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Multiple myeloma gammopathies

Response to 'Evolving M-protein pattern in patients with smoldering multiple myeloma: impact on early progression'

Leukemia volume 32, pages 2083–2085 (2018)Cite this article

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We read with interest, the article titled “Evolving M-protein pattern in patients with smoldering multiple myeloma: impact on early progression”, by Fernandez de Larrea et al. published recently [1]. Their group previously described a cohort of 53 patients of smoldering multiple myeloma (SMM) and identified an evolving subtype [2]. The current study expands on their institutional experience and includes patients who satisfied the 2003 International Myeloma Working Group definition of SMM [3]. They show that, from identification of an evolving pattern, these patients progress rapidly, with a median time of 1.1 years to clinical disease requiring treatment.

In the current study, the authors used two separate criteria to define evolving phenotype based on the M-protein value at diagnosis. For patients with M-protein ≥30 g/L at diagnosis, ≥10% rise was required within 12 months from diagnosis while for those with M-protein <30 g/L, ≥10% rise over 3 years with a progressive increase in each of the annual measurements was required. It would be interesting to know how many patients who demonstrated an evolving pattern belonged to the two categories and what was the time from diagnosis of SMM to diagnosis of evolving pattern in the two subgroups. Furthermore, we believe that using fractional increase alone, without a requirement for minimum absolute rise in M-protein level may reduce the specificity, especially in the group who had M-protein <30 g/L at diagnosis (for a patient with baseline M-protein of 10 g/L, the increase required would be only 1 g/L). The 3 year period for those with lower M-protein probably introduces another layer of heterogeneity. In a similar study examining the impact of evolving changes in M-protein and hemoglobin on progression of SMM, our group defined evolving M-protein as ≥10% increase in serum M-protein and/ or involved immunoglobulin level within the first 6 months of diagnosis (for those with baseline M-protein ≥30 g/L), and/ or ≥25% increase in serum M-protein and/ or involved immunoglobulin level within the first 12 months of diagnosis (for any level of M-protein). We also stipulated that there should be a minimum increase of 5 g/L in M-protein or 500 mg/dL in immunoglobulin or both, so as to avoid minor spurious changes and improve the specificity of our criteria [4]. Data on how many patients actually had a minimum increase of 5 g/L of M-protein over the study period in the present study and how many of them progressed would be very informative.

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References

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Authors and Affiliations

  1. Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA

    Arjun Lakshman, S. Vincent Rajkumar & Shaji K. Kumar

  2. Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA

    Praful Ravi

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  1. Arjun Lakshman
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Correspondence to Shaji K. Kumar.

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SKK- Abbvie, Celgene, Janssen, Merck, Novartis, Roche, Sanofi, and Takeda (research funding) and Skyline Diagnostics (honoraria). The remaining authors declare no conflict of interest.

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Lakshman, A., Ravi, P., Rajkumar, S.V. et al. Response to 'Evolving M-protein pattern in patients with smoldering multiple myeloma: impact on early progression'. Leukemia 32, 2083–2085 (2018). https://doi.org/10.1038/s41375-018-0155-4

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