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April 2002 Volume 4, Issue 10:
THE IMPORTANCE OF KNOWING POTENTIAL OUTCOME: Role for the new International Prognostic Index (IPI)
By Brian G. M. Durie, MD
"...now in 2002, additional factors can be used to precisely predict outcome."
When myeloma is first suspected, knowledge of the projected survival is critical to both patient and physician. Is the diagnosis MGUS or active myeloma? If it is myeloma, will planned treatment work well and can there be long survival? These latter questions were the ones asked in 1975 when the Durie-Salmon staging system was developed. Stages I, II, and III reflect increasing amounts of myeloma plus the fractional likelihood of drug resistant clones evolving as the myeloma cells increase in number. The subscripts A and B indicate the presence or absence of abnormal renal function. Kidney function is the single ?host? or patient factor which impairs bodily functioning and ability to do well or not with therapy.

This system of classifying patients into stages has worked well for decades. But now in 2002, additional factors can be used to precisely predict outcome. During the 1980s, serum b2 microglobulin testing emerged as a powerful prognostic factor. Increasing levels indicate a larger and more aggressive myeloma tumor burden. Several other factors, some simple, such as age and serum albumin level, provide additional predictive power. More complex tests such as the labelling index (a measure of growth fraction), evaluation of the way myeloma cells look under the microscope (classified into immature/plasmablastic or not), and detailed chromosome analysis directly or by fluorescent techniques (FISH) can add further precision. The newest observation of chromosome 13 deletion or abnormality associated with poorer outcome is the most predictive.

So how can all this information be brought together and have international medical consensus? The latter point is the most important and the most difficult to achieve. This is the goal of Drs. San Miguel and Greipp and their colleagues developing the new International Prognostic Index (IPI). NOTE: In 2004, the IPI was renamed the International Staging System or ISS. This project is supported by a grant from the International Myeloma Foundation (IMF). Data collection from over 20 centers from around the world is now proceeding to develop both a basic prognostic system using parameters (such as SbM, s. albumin, and age) available to everyone, and a more complex system integrating kinetic and genetic information which will allow correlation with current molecular and biologic research.

The goal is to have data analysis completed by the end of 2002. The presentation will be made at the International Myeloma Workshop in Salamanca in 2003. These new levels of precision will guide physicians to select the most appropriate treatment for each individual patient as well as allow patients and their families to know what to expect. The results of this project will interface well with another IMF-supported project: the Myeloma Guidelines Consensus report. These guidelines are being developed by a panel of IMF Scientific Advisors, who will meet for the second St. John's Retreat in May 2002. Specifics of treatment and testing guidelines are being summarized to relate both to the diagnostic and prognostic categories as well as to new planned clinical trials. Novel therapies must be integrated into current management in an organized way to maximize the advantages of the combination therapy approach. Each step forward improves both quality and length of survival for myeloma patients.

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