BY LIZZY SMITH One of the hot topics at the 2014 ASH Annual Meeting in December is when to begin treating those with smoldering multiple myeloma, especially those with high risk factors. And, really, when is one considered "smoldering" versus "active" anyway? As a follow-up to that discussion, OncLive features an interesting panel, moderated by Keith K. Stewart, MB ChB, discussing updated data from a Spanish randomized trial of lenalidomide/dexamethasone versus observation for high-risk smoldering multiple myeloma. To watch the panel discussion in its entirety, click here. In summary, the updated data showed that the survival benefit continues to hold up with longer follow-up.  In summary,

Though the panelists agree that this study was not practice-changing, Sagar Lonial, MD, suggests that these results again raise the question of whether practitioners should begin to think about treating some of these high-risk patients. Sundar Jagannath, MD, explains that the treatment has become much better tolerated by patients, and questions whether practitioners should continue to wait until myeloma patients become symptomatic, through the development of bone disease, CRAB criteria, or renal impairment, especially those who are at high risk. The panelists discuss their use of PET and MRI scans to evaluate whether a patient is symptomatic or smoldering. Finally, Lonial describes the new criteria added by the International Myeloma Working Group to help define symptomatic myeloma. These include: 1) the presence of >1 focal bone lesion by MRI or PET scan; 2) free light chain ratio >100; and 3) >60% plasma cells in the bone marrow (Rajkumar SV et al. Lancet Oncol. 2014;15:e538-e548). These additions are based on the identification of biomarkers associated with near-inevitable development of CRAB features (hypercalcemia, renal failure, anemia, and bone lesions) in patients who would otherwise be regarded as having smoldering multiple myeloma.