Staging Monoclonal Plasma Cell Disease: Comparison of the Durie-Salmon and the Durie-Salmon PLUS Staging Systems

Published Online:

The results of this study indicate that the Durie-Salmon and the Durie-Salmon PLUS staging systems are moderately concordant and that MR imaging findings as the basis of staging with the Durie-Salmon PLUS staging system should not solely be the reason for initiating systemic therapy.


To investigate the concordance of the Durie-Salmon staging system with the Durie-Salmon PLUS staging system in monoclonal plasma cell disease.

Materials and Methods

Institutional review board approval was obtained, with waiver of informed consent. Lesions in 403 untreated patients (age range, 21–83 years) with monoclonal gammopathy of undetermined significance (MGUS) (n = 84), solitary plasmacytoma (n = 17), amyloid light-chain amyloidosis (n = 12), and multiple myeloma (MM) (n = 290) were first staged on the basis of the classic Durie-Salmon staging system, which included conventional radiography. After examination with whole-body (WB) magnetic resonance (MR) imaging, lesions in these patients were, in addition, staged by using the Durie-Salmon PLUS staging system. Bone marrow infiltration pattern and focal lesions described as intramedullary, transcortical, and soft-tissue lesions, were assessed. The staging levels of both systems were compared.


Of 84 patients with MGUS, lesions in 33 (39%) would have been staged differently with Durie-Salmon PLUS staging system when compared with Durie-Salmon staging system (stage I MM [37%], stage II MM [0%], and stage III MM [2%]). All 17 patients with plasmacytoma showed additional focal lesions or a diffuse infiltration leading to a classification as stage I MM (76%), stage II MM (12%), or stage III MM (12%) with Durie-Salmon PLUS. Of the 149 patients with stage I MM, lesions in 81 (54%) would have been staged differently with the Durie-Salmon PLUS staging system. Of the 21 patients with stage II MM, lesions in 19 (91%) would have been staged differently with Durie-Salmon PLUS staging system when compared with the Durie-Salmon staging system. Of the 120 patients with stage III MM, lesions in 72 (60%) would have been staged differently with the Durie-Salmon PLUS staging system.


Given the fact that the Durie-Salmon and Durie-Salmon PLUS staging systems were concordant in only 45% of all examined patients with monoclonal plasma cell disease, in most cases, treatment decisions depend on the staging system used and, thus, remain a matter of debate.

© RSNA, 2010


  • 1 Durie BG, Kyle RA, Belch Aet al.. Myeloma management guidelines: a consensus report from the scientific advisors of the International Myeloma Foundation. Hematol J 2003;4(6):379–398. Crossref, MedlineGoogle Scholar
  • 2 Durie BG, Salmon SE. A clinical staging system for multiple myeloma: correlation of measured myeloma cell mass with presenting clinical features, response to treatment, and survival. Cancer 1975;36(3):842–854. Crossref, MedlineGoogle Scholar
  • 3 International Myeloma Working Group. Criteria for the classification of monoclonal gammopathies, multiple myeloma and related disorders: a report of the International Myeloma Working Group. Br J Haematol 2003;121(5):749–757. Crossref, MedlineGoogle Scholar
  • 4 Dimopoulos M, Terpos E, Comenzo RLet al.. International myeloma working group consensus statement and guidelines regarding the current role of imaging techniques in the diagnosis and monitoring of multiple myeloma. Leukemia 2009;23(9):1545–1556. Crossref, MedlineGoogle Scholar
  • 5 Horger M, Claussen CD, Bross-Bach Uet al.. Whole-body low-dose multidetector row-CT in the diagnosis of multiple myeloma: an alternative to conventional radiography. Eur J Radiol 2005;54(2):289–297. Crossref, MedlineGoogle Scholar
  • 6 Moulopoulos LA, Varma DG, Dimopoulos MAet al.. Multiple myeloma: spinal MR imaging in patients with untreated newly diagnosed disease. Radiology 1992;185(3):833–840. LinkGoogle Scholar
  • 7 Libshitz HI, Malthouse SR, Cunningham D, MacVicar AD, Husband JE. Multiple myeloma: appearance at MR imaging. Radiology 1992;182(3):833–837. LinkGoogle Scholar
  • 8 Daffner RH, Lupetin AR, Dash N, Deeb ZL, Sefczek RJ, Schapiro RL. MRI in the detection of malignant infiltration of bone marrow. AJR Am J Roentgenol 1986;146(2):353–358. Crossref, MedlineGoogle Scholar
  • 9 Shortt CP, Gleeson TG, Breen KAet al.. Whole-Body MRI versus PET in assessment of multiple myeloma disease activity. AJR Am J Roentgenol 2009;192(4):980–986. Crossref, MedlineGoogle Scholar
  • 10 Stäbler A, Baur A, Bartl R, Munker R, Lamerz R, Reiser MF. Contrast enhancement and quantitative signal analysis in MR imaging of multiple myeloma: assessment of focal and diffuse growth patterns in marrow correlated with biopsies and survival rates. AJR Am J Roentgenol 1996;167(4):1029–1036. Crossref, MedlineGoogle Scholar
  • 11 Mahnken AH, Wildberger JE, Gehbauer Get al.. Multidetector CT of the spine in multiple myeloma: comparison with MR imaging and radiography. AJR Am J Roentgenol 2002;178(6):1429–1436. Crossref, MedlineGoogle Scholar
  • 12 Bäuerle T, Hillengass J, Fechtner Ket al.. Multiple myeloma and monoclonal gammopathy of undetermined significance: importance of whole-body versus spinal MR imaging. Radiology 2009;252(2):477–485. LinkGoogle Scholar
  • 13 Kyle RA. “Benign” monoclonal gammopathy—after 20 to 35 years of follow-up. Mayo Clin Proc 1993;68(1):26–36. Crossref, MedlineGoogle Scholar
  • 14 Carter A, Tatarsky I. The physiopathological significance of benign monoclonal gammopathy: a study of 64 cases. Br J Haematol 1980;46(4):565–574. Crossref, MedlineGoogle Scholar
  • 15 Baur A, Stäbler A, Bartl R, Lamerz R, Scheidler J, Reiser M. MRI gadolinium enhancement of bone marrow: age-related changes in normals and in diffuse neoplastic infiltration. Skeletal Radiol 1997;26(7):414–418. Crossref, MedlineGoogle Scholar
  • 16 Baur-Melnyk A, Reiser M. Staging of multiple myeloma with MRI: comparison to MSCT and conventional radiography [in German]. Radiologe 2004;44(9):874–881. Crossref, MedlineGoogle Scholar
  • 17 Baur-Melnyk A, Buhmann S, Dürr HR, Reiser M. Role of MRI for the diagnosis and prognosis of multiple myeloma. Eur J Radiol 2005;55(1):56–63. Crossref, MedlineGoogle Scholar
  • 18 Walker R, Barlogie B, Haessler Jet al.. Magnetic resonance imaging in multiple myeloma: diagnostic and clinical implications. J Clin Oncol 2007;25(9):1121–1128. Crossref, MedlineGoogle Scholar
  • 19 Stuart A. A test for homogeneity of the marginal distribution in a two way classification. Biometrika 1955;42(3-4):412–416. CrossrefGoogle Scholar
  • 20 Agresti A. Categorical data analysis. Hoboken, NJ: Wiley, 2002. CrossrefGoogle Scholar
  • 21 Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977;33(1):159–174. Crossref, MedlineGoogle Scholar
  • 22 R Development Core Team. R: A language and environment for statistical computing. Vienna, Austria: R Foundation for Statistical Computing, 2009. Google Scholar
  • 23 Ghanem N, Lohrmann C, Engelhardt Met al.. Whole-body MRI in the detection of bone marrow infiltration in patients with plasma cell neoplasms in comparison to the radiological skeletal survey. Eur Radiol 2006;16(5):1005–1014. Crossref, MedlineGoogle Scholar
  • 24 Edelstyn GA, Gillespie PJ, Grebbell FS. The radiological demonstration of osseous metastases: experimental observations. Clin Radiol 1967;18(2):158–162. Crossref, MedlineGoogle Scholar
  • 25 Baur-Melnyk A, Buhmann S, Becker Cet al.. Whole-body MRI versus whole-body MDCT for staging of multiple myeloma. AJR Am J Roentgenol 2008;190(4):1097–1104. Crossref, MedlineGoogle Scholar
  • 26 Baur A, Stäbler A, Nagel Det al.. Magnetic resonance imaging as a supplement for the clinical staging system of Durie and Salmon? Cancer 2002;95(6):1334–1345. Crossref, MedlineGoogle Scholar
  • 27 Barlogie B, Anaissie E, Haessler Jet al.. Complete remission sustained 3 years from treatment initiation is a powerful surrogate for extended survival in multiple myeloma. Cancer 2008;113(2):355–359. Crossref, MedlineGoogle Scholar
  • 28 Hillengass J, Fechtner K, Weber MAet al.. Prognostic significance of focal lesions in whole-body magnetic resonance imaging in patients with asymptomatic multiple myeloma. J Clin Oncol 2010;28(9):1606–1610. Crossref, MedlineGoogle Scholar
  • 29 Hur J, Yoon CS, Ryu YH, Yun MJ, Suh JS. Comparative study of fluorodeoxyglucose positron emission tomography and magnetic resonance imaging for the detection of spinal bone marrow infiltration in untreated patients with multiple myeloma. Acta Radiol 2008;49(4):427–435. Crossref, MedlineGoogle Scholar

Article History

Received September 29, 2009; revision requested November 13; final revision received March 4, 2010; accepted April 6; final version accepted May 27.
Published online: Oct 2010
Published in print: Oct 2010