Staging in Multiple Myeloma

Two main staging systems exist for multiple myeloma: the Durie-Salmon staging system and the International Staging System. The systems have low concordance with each other (36%), but both seem to be predictive of progression-free and overall survival.

Durie-Salmon Staging System

The older Durie-Salmon staging system uses a combination of 4 factors: immunoglobulin levels, hemoglobin, calcium levels, and the number of bone lesions on radiographs.

• Stage I: All of the following:
  • Hgb > 10 g/dL, AND
  • Calcium ≤ 12 mg/dL, AND
  • Low M-component production rates: IgG < 5 g/dL, IgA < 3 g/dL, Urine light chain M-component on electrophoresis < 4 g/24 hours, AND
  • Radiographs normal or with a single bone plasmacytoma.
• Stage II: neither Stage I or Stage III
• Stage III: One or more of the following
  • Hgb < 8.5 g/dL, OR
  • Calcium > 12 mg/dL, OR
  • High M-component production rates: IgG > 7 g/dL, IgA > 5 g/dL, Urine light chain M-component on electrophoresis > 12 g/24 hours
  • Advanced lytic bone lesions

Each stage is further divided into A and B based on renal function:

• A: Relatively normal renal function, with serum creatinine < 2.0 mg/dL
• B: Abnormal renal function, with serum creatinine ≥ 2.0 mg/dL

International Staging System

This newer staging system uses serum albumin and β2-microglobulin levels to divide patients into 3 stages.

• Stage I: β2-microglobulin < 3.5 mg/L; albumin ≥ 3.5 g/dL
• Stage II: Neither stage I or III.
  Has two categories: β2-microglobulin < 3.5 mg/L but albumin < 3.5 g/dL, or β2-microglobulin 3.5 mg/L - 5.5 mg/L irrespective of the albumin level.
• Stage III: β2-microglobulin ≥ 5.5 mg/L

References

• Durie BG, Kyle RA, Belch A, Bensinger W, Blade J, Boccadoro M, Child JA, Comenzo R, Djulbegovic B, Fantl D, Gahrton G, Harousseau JL, Hungria V, Joshua D, Ludwig H, Mehta J, Morales AR, Morgan G, Nouel A, Oken M, Powles R, Roodman D, San Miguel J, Shimizu K, Singhal S, Sirohi B, Sonneveld P, Tricot G, Van Ness B; Scientific Advisors of the International Myeloma Foundation. Myeloma management guidelines: a consensus report from the Scientific Advisors of the International Myeloma Foundation. Hematol J. 2003;4(6):379-98.
• Greipp PR, San Miguel J, Durie BG, Crowley JJ, Barlogie B, Bladé J, Boccadoro M, Child JA, Avet-Loiseau H, Kyle RA, Lahuerta JJ, Ludwig H, Morgan G, Powles R, Shimizu K, Shustik C, Sonneveld P, Tosi P, Turesson I, Westin J. International staging system for multiple myeloma. J Clin Oncol. 2005 May 20;23(15):3412-20.
• Hari PN, Zhang MJ, Roy V, Pérez WS, Bashey A, To LB, Elfenbein G, Freytes CO, Gale RP, Gibson J, Kyle RA, Lazarus HM, McCarthy PL, Milone GA, Pavlovsky S, Reece DE, Schiller G, Vela-Ojeda J, Weisdorf D, Vesole D. Is the International Staging System superior to the Durie-Salmon staging system? A comparison in multiple myeloma patients undergoing autologous transplant. Leukemia. 2009 Aug;23(8):1528-34.