Join Professor Brea Lipe and Professor Sagar Lonial as they discuss the changing treatment landscape of smoldering multiple myeloma (SMM). With a recently approved treatment for high-risk SMM, knowing how to differentiate and manage SMM compared with monoclonal gammopathy of undetermined significance (MGUS) and multiple myeloma (MM) has never been more crucial. Professors Lipe and Lonial review the case of a 58-year-old man in good health with no anemia or other health concerns, whose annual checkup reveals an isolated finding of elevated total protein. As they follow this patient’s journey, they discuss best practice in diagnosis, risk stratification, and management of SMM. Finally, they consider the factors affecting decision-making in the context of data from early intervention trials that aimed to either delay progression to active MM or, potentially, to cure SMM.

Learning Objectives:

• Explain the distinction between MGUS, SMM and MM
• Describe the key tests required for a basic workup of a case of suspected clonal plasma cell disorder
• Explain how patients with SMM may be risk-stratified
• Evaluate the factors that influence the decision to treat or monitor a case of high-risk SMM
• Discuss published clinical trial data on high-risk SMM management approaches

Monoclonal gammopathy of undetermined significance (MGUS) is a common but often confusing finding on serum protein electrophoresis (SPEP) reports. In this HemeTalks episode, Drs. Rahma Warsame and Jason Chen discuss how to interpret abnormal SPEP results, evaluate patients with suspected MGUS, and differentiate between benign and concerning findings. Using real-world cases, they highlight key clinical decision points, follow-up strategies, and how to communicate results with patients effectively. Tune in for expert guidance on navigating this diagnostic gray zone in hematology.

Learning Objectives:

1. Recognize the clinical significance of MGUS and how it is detected
2. Understand how to interpret MGUS lab testing results in the context of monoclonal gammopathies
3. Identify when to refer, monitor, or investigate further in patients with MGUS

Clinical Pearls:

1. MGUS is a premalignant condition that is a diagnosis of exclusion. It is defined by the presence of a serum monoclonal protein (M-protein) less than 3 g/dL, bone marrow plasma cellsl <10%, and no end organ damage (CRAB)
2. MGUS can progress to multiple myeloma, AL amyloidosis, Waldenstrom’s macroglobulinemia
3. Confirmatory tests for MGUS include: SPEP, FLC assay, and bone marrow (only if high risk features are present.

In this episode, Drs. Ronak Mistry and Jori May discuss the challenging decision of when to test for inherited thrombophilias and how results inform anticoagulation management. The use of thrombophilia testing has long been debated in the hematology community, due in large part to limited data and the complexity of estimating recurrent thrombotic risk. Through the case of a 36-year-old woman with a proximal deep vein thrombosis 4 weeks after an uncomplicated vaginal delivery, we explore the importance of defining provoking factors, evaluating bleeding risk, exploring previous thrombotic challenges and family history, and ultimately whether thrombophilia testing may be helpful to determine the need for long term anticoagulation.

Learning Objectives:

1. Accurately interpret the results of laboratory tests for inherited hypercoagulable disorders.
2. Identify appropriate clinical situations where testing for inherited hypercoagulable disorders can be considered.
3. Discuss how inherited thrombophilias influence decisions on the duration of anticoagulation in VTE without major transient risk factors.

Clinical Pearls:

1. Assay selection, appropriate timing of testing, and accurate interpretation of results are foundational to the use of thrombophilia testing in the care of patients with VTE.
2. The use of thrombophilia testing to guide the duration of anticoagulation in patients with VTE without major transient risk factors is debated and therefore must be individualized to every patient.