Multiple myeloma staging

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Hannan Javed, M.D.[2]; Haytham Allaham, M.D. [3]; Shyam Patel [4]

Overview

Multiple myeloma may be divided into three stages based on either the International Staging System (ISS) or Durie-Salmon Staging System. The International Staging System for multiple myeloma was published by the International Myeloma Working Group in 2003 and is the most widely used staging system. It is used for both guiding treatment as well as predicting prognosis. The Durie-Salmon staging system, first published in 1975, is a clinical staging system for multiple myeloma that correlates measured myeloma cell mass to the presenting clinical features, response to treatment, and survival. Durie-Salmon Staging System is still in use, but has been largely superseded by the more practical ISS and revised ISS

Staging

International Staging System

According to the International Staging System (ISS), there are three stages of multiple myeloma based on both β₂-microglobulin and albumin levels:

Stage	Features	Prognosis
Stage 1	β2-microglobulin <3.5 mg/L and albumin ≥3.5 g/dL	Median survival of 62 months
Stage 2	β2-microglobulin <3.5 and albumin <3.5 or β2-microglobulin 3.5-5.5 mg/L	Median survival of 45 months
Stage 3	β2-microglobulin >5.5	Median survival of 29 months

Revised International Staging System

The Revised International Staging System (R-ISS) was proposed in 2015 and incorporated chromosomal aberrations and LDH level to more accurately risk stratify patients.

Stage	Features	Prognosis
Stage 1	β2-microglobulin <3.5 mg/L and albumin ≥3.5 g/dL and Absence of high-risk chromosomal abnormalities such as del(17p), t(4;14), or t(14;16) and Normal LDH level	5-year overall survival of 82% 5-year progression-free survival of 55%
Stage 2	Not Stage 1 or Stage 3	5-year overall survival of 62% 5-year progression-free survival of 36%
Stage 3	β2-microglobulin >5.5 mg/L, and Presence of high-risk chromosomal abnormalities such as del(17p), t(4;14), t(14;16) or Elevated LDH level	5-year overall survival of 40% 5-year progression-free survival of 24%

Durie-Salmon Staging System

According to the Durie-Salmon Staging System, there are three stages of multiple myeloma based on the hemoglobin level, calcium level, skeletal survey, serum paraprotein level, and urinary light chain excretion:

Stage	Hemoglobin level	Calcium level	Skeletal survey	Serum paraprotein level	Urinary light chain excretion
Stage 1	>10g/dL	8.5-10.2 mg/dL	Normal or single plasmacytoma or osteoporosis	<5 g/dL if IgG or <3 g/dL if IgA	<4 g/24h
Stage 2	8.5-10g/dL	10.2-12 mg/dL	Fulfilling the criteria of neither 1 nor 3	5-7 g/dL if IgG or 3-5 g/dL if IgA	4-12 g/24h
Stage 3	<8.5g/dL	>12mg/dL	3 or more lytic bone lesions	>7g/dL if IgG or > 5 g/dL if IgA	>12g/24h

Stages 1, 2 and 3 of the Durie-Salmon staging system can be divided into A or B depending on serum creatinine:

• A: serum creatinine < 2 mg/dL (< 177 umol/L)
• B: serum creatinine > 2 mg/dL (> 177 umol/L)

SWOG Staging System

The Southwest Oncology Group (SWOG) staging system is not currently widely used. Unlike the other staging systems, there are four stages in the SWOG staging system.

Stage	Features
Stage 1	β2-microglobulin <2.5 mg/L
Stage 2	β2-microglobulin >2.5 mg/L and <5.5 mg/L
Stage 3	β2-microglobulin5.5 mg/L and albumin >3 g/dl
Stage 4	β2-microglobulin>5.5 mg/L and albumin <3 g/dl