4.1 Staging procedures in Multiple myeloma

4.1.1 Required exams
The following exams are required in all cases:

Complete physical examination, necessary to search for lymphoid organs enlargement (lymphadenopathy, hepatosplenomegaly) or for neurological signs indicating early spinal cord compression or peripheral neuropathy.

Bone marrow biopsy and aspiration

Skeletal X-ray survey

Serum and urine electrophoresis or nephelometry and immunoelectrophoresis

Full blood cell count, serum calcium and serum creatinine

4.2 Staging classification

4.2.1 Clinical staging system
A clinical staging system was developed by Durie and Salmon by analysing the presenting clinical features of a series of patients with multiple myeloma who had their total-body tumor burden determined from M-component synthesis measured in vivo and in vitro (4.II). As demonstrated by a number of clinical studies, this staging classification is useful for predicting survival.
Although other parameters are currently used for prognosis evaluation the Durie-Salmon system remains the standard for staging of multiple myeloma.

CRITERIA		Approx. Cell Mass (Cells x 1012/m2)
Stage I		0.6 (low)
All of the following Hemoglobin value > 10 g/dl Serum calcium value normal (<12 mg/dl) On roentgenogram, normal bone structure (scale 0) or solitary bone plasmacytoma only Low M-component production rates IgG value <5 g/dl IgA value <3 g/dl Urine light chain M-component on electrophoresis <4g/24h
Stage II		0.6 - 1.20 (intermediate)
Overall data not as minimally abnormal as shown for stage I and no single value as abnormal as defined for stage III
Stage III		> 1.20 (high)
One or more of the following Hemoglobin value <8.5 g/dl Serum calcium value > 12 mg/dl Advanced lytic bone lesions (scale 3) High M-component production rates IgG value > 7 g/dl IgA value > 5 g/dl Urine light chain M-component on electrophoresis > 12 g/24h Subclassification A : relatively normal renal function (serum creatinine value <2.0 mg/dl) B : abnormal renal function (serum creatinine value > 2.0 mg/dl)

References

4.I
Durie BGM, Salmon SE. A clinical staging system for multiple myeloma correlation of measured myeloma cell mass with presenting clinical features, response to treatment and survival. Cancer 1975;36:842-54.

4.II
Salmon SE, Smith BA. Immunoglobulin synthesis and total body tumor cell number in IgG multiple myeloma. J Clin Invest 1970;49:1114.