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Smoldering to Myeloma- Imaging too?

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While trying to predict the risk of smoldering multiple myeloma (SMM) from becoming full multiple myeloma (MM) is a worthwhile endeavor, no method of predicting SMM to full MM is 100% accurate.

The study linked and excerpted below states that the current three methods used to assess the risk of smoldering myeloma becoming full MM are lacking.

Therefore undergoing chemotherapy in hopes of reducing your risk of smoldering myeloma from becoming full MM is, in my opinion, too great a risk for the possible reward.

Let me explain.

Pre-MM, SBP, MGUS or SMM, are not  health problems. It is the possibility, the increased risk of MM that these diagnoses bring, that is the worry. Over the past few years, conventional oncology has been testing the idea that chemotherapy given to high-risk (HR) SMM patients may slow the HR SMM from becoming full MM.

Based on the studies that I have read about this idea, chemotherapy given to high risk smoldering myeloma patients does slow an MM diagnosis but it also brings short, long-term and late stage side effects.

Again in my opinion,  chemotherapy has risks and rewards. You do not want chemotherapy unless you are clear on the rewards. Undergoing chemotherapy is, in the the case of HR SMM, risk with only possible rewards

This is what I mean when I say “undergoing chemotherapy in hopes of reducing your risk of smoldering myeloma from becoming full MM is, in my opinion, too great a risk for the possible reward.”

The study below mentions that sensitive imaging studies “can aid in risk stratifying patients who are at highest risk of developing symptomatic MM.5″ 

As fate would have it, I happened to read and blog about a study recently, that cites whole body MRI as being superior to positron emission tomography/computed tomography (18F-FDG PET/CT) when it comes to identifying bone disease.

If you are a pre-MM (smoldering) patient/survivor and you are worried about your risk of a full MM diagnosis, consider a whole body MRI. Consider looking deep into your bones to see if there is any sign of monoclonal proteins aka multiple myeloma aka bone involvement.

If you are interested in learning more about evidence-based, non-toxic therapies shown to reduce the risk of MM, scroll down the page and send me an email or question. I will reply to you ASAP.

Thank you,

David Emerson

  • MM Survivor
  • MM Cancer Coach
  • Director PeopleBeatingCancer 

Recommended Reading:

Assessment of Discordance Among Smoldering Multiple Myeloma Risk Models

“Smoldering multiple myeloma (SMM) is a plasma cell disorder with the potential to evolve to multiple myeloma.1 Several risk stratification models—commonly, the Mayo Clinic Risk Stratification Model 2008, the Programa para el Tratamiento de Hemopatias Malignas (PETHEMA) model, and the newer Mayo Clinic Risk Stratification Model 2018—have been developed to prognosticate the risk of progression.2,3

These models use clinical variables of disease burden rather than biological tumor characteristics to predict-

  • low risk (LR),
  • intermediate risk (IR), and
  • high risk (HR)

for progression to multiple myeloma (MM). Multiple clinical trials are investigating the role of treatment in HR SMM. Interpreting the results of clinical trials investigating the role of treatment in HR SMM is problematic owing to variation in the risk stratification criteria used.4 Our study attempts to assess the concordance of these 3 models in a cohort of patients with SMM from 2 clinical trials.


The accurate identification of patients with smoldering myeloma at highest risk of developing MM remains difficult. While the 2018 Mayo Clinic model has a higher concordance rate with the PETHEMA model, it remains significantly discordant.

Furthermore, these models are limited because they do not incorporate sensitive imaging techniques, such as positron emission tomography–integrated computed tomography, which can aid in risk stratifying patients who are at highest risk of developing symptomatic MM.5

These results suggest that the current clinical variables used to determine risk are not reliable, most likely because they are markers of disease burden, subject to increase over time, and not true markers of biological disease characteristics…

As recently outlined by Maura et al,6 the incorporation of genomic signatures has the potential to significantly improve SMM risk stratification and is urgently needed. Until that time, it remains unclear which patients warrant early intervention, and we would caution against treatment of patients with SMM outside of a clinical trial.”

Comparison of the diagnostic performance and impact on management of 18F-FDG PET/CT and whole-body MRI in multiple myeloma

“This study compared the diagnostic performance and impact on management of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) and whole-body magnetic resonance imaging (WBMRI) in treatment-naive myeloma…

Blinded clinical and imaging data were reviewed by two haematologists in consensus and management recorded following clinical data ± 18F-FDG PET/CT or WBMRI. Bone disease was defined using International Myeloma Working Group (IMWG) criteria and a clinical reference standard. Per-patient sensitivity for lesion detection was established. McNemar test compared management based on clinical assessment ± 18F-FDG PET/CT or WBMRI…


Sensitivity for bone lesions was 69.6% (32/46) for 18F-FDG PET/CT (54.3% (25/46) for PET component alone) and 91.3% (42/46) for WBMRI. 27/46 (58.7%) of cases were concordant.

In 19/46 patients (41.3%) WBMRI detected more focal bone lesions than 18F-FDG PET/CT.Based on clinical data alone, 32/46 (69.6%) patients would have been treated. Addition of 18F-FDG PET/CT to clinical data increased this to 40/46 (87.0%) patients (p = 0.02); and WBMRI to clinical data to 43/46 (93.5%) patients (p = 0.002).

The difference in treatment decisions was not statistically significant between 18F-FDG PET/CT and WBMRI (p = 0.08)…


Compared to 18F-FDG PET/CT, WBMRI had a higher per patient sensitivity for bone disease.

However, treatment decisions were not statistically different and either modality would be appropriate in initial staging, depending on local availability and expertise…

A small number of studies, with limited sample sizes, have compared the diagnostic accuracy of 18F-FDG PET/CT and WBMRI in myeloma [2,3,4,5], but to date, there has been a lack of comparative data of the impact on management of 18F-FDG PET/CT and WBMRI.

Both techniques have advantages. While WBMRI has superior sensitivity for diffuse bone marrow infiltration [6], 18F-FDG PET/CT better demonstrates lesion viability following treatment [7];

both convey prognostic information [8, 9].

Additionally, in patients with smouldering myeloma, the presence of >1 focal bone lesion detected by WBMRI [10] or the presence of a focal FDG-avid lesion [11] is a strong prognostic factor for progression to myeloma such that they are now recognised as an indication to treat otherwise asymptomatic myeloma [12, 13]…

…We hypothesised that the greater sensitivity of WBMRI for detection of myeloma compared to 18F-FDG PET/CT would alter patient management in a greater proportion of cases. Thus, the primary aim of this study was to compare the diagnostic performance of 18F-FDG PET/CT and WBMRI for bone disease in patients with a new myeloma diagnosis and to assess whether management differed depending on which imaging was performed initially…


There was moderate agreement between the two readers in scoring for the presence/absence of focal CT and PET disease, with a kappa score of 0.44 and 0.47, respectively. Identification of CT disease was discordant in 3/12 patients, where CT positive but FDG-negative lesions were noted by one reader. Identification of FDG-positive disease was also discordant in 3/12 patients.

Whole-body MRI

There was excellent agreement between the two readers in scoring for the presence/absence of focal lesions on a per patient basis (kappa score, 1.00). With respect to the scoring of the number of lesions across the 7 regions, mean ± SD focal lesion score was 7.4 ± 5.7 for Reader 1 and 7.7 ± 5.5 for Reader 2; with an intraclass correlation coefficient of 0.95 [95%CI: 0.84-0.99].

With respect to the presence/absence of bone marrow infiltration, there was good agreement between both readers with a kappa score of 0.74; one patient with a bone marrow infiltration percentage of 90% on biopsy was assigned incorrectly as negative by one reader…

Impact on clinical management

Based on the review of clinical data alone, 32/46 (69.6%) of patients would be treated for myeloma rather than active surveillance, in accordance with institutional treatment protocols. Review of clinical data with 18F-FDG PET/CT resulted in treatment of 40/46 (87.0%) patients, and review of clinical data with WBMRI resulted in treatment of 43/46 (93.5%) patients…


Our study confirms that WBMRI detects skeletal disease in a higher number of treatment-naïve patients than 18F-FDG PET/CT and also detects a higher number of lesions per patient with concordance in disease positivity/lesion number in only 59% of patients…

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