A simple additive staging system for newly diagnosed multiple myeloma
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Blood Cancer Journal www.nature.com/bcj
ARTICLE OPEN
A simple additive staging system for newly diagnosed multiple
myeloma
Nadine H. Abdallah 1, Moritz Binder 1, S. Vincent Rajkumar 1, Patricia T. Greipp2, Prashant Kapoor 1, Angela Dispenzieri 1,
Morie A. Gertz1, Linda B. Baughn 2, Martha Q. Lacy1, Suzanne R. Hayman1, Francis K. Buadi 1, David Dingli 1, Ronald S. Go 1,
Yi L. Hwa1, Amie L. Fonder1, Miriam A. Hobbs1, Yi Lin 1, Nelson Leung1,3, Taxiarchis Kourelis 1, Rahma Warsame1,
✉
Mustaqeem A. Siddiqui 1, Robert A. Kyle1, P. Leif Bergsagel 4, Rafael Fonseca 4, Rhett P. Ketterling1 and Shaji K. Kumar 1
© The Author(s) 2022
Risk stratification in multiple myeloma is important for prognostication, patient selection for clinical trials, and comparison of
treatment approaches. We developed and validated a staging system that incorporates additional FISH abnormalities not included
in the R-ISS and reflects the additive effects of co-occurring high-risk disease features. We first evaluated the prognostic value of
predefined cytogenetic and laboratory abnormalities in 2556 Mayo Clinic patients diagnosed between February 2004 and June
2019. We then used data from 1327 patients to develop a risk stratification model and validated this in 502 patients enrolled in the
MMRF CoMMpass study. On multivariate analysis, high-risk IgH translocations [risk ratio (RR): 1.7], 1q gain/amplification (RR: 1.4),
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chromosome17 abnormalities (RR: 1.6), ISS III (RR: 1.7), and elevated LDH (RR: 1.3) were independently associated with decreased
overall survival (OS). Among 1327 evaluable patients, OS was 11.0 (95% CI: 9.2–12.6), 7.0 (95% CI: 6.3–9.2), and 4.5 (95% CI: 3.7–5.2)
years in patients with 0 (stage I), 1 (stage II), and ≥2 (stage III) high-risk factors, respectively. In the MMRF cohort, median OS was 7.8
(95% CI: NR-NR), 6.0 (95% CI: 5.7-NR), and 4.3 (95% CI: 2.7-NR) years in the 3 groups, respectively (P < 0.001). This 5-factor, 3-tier
system is easy to implement in practice and improves upon the current R-ISS.
Blood Cancer Journal (2022)12:21 ; https://doi.org/10.1038/s41408-022-00611-x
INTRODUCTION high-risk markers [11]. The R-ISS has subsequently been validated in
Multiple myeloma (MM) is the second most common hematologic several studies [12, 13] and is currently used to risk-stratify patients
malignancy and is responsible for approximately 2% of all cancer with newly diagnosed MM [11]. It is thought to perform better than
deaths in the United States [1]. With the advent of novel its predecessor in certain patient populations [8, 12, 13]. Recent
therapeutic agents and drug combinations, survival outcomes have studies have identified additional cytogenetic abnormalities not
improved considerably [2]. Despite these therapeutic advances, included in the R-ISS to be associated with adverse survival
survival outcomes remain highly variable even in uniformly treated outcomes including monosomy 13 [14, 15], gain/amplification of
clinical trial populations [3, 4]. This disparity highlights the 1q21 [16, 17], and rearrangements involving the MYC gene [18–20].
importance of risk stratification at the time of diagnosis for Even though more powerful high-risk classifiers have been
prognostication and patient selection for clinical trials [5, 6]. Several developed based on gene expression profiles and cytogenetics,
risk stratification systems have been proposed based on clinical their acceptance in clinical practice remains poor due to the
characteristics, laboratory studies, bone marrow cytogenetics, and involved resources and need for complex modeling [21–25]. While
gene expression profiling. Among them, the International Staging the presence of high-risk laboratory and cytogenetic features has
System (ISS) and its successor, the revised ISS (R-ISS), have stood the been incorporated into the R-ISS, the additive effects of multiple co-
test of time in clinical practice. The ISS was first introduced in 2005 occurring high-risk disease features have not been accounted for
and is based on β2-microglobulin and albumin, which are thought [15, 16]. Importantly, as RISS was developed, assessment of 1q
to reflect tumor burden and host status [7]. In clinical practice, the abnormalities was not commonly employed and there was limited
ISS remains a popular choice for risk stratification due to its data to explore the value of adding this variable. Furthermore,
simplicity, although its ability to discriminate among lower-risk unlike the ISS which had a similar proportion of patients in each of
patients is limited in the era of novel therapies [8]. Interphase the three stages, R-ISS resulted in majority of patients being
fluorescence in-situ hybridization (FISH) enabled the identification classified as intermediate. In light of the identification of additional
of high-risk disease independent of ISS stage based on abnorm- cytogenetic risk factors and an improved understanding of the
alities such as t(4;14), t(14;16), and del(17p) [9, 10]. The revised ISS prognostic implications of multi-hit disease, we conducted this
(R-ISS) was introduced in 2015 and includes these cytogenetic study to evaluate a new simple additive staging system in patients
abnormalities as well as elevated lactate dehydrogenase (LDH) as with newly diagnosed MM [14, 17, 19, 20].
1
Division of Hematology, Mayo Clinic, Rochester, MN, USA. 2Department of Laboratory Medicine and Pathology, Rochester, MN, USA. 3Division of Nephrology and Hypertension,
Mayo Clinic, Rochester, MN, USA. 4Division of Hematology, Mayo Clinic, Phoenix, AZ, USA. ✉email: kumar.shaji@mayo.edu
Received: 12 August 2021 Revised: 7 December 2021 Accepted: 12 January 2022
N.H. Abdallah et al.
2
PATIENTS AND METHODS multivariate model were then included in a final multivariate model with
Patients and study design ISS stage III (vs I/II) and elevated LDH. Values above the upper limit of normal
We included all patients with MM seen in Mayo Clinic in Rochester, of the reporting laboratory were considered elevated for lactate dehydro-
Minnesota between 2004 and 2019, who had cytogenetic analysis by FISH genase (above 222 U/l for the Mayo Clinic Laboratories). ISS stages were
performed within 1 year before diagnosis, or within 6 months from the defined as: β2-microglobulin
N.H. Abdallah et al.
3
Table 1. Baseline characteristics. Table 2. Cytogenetic abnormalities in multiple myeloma patients.
Baseline characteristics Median N (%) Primary abnormalities Tested N Abnormality N (%)
(interquartile range) IgH translocations
Age (years) 64 (57–71) t(4;14) 2519 248 (10)
Male 1582 (62) t(14;16) 2517 99 (4)
ECOG PS ≥ 2 (vs 0–1) 141 (20) t(11;14) 2522 519 (21)
Hemoglobin (g/dL) 11.0 (9.5–12.5) Trisomies 2491 1374 (55)
Hemoglobin ≤ 10 g/dL 720 (33) Secondary abnormalities
Platelets (×109/L) 210 (162–262) 1q gain/amplification 1896 585 (31)
Creatinine (mg/dL) 1.1 (0.9–1.5) Chromosome 17 abnormality 2499 337 (13)
Creatinine ≥ 2 mg/dL 319 (16) (17pdel/monosomy 17)
LDH > ULN (units/L) 298 (17) Monosomy 13 2513 926 (37)
B2M (µg/ml) 4.0 (2.7–6.6) MYC rearrangement 1856 160 (9)
B2M > 5.5 vs. (≤5.5) 701 (32) Prevalence of recurrent primary and secondary cytogenetic abnormalities
in patients tested by FISH at diagnosis.
Albumin (g/dL) 3.6 (3.2–3.9)
IgH immunoglobulin heavy chain gene locus, del deletion.
Albumin ≤ 3.5 (vs. >3.5) 928 (48)
Calcium (mg/dL) 9.5 (9.0–10.1)
P < 0.001), chromosome 17 abnormalities (RR: 1.6, P < 0.001), ISS III
Calcium ≥ 11 mg/dL 215 (11)
(RR: 1.7, P < 0.001), and elevated LDH (RR: 1.3, P = 0.01) were all
Serum M spike (g/dL) 2.5 (0.7–3.9) independently associated with decreased OS in the final multi-
Urine M spike (g/24 h) 0.05 (0–0.50) variate model. MYC rearrangements were associated with
Urine albumin (g/24 h) 0.05 (0.02–0.14) decreased survival, but this was not statistically significant (RR:
1.3, P = 0.06). These results are presented in Table 3.
IgA MM 464 (25)
IgG MM 1177 (62) PFS and OS based on the updated R-ISS
LC MM 214 (11) The R-ISS was updated to include 1q gain/amplification in the
Involved LC definition of high-risk cytogenetic abnormalities, in addition to
high-risk IgH translocations and chromosome 17 abnormalities.
Kappa 1252 (65)
Based on this definition, 193 (11%), 1130 (66%), and 396 (23%)
Lambda 674 (35) patients had stage I, II, and III disease, respectively. The median
ISS Stage III (vs. I&II) 710 (33) PFS was 60.0 (95% CI: 46.1–87.1), 44.0 (95% CI: 40.5–48.8), and 28.1
BMPCs (%) 50 (30–70) (95% CI: 23.0–31.4) months in the 3 groups, respectively (P < 0.001)
(Fig. 1a). Median OS was 9.4 (95% CI: 8.9–12.8), 7.5 (95% CI:
PCLI (%) 0.8 (0.3–1.5)
6.4–8.0), and 3.9 (95% CI: 3.6–4.6) years in patients with stage I, II,
First-line treatment and III disease, respectively (P < 0.001) (Fig. 1b).
PI 727 (31)
IMiD 720 (31) Developing a simpler approach for risk stratification – The
MASS
PI + IMiD 804 (34)
Among all patients included in the study, 1327 had simultaneous
Other 107 (5) data available for: high-risk IgH translocations, 1q gain/amplifica-
Transplant 1399 (55) tion, chromosome 17 abnormalities, ISS stage, and LDH. There
Early (≤1 year from 1184 (85) were no significant differences in baseline characteristics
diagnosis) between evaluable patients and the rest of the cohort (Supple-
Late (>1 year from 215 (15) mental Table 1). Among evaluable patients, 476 (36%) had no
diagnosis) high-risk factors (stage I), 442 (33%) had 1 high-risk factor (stage
Clinical and laboratory characteristics at diagnosis of patients diagnosed
II), and 409 (31%) had ≥2 high-risk factors (stage III). Median PFS
with multiple myeloma included in the study. The median (range) are was 63.1 (95% CI: 53.0–70.8), 44.0 (95% CI: 37.8–58.7), and 28.6
presented for continuous variables and number (percentage) for catego- (95% CI: 25.4–34.7) months in the 3 groups, respectively (Fig. 2a).
rical variables. OS was 11.0 (95% CI: 9.2–12.6), 7.0 (95% CI: 6.3–9.2), and 4.5 (95%
B2M beta2microglobulin, BMPCs bone marrow plasma cells, IMiD immuno- CI: 3.7–5.2) years in patients with stage I, II, and III disease,
modulatory drug, ISS international staging system, LC light chain, LDH respectively (Fig. 2b) (Table 4).
lactate dehydrogenase, MM multiple myeloma, PCLI plasma cell labeling
index, PI proteasome inhibitor, PS performance status, ULN upper limit of Subgroup analysis by age and transplant status
normal. The prognostic ability of this staging system was evaluated based
on age group and transplant status. Among patients
N.H. Abdallah et al.
4
Table 3. Univariate and multivariate survival models.
Variable Univariate Multivariate (FISH Multivariate (all)
abnormalities only)
OS RR (95% CI) P value OS RR (95% CI) P value OS RR (95% CI) P value
HR IgH translocations 2.0 (1.7–2.3)
N.H. Abdallah et al.
5
a) b)
PN.H. Abdallah et al.
6
a) b)
PN.H. Abdallah et al.
7
193 193
51
250 250
114
30
373 156
81
168 154
234 291
25% 39% 35%
17% 66% 17%
36% 33% 31%
Fig. 5 Stage migration between R-ISS and MASS and ISS and MASS. The distribution and migration of patients between disease stages
using ISS, R-ISS, and MASS risk stratification systems. ISS International Staging System, R-ISS Revised International Staging System, MASS Mayo
Additive Staging System.
a) b)
P=0.003
PN.H. Abdallah et al.
8
have prevailed in clinical practice and research alike due to their CONCLUSION
simplicity and reliance on readily available baseline characteristics In summary, we developed and validated a simple, additive
[7, 11]. The recognition of additional risk factors motivated the 5-factor 3-tier risk model for newly diagnosed MM in two diverse
revision of the ISS and resulted in a more powerful predictive patient populations that is easy to implement in clinical practice
model [11]. Since the introduction of the R-ISS, data on additional and can play an important role in patient selection for clinical
risk factors including chromosome 13 abnormalities, 1q gains, and trials.
MYC rearrangements have come to light [15–17, 20]. Furthermore,
it has become evident that the co-occurrence of multiple high-risk
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Deletion of the 1p32 region is a major independent prognostic factor in young indicated otherwise in a credit line to the material. If material is not included in the
patients with myeloma: the IFM experience on 1195 patients. Leukemia article’s Creative Commons license and your intended use is not permitted by statutory
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ACKNOWLEDGEMENTS
The MMRF kindly provided the data from the CoMMpass study for the purpose of
© The Author(s) 2022
scientific research. These data were generated as part of the Multiple Myeloma
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