The Fellow on Call: The Heme/Onc Podcast Episode 142: Myeloma Series, Pt.3 - Management of Smoldering Multiple Myeloma (2025)
Dec 17, 2025
Explore the evolving management strategies for smoldering multiple myeloma (SMM) and its higher-risk features. Delve into landmark studies revealing the nuances of this disease's natural history. Learn about the hot debate on whether early treatment or observation is more beneficial. Discover insights from trials like QUIREDEX and AQUILA, highlighting the effectiveness of lenalidomide and daratumumab. Plus, hear about personalized surveillance strategies to empower patient decision-making.
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Progression Risk Peaks Early
- Risk of progression from SMM is highest in the first few years after diagnosis and declines after ~5 years.
- Close monitoring early on is therefore crucial.
Use The 20‑2‑20 Rule
- Use the 20-2-20 rule to identify high‑risk SMM: >20% marrow plasma cells, M spike >2 g/dL, involved/uninvolved FLC ratio >20.
- Treat or surveil based on accumulating risk factors, not a one-size-fits-all approach.
SLIM Criteria Changed Diagnoses
- The 2014 IMWG SLIM additions reclassified some patients from SMM to active myeloma based on biomarkers.
- Not all patients meeting SLIM criteria inevitably develop classic CRAB features, but their near-term risk rose historically.