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This algorithm covers management of smoldering multiple myeloma (SMM), defined by an M-protein of 3 g/dL or higher or 10 to 60% clonal plasma cells without active myeloma. The first step is staging with bone marrow examination, serum free light chains, and whole-body MRI or CT to exclude active myeloma (CRAB or SLiM criteria). Patients are then divided by risk.
Low-risk SMM is observed with surveillance every 3 to 6 months and no therapy. High-risk SMM is defined by the 20/2/20 criteria (M-protein above 2 g/dL, free light-chain ratio above 20, and more than 20% plasma cells). For this group the chart shows early therapy with lenalidomide with or without daratumumab, supported by E3A06, in which lenalidomide delayed progression to active myeloma and showed an overall survival benefit at 6.5 years. Daratumumab is shown as a separate option based on AQUILA, where subcutaneous daratumumab reduced progression to active myeloma compared with active monitoring and led to the first FDA approval specifically for SMM.
Background reading: Multiple myeloma, MGUS, and smoldering myeloma board review notes.
Risk-adapted observation vs early therapy. Starting point: Smoldering myeloma M-protein ≥ 3 g/dL or 10–60% plasma cells. Full background: Multiple myeloma, MGUS, and smoldering myeloma notes.
Simplified board-prep scaffold; verify against current guidelines and primary literature. High-risk by 20/2/20 (M-protein > 2 g/dL, FLC ratio > 20, > 20% plasma cells). Exclude active myeloma (CRAB / SLiM) with marrow, light chains, and whole-body imaging.