Multiple Myeloma
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Multiple Myeloma

Staging

The information gathered from diagnostic testing is used to determine a stage for your multiple myeloma. Staging provides essential information to your medical team. It defines the extent of the disease and helps the team predict outcomes (prognosis, or chance of recovery) as well as determine the best treatment plan for you.

Understanding the stage of your disease is helpful as you take an active role in monitoring your test results and progress. As you learn about test results and discuss future plans, be sure to ask for an explanation about anything that you do not understand.

Staging Systems

Your doctor may refer to one or both of the following staging systems: the commonly used Revised International Staging System (RISS) and the Durie-Salmon Staging System (see Tables 1 and 2). Both systems have three stages, but they have different meanings. A new version of the RISS has been proposed. Ask your physician about the staging system being used for your diagnosis.

RISS distinguishes between the Stages of I, II and III with four factors: the level of three predictive proteins – albumin, beta-2-microglobulin and lactate dehydrogenase (LDH) – measured in the blood, and the presence of chromosome (genetic) abnormalities in the myeloma cells. This system is commonly used to determine prognosis.

  1. Albumin level. Albumin is made in the liver. Low levels may signal a more advanced myeloma.
  2. Beta-2-microglobulin level. This is made by malignant myeloma cells. The level in the blood increases as myeloma progresses, so high levels will sometimes mean that the cancer is more advanced.
  3. Lactate dehydrogenase (LDH) level. LDH helps cells convert sugar to energy. High levels of LDH in the blood may indicate a more advanced myeloma.
  4. Genetic abnormalities. This testing includes cytogenetics, fluorescence in situ hybridization (FISH) and measurable/minimum residual disease (MRD) testing.

The Durie-Salmon Staging System uses results of blood tests, urine tests and imaging to measure the amount of abnormal plasma cells present and determine tumor size and/or extent of cancer in the body. This system considers four main factors: M-protein, calcium, hemoglobin and bone damage.

  1. M-protein. Large amounts of this abnormal protein in the blood or urine may indicate that a high number of malignant plasma cells are present.
  2. Calcium. A high calcium level in the blood (hypercalcemia) may mean that multiple myeloma has caused substantial bone damage.
  3. Hemoglobin. This essential protein is found in red blood cells, and the level indicates the number of red blood cells. Healthy blood cells are crowded out by multiple myeloma cells in the bone marrow, so a low hemoglobin level (anemia) may mean a high level of multiple myeloma cells.
  4. Bone damage. Imaging tests are used to identify the location and severity of bone damage in the body. 

Re-staging may be necessary after treatment or if the multiple myeloma returns. In that case, the same diagnostic tests that were used during the original staging are typically used. 


Additional factors that influence prognosis and treatment

  • The type of plasma cell neoplasm
  • Whether a certain immunoglobulin (antibody) is present
  • Whether there are certain genetic/genomic changes
  • Whether the kidneys are damaged
  • Whether the cancer responds to initial treatment or recurs (comes back)

Table 1. Revised International Staging System (RISS) For Multiple Myeloma

Stage Description
Stage I Serum Beta-2-microglobulin, less than 3.5 mg/L and serum albumin, 3.5 g/dL or more and no high-risk cytogenetics* and normal LDH.
Stage II
Not Stage I nor Stage III.
Stage III Serum Beta-2-microglobulin, 5.5 mg/L or more and high-risk cytogenetics or high LDH.
*Cytogenetics is the field of study that analyzes the number and structure of human chromosomes. Researchers have identified certain high-risk cytogenetics that may be present in some people with multiple myeloma.
Used with permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original and primary source for this information is the AJCC Cancer Staging Manual, Eighth Edition (2017) published by Springer Science+Business Media

Table 2. Durie-Salmon Staging System

Stage Description
Stage I Hemoglobin levels are slightly below normal (but above 10 grams per deciliter of blood).
Calcium levels are in the normal range (12 milligrams per deciliter of blood or less).
M-protein levels are relatively low (less than 5 grams per deciliter for IgG; less than 3 grams per deciliter for IgA; less than 4 grams per 24-hour for urinary light chain).
Bone X-rays are normal or show only one area of bone damage.
Stage II Neither Stage I nor Stage III.
Stage III Hemoglobin levels are very low (less than 8.5 grams per deciliter of blood).
Calcium levels are high (more than 12 milligrams per deciliter of blood).
M-protein levels are high (more than 7 grams per deciliter for IgG; more than 5 grams per deciliter for IgA; more than 12 grams per 24-hour for urinary light chain).
Bone X-rays show at least three areas of bone damage.
These letters may be added to the Durie-Salmon stage to indicate additional factors: A: Mostly normal kidney function. B: Abnormal kidney function.


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