Smoldering Myeloma is actually a heterogeneous disease, basically because the diagnostic criteria are common. More than three grams of monoclonal component, a plasma bone marrow infiltration between 10 and 59%, no myeloma defining events. But we can find some patients in which the progression to myeloma will occur very late, and the progression rate will be one percent per year. And at the same time, we can find some smoldering myeloma patients with a 50% progression risk within the next two years...
Smoldering Myeloma is actually a heterogeneous disease, basically because the diagnostic criteria are common. More than three grams of monoclonal component, a plasma bone marrow infiltration between 10 and 59%, no myeloma defining events. But we can find some patients in which the progression to myeloma will occur very late, and the progression rate will be one percent per year. And at the same time, we can find some smoldering myeloma patients with a 50% progression risk within the next two years. So the first important point to distinguish those patients with a low risk of progression to multiple myeloma from those at high risk of progression to multiple myeloma. Today the models in order to distinguish low, intermediate, and high risk are basically based on clinical markers. And in the near future, we have to incorporate molecular assessments in order to accurate, and in order to improve the models in order to evaluate the risk of progression to multiple myeloma.
From the management point of view, it should be risk-adapted, a low-risk smoldering myeloma should be managed to like MGUS patients. Intermediate-risk smoldering myeloma should we follow it, evaluate an M component, as well as free light chain, hemogram biochemistry, and so on. Definitely high-risk smoldering myeloma patients can benefit from an early intervention. Lenalidomide and dexamethasone, or lenalidomide alone showed a significant benefit in terms of delaying the progression to multiple myeloma with benefit also in overall survival and in the future, maybe we will establish potential curative options. So I think that the management of high-risk smoldering myeloma should be like we are doing right now with the patients with active multiple myeloma. And I think that this is the ideal platform in order to potential establish a cure for asymptomatic myeloma patients.