[Kate]

ISS or Durie Salmon?

by Kate on Fri Feb 15, 2013 10:18 pm

Hello everyone,

My doctor, who is not a myeloma specialist thinks I'm in early stage II. I prefer stage II BUT with all the reading I did, I'm concerned that it could be early stage III D/S.

I have 4 questions:
1) What is the reason that I did NOT get results on Bence Jones protein, etc. even though I had a UPEP/24 hr. (all it said was: Immunofixation shows IgG monoclonal protein with kappa light chain specificity)?
2) What stage do you think I am in?
3) The foam in my urine is increasing. Will it decrease with treatment? M-Spike (Blood Test) shows 4.5, Total Protein, Serum is 9.9 I will start with neck radiation first.
4) Is it correct that the ISS is the more used staging system?

I fit perfectly into ISS stage II
Serum β2-M < 3.5 mg/L and serum albumin <3.5 g/dL
------
And then I'm looking at Durie Salmon and the bone damage in C.R.A.B. (2 cervical vertebras were destroyed), plus my IgG is 7434 mg/dl or > 7 g/dL and I am wondering which stage I should "hang on to" I also have 2 very small lytic lesions and the residue from the plasmacytoma for which I will receive radiation.

Durie Salmon - Stage III - if ONE of the components below is present
Hemoglobin <8.5 g/dL
• Serum calcium >12 mg/dL
• Advanced lytic bone lesions (scale 3)
• High M-component production rate: IgG > 7 g/dL;
IgA > 5 g/dL; Bence Jones protein >12 g/24 hours
Kate

[Trhose]

Re: ISS or Durie Salmon?

by Trhose on Fri Feb 15, 2013 11:02 pm

Hi Kate,
I don't have any answers for you but I'm glad you asked this question. When I asked what stage I was in, my oncologist said with myeloma, "either you have it or you don't". I was just diagnosed so I am still learning.

[terryl1]

Re: ISS or Durie Salmon?

by terryl1 on Sat Feb 16, 2013 9:06 am

Hi Kate, with regards to your 24 hr. urine, call your doctor as the full test will give you the actual quantities and types of proteins found, i.e. albumin, Bence Jones proteins, etc. The UPEP imummofixation only gives you the type of proteins found, not their quantity.

[Ron Harvot]

Re: ISS or Durie Salmon?

by Ron Harvot on Sat Feb 16, 2013 9:53 am

Kate,

I would not get to hung up on what stage you are in as it will not have any impact on your treatment. The main thing is that you have been diagnosed now and treatment has begun. There are many people that were late stage III that have had CR and went into long term remission. IMO the focus should be how you are responding to the treatment and whether any prior damage is being reversed.

Good Luck

Ron

[Dr. Ken Shain]

Re: ISS or Durie Salmon?

by Dr. Ken Shain on Sat Feb 16, 2013 1:12 pm

Staging and risk can be confusing. Three generally things we like to have to communicate the burden of diease (how much), prognostic stage, and risk. The Durie-Salmon stage is thought of as a descripter of burden of disease and organ damage (Monoclonal paraprotien [urine and/or serum], Calcium, anemia, renal function, skeletal disease), but I feel is of less prognostic value. The ISS (international staging system) provides a relative prognostic value (stages I, II, & III) - a prediction of overall survival. ISS stage III is considered a high risk feature. The third aspect is the risk attributed to the genetic make up of the tumor- predicated on metaphase cytogenetic & FISH of the myeloma cells- both look for know changes in the myeloma DNA (FISH: Fluorescence in situ hybridization). There is also an evolving role for gene expression profiling in risk stratification (MyPRS). Together these factors (amoung other patient specfic factors) allow us to best determine therapy and management goals.

You are ISS II, DS IIIA (assuming normal kidney function[Cr <2]), IgG kappa multiple myeloma. Risk I cannot starte without additional information.

Not all myeloma produces Bence Jones proteins (myeloma antibodies in the urine) in a quantitive amount (not enough to be seen in UPEP). You do have Bence-Jones proteins if the urine IFE (immunofixation) is postive just not a lot. You mentioned foamy urine, what is your 24 urine total protein? The bubbles suggest a lot of protein (not necessarily Bence Jones proteins). If the levels are >0.5-1gm/24hrs, It may be appropriate to see a nephrologist (kidney doctor) and consider a renal biopsy to find out how the myeloma is affecting your kidneys. The primary concern being amyloid deposition.

Are you seeing a neurosurgeon regarding the cervicle lesions? For surgical support or kyphoplasties. Personally, I agree with radiation first (especially to the vertebrae), if you have no other signs of acute systemic disease (hypercalcemia, renal failure).

[Kate]

Re: ISS or Durie Salmon?

by Kate on Sat Feb 16, 2013 2:41 pm

Hello Dr. Shain,
thank you so much for your reply.

1) You are asking about a Neurosurgeon. Yes, I’m seeing one. He gave me a cervical corpectomy with an autograft for C6 and C7. This was almost an emergency situation, 2 months ago, due to a compressed spinal cord etc. The plasmacytoma (cd138 stain) was 5cm by 3 cm and the surgeon said he could only get about 80 to 90 percent of the tumor, radiation starts next week. In fact this is what led to the eventual myeloma diagnosis.

2) You are asking about the 24 hr urine protein total. Well, there was NONE given!!! ALL the UPEP stated was: “IFE Interpretation: U; Immunofixation shows IgG monoclonal protein with kappa light chain specificity.” The foam/bubbles have increased at least 7 fold (in size and quantity) since I first noticed them in early December.

3) At surgery the middle of Dec. 2012, chemistry showed:
creatine was 0.80; one month later SPEP showed 0.70
calcium was 9.30; one month later SPEP showed 8.60.
And as mentioned total Blood Protein 11.0, M-spike 4.5, Hematology results at surgery were all within expected results, no hematology done since.

Besides the above surgically removed tumor, skeletal xrays show there is at least one lytic lesion in the calvarium and at least one in the proximal left humerus. Multiple other smaller lytic lesions are suspected in the humeri bilaterall – although assessment is limited due to the osteopenia. … sclerotic lesion in the right scapula is of questionable significance …. And chronic calcific supraspinatus tendonitis bilaterally.

[Dr. Ken Shain]

Re: ISS or Durie Salmon?

by Dr. Ken Shain on Sun Feb 17, 2013 8:40 pm

I am sorry to hear that you presented in such a dramatic manner. Unfortunately, that happens frequently. I am glad that everything is moving a forward direction.

Have you had a bone marrow biopsy with metaphase cytogenetics and FISH? Those are important aspects in diagnosis and risk stratification.

For clarification you gave 3 different and wide ranging numbers for the same value; 0.7, 8.6, and 4.5. SPEP quantifies the serum M-spike. UPEP quantifies the urine M-spike (if quantifiable). Immunofixation identiies the make up of the M-spike (or "Mono"-clonal antibody)- IgG heavy chain and kappa light chain for instance. SFLC (serum free light chains) are another way to assess the burden of disease.

The UPEP should also have a value for total protein (just like seurm) as well as percent albumin in 24hours.

The lesions further (and the relatively high - I am assuming 4.5gm/L M-spike is the most likely based on your serum total protein) suggest that you have active disease and require systemic therapy after you finish radiation.

As I know you have read, I always recommend getting a second opinion at a Myeloma center of excellence- if you are not at one already.

Best of luck and please keep us updated.