Stages of myeloma

The stage of your myeloma tells your doctor about how it is affecting you and how it might develop. Doctors use the international staging system to stage myeloma. There are 3 stages: stage 1, stage 2 and stage 3.

You have tests to look for symptoms of myeloma. Using these results, your doctor classifies your myeloma as either:

• smouldering - you don't have symptoms (asymptomatic)
• symptomatic - you have symptoms

The International Staging System

Doctors use the International Staging System (ISS) to stage myeloma. It looks at the results of blood tests. These measure the amount of these substances in the blood:

• ß2-microglobulin
• albumin
• lactate dehydrogenase (LDH)

You will also have blood tests to look for particular gene changes (mutations). You might hear these called cytogenetic tests. Doctors describe the results as low or high risk cytogenetics. 

 Doctors use this system to help them predict how you might respond to treatment. 

The ISS divides myeloma into 3 stages:

Stage 1 means:

• the level of the protein called beta 2 microglobulin (ß2-microglobulin or ß2-M) is less than 3.5 milligrams per litre (mg/L)​
• the level of albumin in the blood is more than 3.5 grams per decilitre (g/dL)
• normal LDH level
• low risk cytogenetics

Stage 2 means you don't have either stage 1 or stage 3 myeloma.

Stage 3 means:

• the level of ß2-M is more than 5.5 mg/L 
• high LDH level
• high risk cytogenetics

How doctors classify myeloma

The doctor looks for signs and symptoms of myeloma in your blood tests and scans. They call this group of symptoms CRAB, which stands for:

• calcium (high levels)
• renal (kidney damage)
• anaemia (low levels of red blood cells)
• bone damage 

There are other factors that your doctors use to decide about your treatment. They include:

• the number of plasma cells in the bone marrow biopsy
• levels of light chains in the blood or urine tests
• the number and size of areas of bone damaged by myeloma, showing on scans (such as MRI or CT)

Doctors then describe your myeloma as either:

• smouldering (asymptomatic or without symptoms)
• symptomatic (with symptoms)

Myeloma without symptoms (smouldering myeloma)

Asymptomatic myeloma is also called smouldering or indolent myeloma. This means you don't have symptoms or any tissue or organ damage. 

But your tests show:

• paraprotein in your blood that is more than 30 g/L, or in your urine that is more than 500mg in 24 hours or
• a level of abnormal plasma cells in your bone marrow that is between 10% and 60%
• no features of CRAB (including bone lesions on scans that are not causing symptoms)

You might have either abnormal blood and urine test results, or have myeloma cells in your bone marrow. Or you might have both.

You don't usually have treatment for smouldering myeloma. Your doctors monitor you closely.  But smouldering myeloma can progress to symptomatic myeloma. You start treatment if your smouldering myeloma is developing into active symptomatic myeloma.

About 50 out of 100 people (about 50%) with smouldering myeloma will develop symptoms and need treatment within the first 5 years. After 5 years, the risk of progressing to myeloma goes down. Some people never develop symptoms.

Myeloma with symptoms (symptomatic myeloma)

If you have symptomatic myeloma, you need to have treatment. Symptomatic myeloma means you have more than 10 out of 100 (10%) abnormal plasma cells in your bone marrow. Or you have an area of abnormal plasma cells in your bone or soft tissue (plasmacytoma).

As well as this, you have any one or more of the following:

• more than 60 out of 100 (60%) abnormal plasma cells in your bone marrow
• a serum free light chain ratio of more than 100
• more than 1 area of damage (involving your bone or bone marrow) on an MRI scan
• damage to tissues or organs (such as bone problems, high calcium levels, kidney problems or low levels of red blood cells)

Remission and relapse

Treatment usually aims to get myeloma under control. Doctors call this remission. Remission means:

• there are no signs of myeloma in your blood or bone marrow
• you have no other symptoms of myeloma

Your doctor might say you have a partial remission, or a plateau. This means there might still be signs of myeloma. But it is under control and at a steady level.

You specialist (haematologist) monitors how your myeloma is responding throughout treatment. 

You might be in remission or plateau for some time and remain well. It can be months or even years. But at some point, your myeloma will become active again and you will need further treatment. This is called a relapse.

Relapse means your myeloma has come back. Or it has become active again after a period of being in remission or having stable disease.  

Signs of relapse include:

• an increase in paraprotein or free light chain levels 
• myeloma symptoms coming back

You might have several relapses during the course of your illness. There are usually treatment options for you when you relapse.