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For the October 2021 Treating Blood Cancers healthcare professional podcast episode, Dr. Ken Miller sat down with Dr. Joshua Richter to discuss the physician’s role in treating newly diagnosed patients. Here are some highlights. 

Ken Miller, MD, medical oncologist and hematologist affiliated with the University of Maryland Midtown Medical Center and Sinai Hospital of Baltimore and LLS volunteer, Maryland.

Dr. Miller:  I’ve wondered as a community hematologist and oncologist when to start treatment. There are patients who have smoldering myeloma and it’s a decision on what to do and when. How do you think through that situation?

Dr. Richter:  This is a hot topic and a lot has to do with our definitions of what is truly a smoldering patient who is okay to watch and observe without directed therapy and who needs therapy. For years we separated out things succinctly between smoldering myeloma, defined at more than 10% or more bad plasma cells or myeloma cells in the marrow, or greater than an M spike in the blood of 3 grams per deciliter but no CRAB symptoms, the classic CRAB they talk about: high calcium, renal problems, anemia, or bone lesions.  And then myeloma patients, people who needed therapy were patients who had CRAB symptoms.

One of the biggest shifts in recent years was a major paper published, led by the group at the Mayo Clinic and Dr. S. Vincent Rajkumar, November 2014, Lancet Hematology. They looked at thousands of patients who had smoldering myeloma and tried to pick out independent risk factors for reasons that would make them progress because we classically would say smoldering myeloma has a 10% chance per year of progression.  But we know it’s heterogeneous. In that group, there’s some people who are 2% and some like 80%. They found three things that if a smoldering patient had any of these three, they were about 80-90% likely to progress within the next two years. Now we consider treating those patients earlier on. We call those the SLiM criteria. CRAB has evolved. It’s lost weight and is now the SLiM CRAB, S Stands for 60. If you have 60% or more plasma cells in your marrow, even if you don’t have any CRAB symptoms, we consider treating you.

Joshua Richter, MD, Assistant Professor in the Myeloma Division at the TISH Cancer Institute, at the Icahn School of Medicine at Mt. Sinai and Director of Myeloma Care at the Blavatnik Family Chelsea Medical Center at Mt. Sinai, New York.

LI stands for light chain ratio. We measure the kappa and lambda levels in the blood and if your ratio of kappa to lambda or lambda to kappa is greater than 100 to 1, you’re at such a high risk of progression, we consider treating you.

M stands for MRI. In the old days the B for bone lesions came from old classic x-rays. We know patients can have lesions on MRI or PET CT years before it shows up on plain film. So, the definition is now if you have more than one lesion of at least 5 millimeters on an MRI, we consider treating you.

Dr. Miller:  I’d love to hear more about what does MRI mean in that setting?

Dr. Richter:  That’s one of the most important answers, the question is what does that really mean? The IMWG has kind of endorsed three modalities of imaging we call MRI, but we mean higher order imaging, or something better than an x-ray.

The old-fashioned skeletal survey or metastatic bone survey is no longer considered a standard of care. It doesn’t get the high-resolution look at the bones, shows nothing about soft tissues, and some patients can have soft tissue plasma cytomas. The three recommended higher order modality imaging tests are either low dose whole body CT, PET CT, or whole-body MRI. For whole body we like to use at our institution, DWIB. A diffusion weighted MRI. This allows us to almost get that feel of a PET scan. What lesions are not only there, but are they active or not active?

Dr. Miller:  If insurance authorizations were not an issue, do you have one you’d choose or one you’d recommend of those three?

Dr. Richter:  In general, PET CT is probably my favorite because it gives a lot of great information, but there are a few advantages of the MRI. It’s not radiation. If you’re doing a lot of them, especially for young patients you anticipate living a long time, you avoid radiation. The other benefit of the MRI is that many of our patients have back problems from non-myeloma reasons, and it helps delineate when someone says my back hurts, what’s a disc out of place, what’s a little arthritis, and what’s really myeloma?

Dr. Miller:  How has COVID affected your practice?

Dr. Richter:  One of the biggest things has been TeleMedicine. If you live in a place where you don’t have easy access to a myeloma center, you can visit any center, any myeloma physician, by TeleMedicine to help guide care. One of the biggest issues now is vaccination and booster vaccination and combined with therapy.

Listen to more of this conversation, including examples of what goes into treatment decisions and what’s exciting coming on the horizon, such as bispecific antibodies, at    


The Patti Robinson Kaufmann First Connection Program is a free service of The Leukemia & Lymphoma Society that introduces patients and their loved ones to a trained peer volunteer who has gone through a similar experience.

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