learning logistic regression. The most effective one resulted from integrating cytogenetic [t(4;14) and/or del(17p13)], tumor burden (plasma cell clonality in bone marrow and circulating tumor cells in peripheral blood) and immune related (myeloid precursors, mature B cells, intermediate neutrophils, eosinophils, CD27negCD38pos T cells and CD56brightCD27neg NK cells) biomarkers. Data obtained for an individual patient can be substituted into our formula, which results in a numerical probability of achieving undetectable (>0.5) vs persistent (0.685 or <0.365 (observed in 102/212 patients), MRD outcomes are respectively predicted with higher confidence. Standard-confidence, high-confidence, and external validation predictions were accurate in 152/212 (71.7%), 85/102 (83.3%), and 48/66 (72.7%) patients respectively. Patients predicted to achieve undetectable MRD using standard and high-confidence values showed longer PFS and OS than those with probability of persistent MRD. <h3>Conclusions</h3> We demonstrated that selecting a regimen based on probable MRD outcomes, and confirming soon after if that probability was accurate, is a possible new approach towards individualized treatment in MM. The model is available at www.MRDpredictor.com to facilitate its use in clinical practice.

Pilot Study of Pembrolizumab for Immunoprevention in Smoldering Multiple Myeloma

Background: The current management of patients with smoldering multiple myeloma (SMM) is watchful waiting. However, a fraction of these patients are at significant risk of progression to symptomatic multiple myeloma (MM). In a recent study, expression of PD-L1 on tumor cells correlated with increased risk of progression from SMM to MM (Dhodapkar et al Blood. 2015; 126(22): 2475-2478) suggesting a role for immune checkpoint blockade for immunoprevention of MM. Pembrolizumab is a humanized monoclonal antibody against programmed death receptor-1 (PD-1) and blocks the interaction between PD-1 and PD-L1. Here, we report the results of a pilot study evaluating the safety and efficacy of pembrolizumab in intermediate- and high-risk SMM patients (I-HR-SMM). Methods: Patients with I-HR-SMM by PETHEMA, Mayo or SWOG criteria were eligible. Permbrolizumab was administered at a dose of 200 mg IV every 21 days for up to 8 cycles. Patients were eligible to continue treatment for up to 24 cycles if they achieved ≥ minor response after 8 cycles. The primary objective was the overall response rate (ORR) after 8 cycles. The target ORR was 25%. The trial was conducted by the Simon's Minimax design and the ORR was estimated accordingly (Simon, 1989). Twelve patients were planned for the first stage. If at least one patient had ≥ partial response, 4 more patients could enroll for a total of 16 patients. Serial peripheral blood mononuclear cells and bone marrow samples were collected for comprehensive immunophenotyping using multiparametric flow cytometry, and molecular profiling with gene expression profiling (GEP) and exome sequencing. Results: Twelve patients with I-HR-SMM were dosed on the first stage between 08/2016 and 06/2017 (Table 1a/b). Median age was 67.5 years (range 49-74). Median number of cycles received was 8 (range 3-8) and all 12 were evaluable for safety and efficacy. Median follow up was 8.54 months (4.7 to 9.6 months). One patient achieved a stringent complete remission (sCR) (8%), ten patients had stable disease (83%), and one patient had progressive disease (8%). The patient with sCR had HR-SMM by GEP70 and FISH (deletion 17p and amplification of CKS1B) and 50% plasma cells infiltration in the bone marrow at study entry. The sCR with negative flow cytometry on bone marrow was noted in this patient after only 3 cycles of therapy and response is ongoing 8 months after the end of treatment. Five patients discontinued therapy due to related adverse events: grade 2 elevation in LFT (n=2), grade 3 myalgia (n=1), and grade 3 acute kidney injury (AKI) due to tubulo-interstitial nephritis (n=2) [all resolved with discontinuation of treatment or prednisone administration]. There were no grade 4/5 adverse events. Enrollment on second stage is ongoing. Imunophenotyping of paired baseline and end of treatment bone marrow samples showed that the patient who achieved sCR had high levels of PD-1 expression on CD4+ and CD8+ T cells at baseline and showed evidence of CD8+ T-cell activation after therapy with greater upregulation of CD69, CTLA-4, PD-1, TIM-3, 4-1BB, and ICOS relative to non-responders. In contrast, expression of other immune checkpoint molecules such as TIM-3, LAG-3, and CD244 were greater on T cells in non-responders at baseline relative to the responder suggesting greater exhaustion of T cells in non-responders. Molecular profiling including GEP, exome sequencing, and neoantigens analysis is ongoing and will be presented at the meeting. Conclusions: This pilot study of pembrolizumab monotherapy showed that it is tolerable and can induce sCR in patients with SMM. More importantly, it suggested that immunoprevention to prevent progression of SMM to MM is possible. Additional biomarker studies are needed to identify patients that are most likely to respond to this approach. Our correlative studies also provide insights into potential future combination approaches to further improve efficacy of immunoprevention strategies in SMM. [Display omitted] DisclosuresManasanch:takeda: Consultancy; celgene: Consultancy; sanofi: Research Funding; quest diagnostics: Research Funding; merck: Research Funding; adaptive biotechnologies: Consultancy. Lee:Eutropics Pharmaceuticals: Research Funding; Adaptive: Membership on an entity's Board of Directors or advisory committees; Pimera Inc: Consultancy; Celgene: Consultancy; Daiichi Sankyo: Research Funding; Takeda: Consultancy. Patel:Pfizer: Membership on an entity's Board of Directors or advisory committees, Research Funding; Juno: Consultancy; Celgene: Consultancy. Thomas:Celgene: Research Funding; Bristol Myers Squibb: Research Funding. Neelapu:Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Karus: Research Funding; Cellectis Inc.: Research Funding; Poseida Therapeutics, Inc: Research Funding; Merck: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Kite Pharma: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Bristol-Myers Squibb: Research Funding. Orlowski:BioTheryX: Consultancy, Membership on an entity's Board of Directors or advisory committees.

Telomere Architecture Correlates with Aggressiveness in Multiple Myeloma.

Simple SummaryMultiple myeloma (MM) remains an incurable blood cancer. One of the current challenges in patient management is the risk assessment and subsequent treatment management for each patient with MM. Patients with an identical diagnosis may present very different disease courses and outcomes. This challenge of MM is a current focus of the scientific and medical communities. In our research, we have used an imaging approach to determine the risk of MM patients to progressive/aggressive disease. Using three-dimensional (3D) imaging of telomeres, the ends of chromosomes, we report that specific telomeric profiles are associated with aggressive disease.The prognosis of multiple myeloma (MM), an incurable B-cell malignancy, has significantly improved through the introduction of novel therapeutic modalities. Myeloma prognosis is essentially determined by cytogenetics, both at diagnosis and at disease progression. However, for a large cohort of patients, cytogenetic analysis is not always available. In addition, myeloma patients with favorable cytogenetics can display an aggressive clinical course. Therefore, it is necessary to develop additional prognostic and predictive markers for this disease to allow for patient risk stratification and personalized clinical decision-making. Genomic instability is a prominent characteristic in MM, and we have previously shown that the three-dimensional (3D) nuclear organization of telomeres is a marker of both genomic instability and genetic heterogeneity in myeloma. In this study, we compared in a longitudinal prospective study blindly the 3D telomeric profiles from bone marrow samples of 214 initially treatment-naïve patients with either monoclonal gammopathy of undetermined significance (MGUS), smoldering multiple myeloma (SMM), or MM, with a minimum follow-up of 5 years. Here, we report distinctive 3D telomeric profiles correlating with disease aggressiveness and patient response to treatment in MM patients, and also distinctive 3D telomeric profiles for disease progression in smoldering multiple myeloma patients. In particular, lower average intensity (telomere length, below 13,500 arbitrary units) and increased number of telomere aggregates are associated with shorter survival and could be used as a prognostic factor to identify high-risk SMM and MM patients.

What Is New in the Treatment of Smoldering Multiple Myeloma?

Smoldering multiple myeloma (SMM), an asymptomatic plasma cell neoplasm, is currently diagnosed according to the updated IMWG criteria, which reflect an intermediate tumor mass between monoclonal gammopathy of undetermined significance (MGUS) and active MM. However, SMM is a heterogeneous entity and individual case may go from an “MGUS-like” behavior to “early MM” with rapid transformation into symptomatic disease. This wide range of clinical outcomes poses challenges for prognostication and management of individual patients. However, initial studies showed a benefit in terms of progression or even survival for early treatment of high-risk SMM patients. While outside of clinical trials the conventional approach to SMM generally remains that of close observation, these studies raised the question of whether early treatment should be offered in high-risk patients, prompting evaluation of several different therapeutic approaches with different goals. While delay of progression to MM with a non-toxic treatment is clearly achievable by early treatment, a convincing survival benefit still needs to be proven by independent studies. Furthermore, if SMM is to be considered less biologically complex than MM, early treatment may offer the chance of cure that is currently not within reach of any active MM treatment. In this paper, we present updated results of completed or ongoing clinical trials in SMM treatment, highlighting areas of uncertainty and critical issues that will need to be addressed in the near future before the “watch and wait” paradigm in SMM is abandoned in favor of early treatment.

Serum markers alone can define high-risk smouldering multiple myeloma: new insights from the Czech Myeloma Group model.

The overall risk of developing symptomatic multiple myeloma (MM) from the asymtomatic precursor state, smoldering multiple myeloma (SMM), is 10% per year, but varies greatly with the presence of certain risk factors.1 The heterogeneous clinical course of SMM has led the International Myeloma Working Group (IMWG) to propose that patients with an 80% risk of progression at two years after an SMM diagnosis should be regarded as symptomatic MM patients and offered treatment.2 Therefore, the updated diagnostic MM criteria included three biomarker sassociated with a very high risk of progression; BMPC% ≥60, sFLCr ≥100 and/or more than one focal lesion on MRI.2 Within the last decades, several variables have been identified as associated with an increased risk of SMM progression to MM. Most risk-models are composed of a combination of serum markers3, 4 or a combination of serum markers along with bone marrow biopsy5, 6 flow-cytometry,7 imaging8 or molecular markers.9, 10 However, there is still no international consensus on which factors should be used as the standard risk stratification. Furthermore, one study found poor consistency between two widely used risk-models (PETHEMA and Mayo Clinic) when applied to the same patient cohort.11 Also, in the Danish study we found that the two-year progression-risk of having an abnormal FLC ratio ≥100 was only 30% and thus nowhere near the >80% risk as shown in the two studies which formed the basis of the IMWG guidelines.4 There are two important problems with the different SMM risk-models published so far: (i) the models are usually based on single-centre observations, and (ii) not all models consist of easily accessible markers for risk stratification. Together, this increases the risk of bias and to a certain degree compromises the ability of the risk-models to be used in the broader SMM population. It seems reasonable to assume that the lack of reproducibility of SMM high-risk models is also influenced by the biological heterogeneity of precursor diseases. A study analysing the whole genome sequence of pared tumour samples from 10 patients progressing from SMM to MM showed that the complexity of the genomic profile is generally not associated with a shorter time-to-progression (TTP) and that both a static and spontaneous sub-clonal evolution was found among the tested patients.12 How conventional serum and/or bone marrow markers serve as the correct proxy for the underlying genomic profile of the individual SMM patient is unknown. In this issue of the journal, Hájek et al. presents a new risk-model based on the data from the Czech Myeloma Group (CMG) and Heidelberg group. Based on data from the nationwide CMG registry, the authors first identified a high-risk subpopulation of SMM patients with a 78·7% two-year progression risk using immunoparesis, M-protein level ≥2·3 g/l and a FLC ratio >30 risk factors only. The risk-model was subsequently tested externally in the Heidelberg cohort, which arguably represents a specialised MM centre. Interestingly, the authors found a remarkably similar two-year progression risk (81·3%) when the model was tested in the Heidelberg population. Furthermore, Hájek et al. used the same data for a post-hoc comparison with other published risk-models and found that the CMG data did not meet the 80% progression rate threshold, indicating that the CMG model is more robust than previously proposed risk-models. Do we need more risk-models for SMM? With the QuiRedex study we saw that upfront treatment with lenalidomide-dexamethasone of high-risk patients does prolong TTP and overall survival (OS).13 Side effects were fairly modest with few grade 3 events.13 Arguably, if patients have a better OS and side effects are manageable, then the risk of doing more harm than good when starting anti-MM treatment is low. However, if high-risk SMM patients with high-risk features are to be considered as symptomatic MM patients, standard treatment should arguably involve three-drug induction treatment followed by ASCT for younger as well as fit elderly patients. Recently, daratumumab monotherapy for high-risk SMM patients was evaluated in the phase 2 Centaurus trial.14 The study did not meet the co-primary endpoint of CR >15%, thus indicating that a more aggressive multi-drug regimen is probably needed for disease eradication. Several clinical trials using different risk-models are underway to evaluate intensive treatment approaches in SMM. A real strength with the new CMG model is the external validation and use of accessible serum risk factors which makes this model practical for inclusion in future clinical trials or for the evaluation of SMM patients in everyday clinical practice.

Recent Advances in the Management of Smoldering Multiple Myeloma.

There is remarkable progress in the treatment of multiple myeloma (MM) with significant improvement in survival in the past 10 years. Monoclonal gammopathy of undetermined significance (MGUS) and smoldering multiple myeloma (SMM) can evolve into symptomatic multiple myeloma (sy-MM) with organ involvement. SMM has associated with a much higher progression to MM compared to MGUS. In 2014, International Myeloma Working Group (IMWG) reclassified ultra-high-risk smoldering myeloma patients with bone marrow plasma cells > 60% or serum-free light chain ratio (FLCr) > 100 or > 1 focal bone lesion on the magnetic resonance imaging as MM. SMM is a heterogeneous disorder with probability for progression to myeloma up to 50% in the first 5 years. Several risk models and clinical features have been identified to stratify the risk of progression to MM. Thanks to advances in our understanding of the genomic profile of MM, there are several ongoing clinical trials, and genomic studies are being done to assess the risk of progression to MM and early intervention. There is still no standard criterion regarding when to start therapy. This review discusses identifying SMM patients who are at high risk of progression to sy-MM and recent development of new and early treatment strategies and ongoing clinical trials for these high-risk SMM patients.

Early or deferred treatment of smoldering multiple myeloma: a meta-analysis on randomized controlled studies.

PurposeSmoldering multiple myeloma (SMM) is a rare asymptomatic plasma cell disorder. Even with emerging therapeutic approaches and risk stratification, the optimal time to treat SMM remains controversial. This meta-analysis aimed to compare early treatment with deferred treatment of SMM, especially high-risk SMM.MethodsEarly treatment was defined as treatment immediately after diagnosis. Deferred treatment was initiated after progression. The primary outcome was progression. Secondary outcomes were mortality, response, and safety. PubMed, EMBASE, Medline, Cochrane, and ClinicalTrials.gov databases were searched from January 1990 to March 2019. Randomized controlled trials (RCTs) comparing early treatment with deferred treatment in SMM patients were eligible. Risk ratios (RRs) with 95% confidence interval (CI) were pooled.ResultsEight RCTs covering 885 SMM patients were included. Considering all the different treatment approaches, early treatment significantly decreased progression of SMM (RR=0.53, 95% CI 0.33–0.87, P=0.01). In subgroup analysis, melphalan plus prednisone (RR=0.22, 95% CI 0.08–0.64, P=0.005) and immuno-modulatory drugs (RR=0.43, 95% CI 0.31–0.59, P<0.00001) significantly reduced progression. However, neither mortality nor response rate was significantly affected by early treatment. In terms of high-risk SMM patients, early treatment significantly decreased both progression (RR=0.51, 95% CI 0.37–0.70, P=0.0001) and mortality (RR=0.53, 95% CI 0.29–0.96, P=0.04). Frequently seen adverse events were infection, constipation, asthenia, and second primary malignancy. A remarkably elevated risk of constipation was associated with early treatment using immuno-modulatory agents (RR=4.43, 95% CI 2.14–9.12, P<0.0001). Second primary malignancy was significantly increased with early treatment (RR=4.13, 95% CI 1.07–15.97, P=0.04). No significant difference was identified in infection or asthenia.ConclusionThese findings suggest that early treatment could decrease progression and mortality of high-risk SMM patients with a tolerable safety profile.

Bone Marrow DKK-1 Levels in Smoldering Multiple Myeloma Patients: A New Independent Risk Factor for Progression

The presence of bone disease is the hallmark to differentiate patients with active multiple myeloma (MM) from those with smoldering MM (SMM). The diagnostic criteria for active MM have been recently updated; including patients previously defined high-risk SMM among those with active MM in the presence of biomarkers of malignity. Actually SMM patients can be stratified for the risk of progression to active MM based on several factors but new parameters to identify patients with a high risk of progression need to be defined. Particularly there are not any molecular factors able to differentiate the new high-risk SMM patients. Recently, we analyzed bone marrow (BM) levels of several cytokines and chemokines involved in the MM-induced alterations of the bone remodeling finding that BM levels of Activin A, C-C motif chemokine ligand 20 (CCL20), Dickkopf 1 (DKK-1) and osteoprotegerin (OPG) were significantly different among patients with Monoclonal Gammopathy of Undetermined Significance (MGUS), SMM and MM (Dalla Palma B et al. Leukemia 2016). Thus, in this study we focused on those soluble factors in order to evaluate their possible role as new markers of risk progression in SMM patients.We analyzed a total cohort of 87 patients with SMM as defined by the International Myeloma Working Group updated diagnostic criteria for MM and related disorders (serum monoclonal protein (IgG or IgA) ≥ 3 g/dL, or urinary monoclonal protein ≥500 mg/24 h and/or clonal BM plasma cells 10%-60%, and absence of myeloma defining events or amyloidosis) admitted to our Myeloma Unit between 2007 and 2015 and who underwent to BM aspirate. The median age of the patients was 65 years (range 38-92); 50 were males and 37 were females; light chain was kappa in 68% of patients and lambda in 32%, whereas heavy chain was IgG in 76%, IgA in 23% and IgD in 1%. Standard risk factors evaluated were size of serum M protein (≥ 3 g/dL in 14% of patients), percentage of BM plasma cells and immunoparesis (present in 66% of patients). Free Light Chain (FLC) ratio was not available in all patients. DKK-1, Activin A, CCL20, and OPG BM plasma levels were measured by ELISA assay. Quantitative variables were compared by non-parametric Kruskal-Wallis and Mann-Whitney tests as appropriate and categorical variables were analyzed by Chi-square and Fisher’s exact test. P value of <0.05 was considered significant. The influence of BM cytokine and chemokine levels on the progression to active MM in SMM patients was examined by Kaplan-Meier and Cox regression analysis.With a median follow-up time of 42 months, 21 patients progressed to active MM; median time to progression was 16 months. BM Activin A, CCL20 and OPG median levels were not significantly different between progressed and not SMM patients (median levels: Activin A 401.97 pg/mL vs 402.93 pg/ml, p=0.70; CCL20 68.68 pg/mL vs 62.08 pg/mL, p=0.80; OPG 101.94 pg/mL vs 118.74 pg/mL, p=0.86). Conversely SMM patients progressed to active MM showed significantly higher DKK-1 BM levels as compared to patients who had not progressed (median levels: 1777.50 pg/mL vs 782.77 pg/mL, p=0.007). The progression-free survival was significantly worse in patients with BM DKK-1 above the median (DKK-1 median level: 971 pg/mL; p=0.021 by log rank test). In multivariate analysis, adjusted for standard risk factors such as the size of serum M protein, the percentage of BM plasma cells, the presence of the immunoparesis, we found that BM DKK-1 levels remained an independent prognostic factor for progression to active MM (p=0.001).In conclusion, our study indicates that BM median levels of DKK-1 are able to identify the SMM patients with higher risk of progression to active MM, and may represent a new independent risk factor for progression in SMM patients. DisclosuresGiuliani:Celgene: Research Funding; Janssen: Research Funding.

Sustained High Rates of Complete Response and Minimal Residual Disease Negativity after 8 Cycles of Carfilzomib (CFZ), Lenalidomide (LEN), and Dexamethasone (DEX) Followed By 2 Years of Lenalidomide Maintenance (CRd-R) in Patients with High-Risk Smoldering Multiple Myeloma: Updated Results of Clinical and Correlative Phase 2 Study

Background:High-risk smoldering multiple myeloma (HR-SMM) is a plasma cell dyscrasia which has a 5-year risk of progression to symptomatic multiple myeloma (MM) of approximately 75% based on current risk models. With the availability of novel therapies, early treatment may decrease the risk of progression and prolong survival as evidenced by the recent QuiRedex study results. More recently, studies have demonstrated that triplet regimens are superior to doublet in MM and whole exome sequencing in HR-SMM is indicative of treatment susceptible biology in early disease; supporting the use of effective combination therapy as early intervention. Expanding on our initial results using modern CRd-R therapy in HR-SMM patients (Korde et al. JAMA Onc 2015) we show unprecedented high rates of obtained and sustained complete response (CR) and minimal residual disease negativity (MRDneg CR) in an expanded cohort of patients with a median follow-up of ~3 years.Methods:Treatment-na•ve patients with HR-SMM (IMWG 2010 criteria; Mayo or PETHEMA models) were treated for 8 cycles (28-day cycles) with CFZ 20/36 mg/m2 IV days 1, 2, 8, 9, 15, 16; LEN 25 mg PO days 1-21, and DEX 20/10 mg IV/PO days 1, 2, 8, 9, 15, 16, 22, 23. Transplant eligible patients underwent stem cell collection after ≥4 cycles of CRd and then continued CRd treatment (i.e. by-default-delayed high-dose melphalan with autologous stem cell transplant; HDM-ASCT). After 8 cycles of combination therapy, patients with SD or better received 2 years of LEN 10 mg PO maintenance. The primary objective was best response (ORR), followed by secondary objectives of progression free survival (PFS) and response duration (DoR) which were assessed after every cycle of induction and every 90 days during maintenance. Correlative studies including assessment of minimal residual disease (MRD) by multi-color flow cytometry (bone marrow aspirate; 10-5 sensitivity) as defined by updated 2016 IMWG response criteria were performed after 8 cycles of induction and 1 and 2 years of maintenance LEN.Results:Eighteen patients meeting eligibility criteria were enrolled (data-lock 7/20/2016). Demographics and disease characteristics are shown in Table 1. Best ORR and >= VGPR rate (n=18) with CRd-R was 100% (Table 2). The proportion of patients who obtained stringent CR/CR after 8 cycles of induction, 1 year of maintenance and 2 years of maintenance was 61%, 89%, and 89%, respectively. Of evaluable patients who achieved at least a CR, the proportion of patients who obtained MRD negativity (MRDneg CR) at the same time-points was 91%, 71%, and 75%, respectively. DoR and PFS at 36 months was 94% and overall survival with a median follow-up duration of 31 months was 100%. Toxicities Grade 3-4 occurring in >1 patient included lymphopenia (39%), neutropenia (28%), anemia (22%), diarrhea (17%), lung infection (17%), hypophosphatemia (11%), and thromboembolic event (11%). Significant serious adverse events included CHF which occurred in one patient.Conclusions:Early treatment of HR-SMM with modern CRd-R combination therapy with by-default-delayed HDM-ASCT resulted in unprecedented high rates of CR and MRDneg CR after 8 cycles of CRd. Following 2 years of additional LEN maintenance therapy, the CR and sustained MRDneg CR rates were 89% and 69%, respectively. Given the significant risk of progression to symptomatic MM and associated life limiting end-organ damage, early intervention for patients with HR-SMM with effective triplet-based therapies may be warranted. This first proof-of-principle study has thus far demonstrated exceptional clinical benefit. Therefore, this study will be re-opened to enrollment and long-term follow up results collected to expand on these promising results. Updated results will be presented at the Annual Meeting. [Display omitted] [Display omitted] DisclosuresKorde:Medscape: Honoraria. Bhutani:Prothena: Research Funding; Takeda Oncology: Research Funding, Speakers Bureau; Bristol-Myers Squibb: Speakers Bureau; Onyx, an Amgen subsidiary: Speakers Bureau. Landgren:BMS: Honoraria; Amgen: Honoraria, Research Funding; Novartis: Honoraria; Celgene: Honoraria, Research Funding; Takeda: Honoraria.

Bence Jones proteinuria in smoldering multiple myeloma as a predictor marker of progression to symptomatic multiple myeloma.

The diagnosis of smoldering multiple myeloma (SMM) includes patients with a heterogeneous risk of progression to active multiple myeloma (MM): some patients will never progress, whereas others will have a high risk of progression within the first 2 years. Therefore, it is important to improve risk assessment at diagnosis. We conducted a retrospective study in a large cohort of SMM patients, in order to investigate the role of Bence Jones (BJ) proteinuria at diagnosis in the progression to active MM. We found that SMM patients presenting with BJ proteinuria had a significantly shorter median time to progression (TTP) to MM compared with patients without BJ proteinuria (22 vs 88 months, respectively; hazard ratio=2.3, 95% confidence interval=1.4-3.9, P=0.002). We also identified risk subgroups based on the amount of BJ proteinuria: ⩾500 mg/24 h, <500 mg/24 h and without it, with a significantly different median TTP (13, 37 and 88 months, P<0.001). Thus, BJ proteinuria at diagnosis is an independent variable of progression to MM that identifies a subgroup of high-risk SMM patients (51% risk of progression at 2 years) and ⩾500 mg of BJ proteinuria may allow, if validated in another series, to reclassify these patients to MM requiring therapy before the end-organ damage development.

Immune status of high-risk smoldering multiple myeloma patients and its therapeutic modulation under LenDex: a longitudinal analysis

AbstractThere is significant interest in immunotherapy for the treatment of high-risk smoldering multiple myeloma (SMM), but no available data on the immune status of this particular disease stage. Such information is important to understand the interplay between immunosurveillance and disease transformation, but also to define whether patients with high-risk SMM might benefit from immunotherapy. Here, we have characterized T lymphocytes (including CD4, CD8, T-cell receptor γδ, and regulatory T cells), natural killer (NK) cells, and dendritic cells from 31 high-risk SMM patients included in the treatment arm of the QUIREDEX trial, and with longitudinal peripheral blood samples at baseline and after 3 and 9 cycles of lenalidomide plus low-dose dexamethasone (LenDex). High-risk SMM patients showed at baseline decreased expression of activation-(CD25/CD28/CD54), type 1 T helper-(CD195/interferon-γ/tumor necrosis factor-α/interleukin-2), and proliferation-related markers (CD119/CD120b) as compared with age-matched healthy individuals. However, LenDex was able to restore the normal expression levels for those markers and induced a marked shift in T-lymphocyte and NK-cell phenotype. Accordingly, high-risk SMM patients treated with LenDex showed higher numbers of functionally active T lymphocytes. Together, our results indicate that high-risk SMM patients have an impaired immune system that could be reactivated by the immunomodulatory effects of lenalidomide, even when combined with low-dose dexamethasone, and support the value of therapeutic immunomodulation to delay the progression to multiple myeloma. The QUIREDEX trial was registered to www.clinicaltrials.gov as #NCT00480363.

Low-Dose Dexamethasone Does Not Abrogate the Immunomodulatory Effects of Lenalidomide and Both Reactivate the Impaired Immune System of High-Risk Smoldering Multiple Myeloma Patients

Introduction: While dexamethasone (Dex) has been commonly used in the treatment of multiple myeloma (MM), its immunosuppressive effect is becoming a matter of concern with the advent of immune-based therapies. One example is the combination of lenalidomide and Dex (LenDex) because it has been reported that Dex abrogates the immunomodulatory effects of Len; however, most of the studies have been performed in vitro, using high-doses of Dex, and in small series of relapsed patients previously exposed to other drugs.Methods: Because the potentially antagonist effect of Dex may represent a dilemma in the design of clinical trials, here we aim to shed light into the question about whether or not low-dose Dex abrogates the immunomodulatory effect of Len by studying the phenotypic profile of T-lymphocytes, NK-cells and dendritic cells (DCs) of 31 previously untreated high-risk smoldering MM (SMM) patients enrolled in the Quiredex trial at baseline, after 3 and 9 cycles of LenDex, and during maintenance with Len as single-agent.Results: Patients with high-risk SMM showed at baseline normal numbers of CD4 and CD8 T-lymphocytes as well as CD56dim and CD56bright NK-cells compared to age-matched healthy individuals. By contrast, they displayed an increment of TCRγδ positive T-lymphocytes (P =.02) and Tregs (P =.04), as well as an altered distribution of BDCA-1 positive myeloid DCs (P =.02) and tissue macrophages (P =.06). Moreover, the expression levels of activation markers (CD25, CD28 and CD54) as well as Th1-related markers (CD195, IFN-γ, TNF-α, or IL-2) were significantly inferior in T-lymphocytes from high-risk SMM patients. A significantdown-regulation of proliferation-related markers (CD119 and CD120b) was also noted. To assess the combined effect of LenDex in T-lymphocytes and NK-cells, we compared the immune status of the 31 high-risk SMM patients at baseline vs. after 3 and 9 cycles of LenDex. Interestingly, TCRγδ positive T-lymphocytes as well as Tregs were further increased with LenDex; conversely, CD4 T-lymphocytes were significantly decreased at the end of induction. There was a marked shift on the distribution of antigen-related maturation subsets induced by LenDex, and reflected by a significant increase of central memory CD4 (P<.001) and effector memory CD8 (P<.001) T-lymphocytes. Accordingly, CD4 and/or CD8 T-lymphocytes showed an increased expression of activation markers (CD69, CD25, CD28, and CD54), together with an up-regulation of the Th1 related chemokine CCR5 (CD195) and increased cytokine production of IFNγ, TNFα, and IL-2. NK-cells showed an up-regulation of the activation marker HLA-DR (P<.001), the ADCC associated receptor CD16 (P≤0.005), and the adhesion molecules CD11a (P≤0.001) and CD11b (P≤0.005) after 3 and 9 courses of LenDex. The percentage of cells in S-phase progressively increased from baseline vs. 3 and 9 cycles of LenDex for CD4 (P<0.001) and CD8 (P<0.001) T-lymphocytes as well as NK-cells (P<0.001). Most interestingly, high-risk SMM patients treated with LenDex and without disease progression showed higher numbers of functionally active T-lymphocytes as compared to those progressing to MM. To address the question whether Dex antagonizes Len, we compared the immune profile of 13 patients with PB samples collected at cycle 9 of induction vs. during maintenance (single-agent Len at least 3 months after Dex discontinuation). No significant differences were observed for the absolute numbers of all cell populations analyzed. From the total 63 phenotypic parameters analyzed, only 7 were found to be differently expressed. Namely, the expression of CD94, CD154 and CD212 positive T-lymphocytes as well as CD11a in T-lymphocytes and NK-cells were down-regulated during maintenance.Conclusions: Our results, obtained from a carefully selected population of patients without previous exposure to anti-MM therapy and with available longitudinal samples after consecutive cycles of LenDex, shed new light on the synergy between lenalidomide and dexamethasone which, at low doses, does not abrogate the immune modulatory effects of lenalidomide here analyzed. Accordingly, high-risk SMM patients have an impaired immune system that could be re-activated with LenDex, and support the value of therapeutic immunomodulation to delay the progression to MM. DisclosuresPaiva:Millenium: Consultancy; BD Bioscience: Consultancy; Janssen: Consultancy; Celgene: Consultancy; Onyx: Consultancy; Sanofi: Consultancy; EngMab AG: Research Funding; Binding Site: Consultancy. Mateos:Takeda: Consultancy; Celgene: Consultancy, Honoraria; Onyx: Consultancy; Janssen-Cilag: Consultancy, Honoraria. San Miguel:Celgene: Honoraria; Bristol-Myers Squibb: Honoraria; Janssen-Cilag: Honoraria; Sanofi-Aventis: Honoraria; Millennium: Honoraria; Novartis: Honoraria; Onyx: Honoraria.

Smoldering Multiple Myeloma

Smoldering Multiple Myeloma (SMM) is an asymptomatic disorder characterized by the presence of ≥ 3 g/dL serum M-protein and/or 10-60% bone marrow plasma cell infiltration with no myeloma-defining event. Kristinsson et al., through the Swedish Myeloma Registry, recently reported that 14% of patients diagnosed with myeloma had SMM and, taking the world population as a reference, that the age-standardized incidence of SMM was 0.44 cases per 100,000 people. The risk of progression to active MM is not uniform, and several markers are useful for identifying patients at high risk of progression, approximately 50% at 2 years. The definition of the disease has recently been revisited and asymptomatic MMs at 80-90% of progression risk at 2 years are now considered to be MMs. The biomarkers for the identification of this subgroup of patients are: 1) the presence of more than one focal lesions in magnetic resonance imaging, 2) more than 60% of plasma cells within the bone marrow, or 3) a ratio of involved versus uninvolved serum free light ratio equal to or higher than 100. For the rest of patients, the standard of care is observation, although a randomized trial in high-risk SMM patients comparing early treatment versus observation has shown early intervention to provide a significant benefit in terms of time to progression and overall survival. These findings highlight the need to follow a correct diagnosis by accurate risk stratification in order to plan an optimized follow-up according to the risk of progression: if ultra high-risk of progression, patients should be called myeloma and treated; if low or intermediate risk of progression, it would be necessary to do follow-up every year or twice-year; and if high-risk of progression to myeloma is present, the best option is the patients to be refered to a center specialized in myeloma and include them in a clinical trial if available.