The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice.

A 54-year-old man was seen for smoldering multiple myeloma (SMM). Five years ago, a routine physical examination showed an elevated total protein level. Laboratory studies at that time revealed an immunoglobulin G (IgG) lambda monoclonal protein level of 2.39 g/dL, with a normal CBC and metabolic panel, consistent with monoclonal gammopathy of undetermined significance. Serum protein electrophoresis now shows a monoclonal protein level measuring 4.52 g/dL. Serum free lambda chains were elevated at 426.6 mg/L, with an elevated involved/uninvolved free light chain ratio of 40. A positron emission tomography (PET)–computed tomography (CT) scan did not show any evidence of bone disease. A bone marrow biopsy confirmed the presence of 26% clonal plasma cells, and fluorescence in situ hybridization (FISH) showed monosomy 13 and hyperdiploidy. The patient returns to discuss therapeutic options.