Staging of Multiple Myeloma and AL Amyloidosis

Staging of Multiple Myeloma (MM) Requiring Therapy

The standard Durie-Salmon and initial International Staging Systems for Multiple Myeloma requiring therapy have been improved by including other variables. At Tufts Medical Center in downtown Boston, we use the revised ISS (R-ISS), as described in the far right-hand column of this table:  

Myeloma staging

From the Leukemia and Lymphoma Society

Our multiple myeloma and amyloid experts assess genetic risk by interphase Fluorescence in situ hybridization (FISH) with plasma cells from the bone marrow that have been selected to insure a relatively pure population of MM cells for the  study. The staging system reflects the improvements in disease assessment. In 2015 the median survival by stage is about 10 years for stage I, 7.5 years for stage II and 5 years for stage III. Age remains an important factor. The availability of monoclonal antibody therapy (daratumumab, elotuzumab) for MM means that survival overall will increase in the coming years.

The organ damage associated with MM always requires close attention and care. Bone and kidney health are matters of the highest concern and preservation of robust bone marrow function and blood counts is also. The immune system of MM patients needs to be a constant area of care – from timely vaccinations after stem cell transplant, to adequate protections with travel, to a need for intravenous immunoglobulin or rotating antibiotics in the winter to prevent pneumonia – we teach patients and families to make sure they know what their choices are. The organ damage of MM can be reversed with therapy and best supportive care allowing the patient to have an excellent quality of life.

Staging of Systemic AL Amyloidosis (AL)

The plasma cells in the bone marrow of AL patients are also selected for FISH studies in order to insure that we can detect the most common abnormalities that occur in AL plasma cells – findings that can influence the choice of therapies. In addition, for patients who have baseline bone marrow studies done at Tufts, we offer on protocol sensitive minimal residual disease testing of bone marrow cells at 1, 2 and 3 years after patients achieve complete or very good partial responses to initial therapy as part of our attempt to advance the care of patients with AL. 

The staging systems we use for AL, however, are focused on the organ damage that AL can cause. Cardiac biomarkers enable us to stage the cardiac damage that patients often have at diagnosis and studies of the amount and type of protein in 24-hour urine collections allow us to stage the kidney disease. Standard blood tests also enable us to determine the extent of kidney disease in all patients. Importantly, the organ damage in AL can be reversed with treatment of the plasma cell disease – eliminating the culprit light chain protein can enable the body to heal itself.