[Music] what is high risk smoldering myeloma compared to low and intermediate risk smoldering myeloma patients identified as having high risk smoldering myeloma have a significantly higher rate of progression to actu myeloma at two years the definition of what criteria should we use to identify someone as having high risk smoldering myeloma has been evolving over time and will continue to do so as more is learned high risk smoldering myeloma is a definition that's changing right now we don't actually have a good answer for it in general we use markers like how high is the EM spike how high is the light chain ratio how much tumor burden they have meaning the bone marrow involvement and you can have different markers so the old kiled criteria or Mayo criteria was based on certain numbers and this was updated by the to 2020 which is now trying to redefine it so that we can understand better and talk to each other however in general those are all markers of turan burden and we need better markers we just put together the genomic data on trying to redefine smoldering myeloma and having genomic markers of high risk disease so that when we can use these numbers you can actually be more accurate in seeing who is truly going to progress to overt myeloma what are the two 20/20 guidelines for smoldering myeloma smoldering myeloma high risk to 2020 is a new classification that came along after we removed in the old days what we called ultra high risk smoldering myeloma were the people who had a very high risk of developing myeloma so 60% plasma cells having a life change ratio that's very that's very high like over 100 and having multiple lesions on an MRI or a PET CT scan these categories are now taken into overt myeloma and we treat patients when they have those numbers so we started saying well can we redefine what is going on with the smoldering myeloma and this is when over a thousand patients were put together by the International myeloma working group and it came with the definition of 220 22 grams of M spike 20% plasma cells in the bone marrow and a lysine ratio of 20 or higher I think it's a great definition it's not good enough we need better markers because to 20/20 is still defining like Shayne's bone-marrow involvement and M spike and these are just tumor burden markers we need to understand the biology better are the two 20/20 criteria considered standardized guidelines for diagnosing high-risk smoldering myeloma they're not considered standard because we're still trying to define smoldering myeloma I see it's probably a new definition that we can use but we need to add to it and there are so many other factors that were not included in this definition high-risk cytogenetics is very bad and we need to make sure that we have that data involves evolving M spike if there are light chains or there M spike keeps increasing I think that's such an important factor let's not forget about that so in general in clinical trials were saying we will use to 2020 and other factors to make sure that we're including everyone and were not over simplifying it and removing so many other important factors in high-risk smoldering myeloma [Music]