This week’s Ask Dr. Durie is actually a
very insightful question from a lady who wants to know, since we have introduced new criteria
for the diagnosis for multiple myeloma, what does that do concerning the criteria for high-risk
smoldering multiple myeloma. In 2018, high-risk smoldering multiple myeloma
is diagnosed if the patient has CRAB features and myeloma-defining events. And the answer is this has really required
some very careful attention by myeloma experts. Now the diagnosis of active
multiple myeloma
can be established based upon the old criteria, which is the presence of the CRAB criteria,
plus the presence of what are called myeloma-defining events, and these events which have been introduced
are the presence of more than 60% of plasma cells in the bone marrow, the presence of
a serum free-light ratio of a 100 or more, and the presence of more than one lesion on
an MRI-scanning assessment. But what this means is, for the patients who
do not meet these criteria, for those o
ther patients, what are the criteria that would
indicate that there is a high-risk of progression for these other patients. And this has taken some thought and some further
investigation. The group at the Mayo Clinic has looked at
this. And the International Myeloma Working Group
is currently looking, with a very, very large database analysis of what will be between
3000 and 4000 patients to assess what will be the best new criteria. However, for a now, a new set of criteria
are available that d
o seem to work well, and this is called the 2-20-20 rule. And this a rule in which we use the level
of the serum myeloma protein, the M-component, with a cutoff level of 2 grams/deciliter,
so anything above that. The percentage of the bone marrow plasma cells
with a cutoff of 20 percent. And the serum free light ratio, the involved
over the uninvolved with a cutoff of 20 percent. And so a combination of the 2, 20, and 20
does give an excellent indication of a high likelihood of progression withi
n 2 years. And so this is a group of smoldering patients
who are at the highest risks and would now be classified as falling into this high-risk
smoldering category. More work needs to be done. So this is a working definition for now. Other factors being looked at include the
FISH test results, particularly the 1Q+ finding, and it seems that the presence of the translocation
(14;16) could also be important. We are also looking at the significance of
the presence of circulating plasma cells in th
e blood. We’re also looking at the significance of
circulating plasma cells in the blood. So more work to be done, but for now, this
is an important topic, and I would strongly advise that anyone in this smoldering myeloma
category take time to talk to really talk through these results with their doctor very
carefully to see if 1) they do have smoldering myeloma.
2) they might or might not fall into the higher risk classification using these evolving new
criteria.
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