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Diagnosis and Prognosis of Multiple Myeloma

Diagnosis often starts when someone sees their doctor for symptoms, such as fatigue, pain, or persistent infections. For others, abnormal test results during routine physical exams may prompt an investigation into blood disorders like multiple myeloma.

There are several noncancerous reasons with similar symptoms as multiple myeloma. Your doctor will ask about any symptoms, and family and medical history. A thorough physical exam will be done, which may include checking for swelling of the legs, or enlargement of the liver, spleen, or tongue. If there are no obvious reasons for these symptoms, a blood disorder may be suspected.

Testing for Multiple Myeloma

If you are having symptoms and your doctor suspects a blood disorder, tests can identify certain abnormalities. These may include:

Blood and Urine Tests

Blood tests will help identify any abnormalities in the development or numbers of blood cells. Blood tests can include:

  • Complete blood count—Measures the number of red blood cells, white blood cells, and platelets. Low numbers of healthy blood cells or high numbers of plasma cells may indicate the presence of multiple myeloma.
  • Blood smear—Examines a drop of blood under a microscope to look for abnormalities of the blood cells. Abnormalities include cell counts and genetic markers that may be present or missing.
  • Immunoglobulin—Measures the amount of specific blood proteins to look for signs of multiple myeloma. Some proteins may be present or missing.

Other blood tests may be done to look for abnormalities caused by complications of multiple myeloma:

  • Erythrocyte sedimentation rate (ESR)—To detect or measure inflammation.
  • A check of blood calcium levels to see if it is elevated or high.
  • An evaluation of kidney function.

Urine tests may also help identify abnormal levels of certain proteins or calcium levels.

Bone Marrow Aspiration and Biopsy

A bone marrow test is usually done to evaluate the blood cell counts and overall all health of the bone marrow. Blood stem cells are made in the bone marrow. If there are too many of one blood cell type, they may crowd out other blood cell types and interfere with their function.

A bone marrow aspiration removes a sample of bone marrow from the bone. In most cases, the sample is taken from the hipbone. A needle is inserted through the bone and the marrow is removed with a syringe. A piece of bone may also be removed for biopsy.

Both marrow and bone sample will be examined under a microscope to look for an abnormally high number of plasma cells, which indicate the presence of multiple myeloma.

Skeletal Survey

A series of x-rays of all the body's bones may be done to look for fractures or other bone abnormalities. People with multiple myeloma may have bones with holes or other lesions that indicate the presence of disease. Bones examined include the skull, spine, pelvic area, ribs, and the long bones of the arms and legs.

Diagnosis of Multiple Myeloma

A multiple myeloma diagnosis is made when either one of the following is present:

  • A plasma cell tumor is confirmed by the bone marrow biopsy OR the presence of 10% or more of plasma cells in the bone marrow WITH one or more of the following:
    • Kidney problems
    • High blood levels of calcium—hypercalcemia
    • Low red blood cell count—anemia
    • Bone abnormalities, such as holes, that can be seen on the skeletal survey tests
    • Increased levels of one type of light chain found in the blood
  • The presence of plasma cells in the bone marrow (60% or higher)

Staging of Multiple Myeloma

If multiple myeloma is confirmed, the results of the biopsy and new tests will help determine the stage of the cancer. Staging is used to identify characteristics of the cancer. Staging as well as other information like age and overall health will help develop the prognosis and treatment plan.

Staging Tests

Staging is determined by a number of factors. Tests will vary by individual, but may include:

  • Blood tests to look for abnormal numbers of certain blood cells, proteins, indications of cancer, and abnormal cells. The tests may also show changes in kidney or liver function.
  • Flow cytometry and cell marker tests to examine cells for specific characteristics, like proteins.
  • Tests to evaluate changes or damage to cellular DNA.
  • Imaging tests may be used to evaluate the extent of cancer and involved organs. Some tests use contrast material to highlight structures so images are more clear and detailed. Imaging tests may depend on suspected location of cancer based on symptoms, but may include:
  • Tissue biopsies are done to confirm the presence of cancer in specific locations. It may also be used to look for abnormally-shaped proteins that are stuck together (amyloids). Amyloids can deposit and build up in any bodily tissue, including the heart or kidneys, and cause problems. Biopsies are done with a:
    • Fine needle—A thin needle is inserted into a tumor, lymph node, or other tissue. Both tissue and fluid are removed.
    • Core needle—A larger, hollow needle is used in the same manner. It allows for the removal of a larger sample.
Stages of Multiple Myeloma

There are 2 different systems for staging multiple myeloma:


The Durie-Salmon staging system is used to stage multiple myeloma. The amount of cancer in the body is estimated based on the following factors:

  • Blood or urine level of abnormal proteins produced by the cancer cells.
  • Blood level of calcium—High levels are linked to bone damage caused by cancer cell growth in the bone marrow. Calcium is released into the blood when bone tissue is damaged.
  • X-ray evidence—Myeloma may be evident on an x-ray based on the appearance of specific bone damage.
  • Blood hemoglobin level—Hemoglobin is an iron-containing protein in red blood cells that carries oxygen to the cells. The presence of cancer cells in the bone marrow may interfere with red blood cell production and cause anemia.

Under normal circumstances, each substance in the blood or urine falls into a range that is considered normal. In people with multiple myeloma or other cancers, the substances may be too low or too high. Multiple myeloma is staged from I-III:

  • Stage I—A small number of cancer cells are found with ALL of the following:
    • Small amounts of abnormal proteins are present in the blood or urine.
    • Calcium in the blood falls into a normal range (less than 12 milligrams per deciliter [mg/dL])
    • X-ray appears normal OR may show one area of bone damage
    • Hemoglobin level is more than 10.5 g/dL (grams per deciliter)
  • Stage II—A moderate amount of cancer cells are found. Other factors fall in a range BETWEEN Stage I and Stage III.
  • Stage III—A large number of cancer cells are found with ONE or MORE of the following:
    • Large amounts of abnormal proteins are present in the blood or urine.
    • Calcium levels fall into a high range (more than 12 mg/dL)
    • X-rays show 3 or more areas of bone damage.
    • Hemoglobin levels fall into a low range (less than 8.5 g/dL)
International Staging System (ISS)

Multiple myeloma is staged I-III with the ISS. Cancer stage is based only on the blood levels of beta-2 microglobulin and albumin.

  • Stage I—Beta-2 microglobulin is less than 3.5 mg/L (milligrams per liter) and albumin is 3.5 g/dL or higher
  • Stage II—Beta-2 microglobulin is 3.5-5.5 mg/L with any albumin level OR albumin is less than 3.5 g/dL with beta-2 microglobulin less than 3.5 mg/L
  • Stage III—Beta-2 microglobulin is more than 5.5 mg/L.
Treatment Grouping

For treatment purposes, multiple myeloma may also be grouped as:

  • Smoldering—Disease is present, but it progresses slowly without symptoms.
  • Symptomatic—Disease is present and causing associated symptoms, such as bone or kidney disease, or is affecting healthy blood cell counts.

Revision Information

  • Diagnosis. Leukemia & Lymphoma Society website. Available at: Accessed May 12, 2016.

  • General information about plasma cell neoplasms. National Cancer Institute website. Available at: Updated October 1, 2015. Accessed May 12, 2016.

  • Greipp PR, San Miguel J, Durie BG, et al. International staging system for multiple myeloma. J Clin Oncol. 2005;23(15):3412-3420.

  • Lecouvet FE, Malghem J, Michaux L, et al. Skeletal survey in advanced multiple myeloma: radiographic versus MR imaging survey. Br J Hematol. 1999;106(1):35-39.

  • Multiple myeloma. American Cancer Society website. Available at: Accessed May 12, 2016.

  • Multiple myeloma. EBSCO DynaMed website. Available at: Updated March 7, 2016. Accessed May 12, 2016.

  • Myeloma staging. Leukemia & Lymphoma Society website. Available at: Accessed May 12, 2016.

  • Stages of plasma cell neoplasms. National Cancer Institute website. Available at: Updated October 1, 2015. Accessed May 12, 2016.