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Managing smoldering myeloma—or more broadly, plasma cell dyscrasia—isn’t always straightforward. Some patients show early signs of plasma cell disorders, yet remain largely healthy, leaving clinicians to weigh whether to act or watch closely.
Deciding when to treat versus monitor involves balancing potential disease progression with patient quality of life, understanding the limited data on early intervention, and navigating differing approaches among specialties. Recently, a clinician on Healthcasts sought peer perspectives on how to proceed with a patient case of plasma cell dyscrasia that points to smoldering myeloma, but it is overall great health.
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Post:
57-year-old female patient referred by neurology. As part of her workup for neuropathy, an SPEP was drawn. This showed a monoclonal protein of 1.8 grams. IFE showed an IgG kappa monoclonal protein. Light chains showed elevated kappa at a 10:1 ratio.
Bone marrow biopsy was done, showing 12% plasma cell involvement of the bone marrow (IgG kappa). The PET scan was negative. CRAB criteria show no hypercalcemia, renal insufficiency, anemia, and no bone lesions on PET. Patient has little in the way of PMH, but for her neuropathy and hypothyroidism. Excellent performance status.
Questions for consult
1. Patient meets the criteria for smoldering myeloma. Would you treat her? If so, with what therapy?
Comments
Key takeaways about smoldering myeloma management:
- Monitoring is the standard approach for smoldering myeloma
Most clinicians recommended careful observation rather than immediate treatment, using regular labs (SPEP, IFE, serum free light chains, CBC, CMP) and imaging only if disease progression is suspected. - Early intervention is nuanced and case-dependent
Some clinicians noted that while data on early treatment is limited, intervention may be considered in select cases—particularly if symptoms like neuropathy suggest active disease. - Specialist referral is common and prudent
Even when monitoring is chosen, many clinicians suggested involving a hematologist or oncology specialist to guide decisions and ensure patient safety.
Oncology/Hematology
"Treatment for smoldering myeloma is controversial. Some can consider daratumumab, but you can also opt to just monitor."
Internal Medicine
"I would not treat, but would monitor every 3 to 4 months for the first year and then every six months thereafter. I would do SPEP, IFE, serum free light chains, CBC, CMP, and consider bone marrow or imaging only if progression is suspected."
Internal Medicine
"One thing I have learned in my 30 years of practice is that we wait too long to treat conditions, and we have been educated to be more reactive than proactive in treating patients. That being said, we all know that if we stomp out a smoldering fire, it prevents it! There probably isn't much data on early intervention.
I would immediately have this patient change their diet to an anti-inflammatory one, which eliminates simple sugars and substitutes whole fruits and vegetables. As far as starting pharmaceuticals doesn't really matter which one you start; there simply aren't many studies regarding this stage of disease. I would probably pattern one that would show more benefit on the neuropathy, which is likely being caused by the gammopathy apparent in the SPEP."
Internal Medicine
"I personally would refer the patient to a hematologist for them to decide/monitor, but generally for smoldering myeloma, it's monitor, and no treatment."
Oncology/Hematology
"I would treat her. Her neuropathy may be secondary to the plasma cell dyscrasia if no other cause is identified."
Would you proceed with treatment or simply monitor this patient? Visit the full post on Healthcasts to share your next steps and read other perspectives from the community.
