Below is a chapter on myeloma diagnosis and staging written by Peter Tischer -
I urge all newly diagnosed myeloma patients to get a second opinion. The correct diagnosis and staging of your cancer is critical to your prognosis.
Staging Myeloma
Simple Explanation: Staging for a disease has two purposes.
First, it tells the medical team, and the patient and caregiver, how far the disease has progressed. Generally, the lower stage number is better news for you and the medical team. Knowing the stage can be a mixed blessing for you. Hearing that your myeloma has a relatively low stage number can make you feel better about your future, while hearing that it’s a high number can be frightening. This is deceptive, because it’s often not the stage that’s important but rather the aggressiveness or trend of the disease
For the most part, knowing the stage does little for the patient and the family. Second, the stage can sometimes determine the treatment you will receive. Some clinical trials might allow only, say, stage 3 patients. Sometimes the lowest stage patients might be given a fairly benign treatment rather than a harsh one.
Quite often, however, patients will be treated pretty much the same, by a given oncologist, regardless of the stage. An additional point: staging can be somewhat an “art” as well as science. Although most staging systems have fairly strict criteria, there is some gray area between stages. One oncologist might stage a patient as stage 2, while another might call it stage 3.
One final point: Knowing a stage number doesn’t mean much unless you know which staging system is being used by the oncologist. There are four different staging systems in use at this time (although only one is most commonly used), so you might get two different stage numbers from two different consultations, even though they really mean the same thing.
More Details: There are four usual staging systems in use as of this date. In order of usage, they are:
• The Durie/Salmon Staging System
• The SWOG (SouthWest Oncology Group) Staging System
• The Durie/Salmon Plus Staging System
• The new International Prognostic Index (IPI) Staging System
At this date, most patients have been staged with the Durie/Salmon Staging System. This system has three stages (I, II, and III) and each stage has a sub-classification indicating renal (kidney) function.
The factors weighed for the three stages are hemoglobin value (anemia), serum calcium value (bone destruction), bone x-rays results (lytic lesions), m-component production rates (IgG, IgA, etc. and kappa, lambda), and myeloma cell mass (tumor burden) from a bone marrow biopsy and aspiration. Subclassification (“A” or “B”) refers to the serum creatinine value (renal function).
The SouthWest Oncology Group (SWOG) Staging System is a simple prognostic classification system that has four stages (I, II, III, and IV). This system weighs only two factors: serum beta-2-microglobulin (b2m) and serum albumin. Stages I and II result from normal or higher b2m, respectively. Stages III and IV result from high b2m, and normal or low serum albumin, respectively.
The Durie/Salmon Plus Staging System uses the factors used in the standard Durie/Salmon Staging System for stages IB, IIA and IIB, IIIA, and IIIB, although it adds the criterion of number of focal lesions to the I, II, and III stages. Stage IA is reserved for smoldering or indolent myeloma if there is a single plasmacytoma and/or limited disease seen on imaging studies.
The sub-classification (A or B) weighs the factors serum creatinine, platelet count, and presence or absence of extramedulary disease. The International Prognostic Index (IPI) Staging System is a simple system similar to the SWOG system. Like the SWOG system, it weighs only the two factors: serum beta2- microglobulin (b2m) and serum albumin. Stages I results from normal-to-low b2m and normal-to-higher serum albumin. Stage II results from either normal-to-low b2m and low serum albumin, or low-to-medium b2m. Stages III results from high b2m. There is no Stage IV in the IPI Staging System.
Jim Bliss is the contributing editor for the diagnosis section of beating-myeloma.org
The Kappa / Lambda Freelite Chain Test by Jim Bliss
Approximately 15% of all cases of MM are Bence Jones (light chain) myeloma. This version of MM has been more difficult to diagnose and monitor because these cases can be negative on the conventional serum protein electrophoresis (SPE) test and immunofixation electrophoresis (IFE) on both serum and urine.
However, there is a blood test, called the Freelite™ test, which gives a quantitative measure of the kappa and lambda light chains. So it is important for these patients to have the Freelite test done regularly to monitor the MM and the effectiveness of treatment.
My Freelite test results over the past year illustrate how the chemo that I had before June 2003 reduced the Kappa Light Chains to a relatively low level and how the thalidomide I have taken regularly since has maintained this level.
According to David E. Smith, Ph.D, Technical Director-Freelite, the normal ranges for the Freelite test are:
- Kappa/Lambda Ratio ..................... 0.26 to 1.65
- Kappa ............................................ 3.3 to 19.4 mg/L
- Lambda .......................................... 5.75 to 26.3 mg/L
The Freelite test was developed by the Binding Site in the U.K. and is offered by a number of labs in the U.S. Labs can run the test in about 15 minutes for a cost of supplies of around $20. Many hospitals send the test to an outside lab instead of doing it themselves, which results in a turnaround time of a week or so.
More information about the Freelite test can be found at the web sites listed below. In addition, David E. Smith, Ph.D david.smith@thebindingsite.com has offered to answer questions.
Since 2005 I have relied on the Freelight Chain Test to monitor my myeloma.
1-26-07
Kappa quantitative free light chains 0.89 mg/dl (reference range 0.33-1.94)
Lambda quantitative free light chains 0.72 mg/dl (reference range 0.57-2.63)
K:L free light chain ratio 1.24 (reference range 0.26-1.65)
4-14-06
Free Kappa light chains 1.25 mg/dl same reference ranges as above
Free Lambda light chains 1.53 mg/dl
K:L ratio 0.82
7-19-05
Free Kappa light chains 0.94 mg/dl
Free Lambda light chains 0.64 mg/dl
K:L ratio 1.47
Use the articles and links below, and then the "discussion" to help understand BJ, mgus, smm, and the flc test.
This is an article explaining the clinical differences between mgus and smm.
FDG PET Reassures and Reveals High Risk Multiple Myeloma
This article is about the importance of staging, especially if you have MGUS or non-secretory myeloma. Myeloma is a very individual and obscure disease and is not well understood by oncologists. Get a second opinion. Go to a myeloma specialist. I recommend Dr. Brian Durie at Cedars Sinai or Dr. Ken Anderson at Dana-Farber.
This is an article that discusses the benefit of the combined technology of a ct scan combined with a pet scan. As always it is important to talk to your oncologist as well as your insurance carrier. Newer technologies may not be covered.
This is an article which discusses how a ct scan during your therapy might give you insight as to how your myeloma/lesions are responding to the therapy.