But one might speculate that this could be due to a high exposure to carcinogenic agents in Brazil. It has been shown that herbicides and pesticides are risk factors for the genesis of multiple myeloma. But not only farm workers with direct contact to these toxins are at risk. The general population may be Dinaciclib frequently exposed to residual toxins in food. Our patients showed a high frequency of advanced disease according to the ISS and additional poor risk factors. This resulted in a median survival of months for all patients, much shorter than that reported by other studies. There are several possible explanations for this phenomenon. Delayed diagnosis in patients who depend on a public health system, as in our case, is not rare. In addition, unawareness of symptoms or indolence might be common in patients from lower socio-economic classes. And finally, a more aggressive character of MM in our country cannot be totally excluded. The patients with additional poor prognostic factors had a median survival which is close to reported. However,BAY 43-9006 only of the total population reported in that study had these criteria for additional high risk. The International Staging System, based only on two laboratory variables, the b2-microglobulin and albumin serum concentrations, has replaced the Durie-Salmon staging system in 2005 and is currently considered standard for staging of myeloma. It was further validated in patients in North America, Europe, and Asia; in patients below and above 65 years of age; in patients with standard therapy or autologous bone marrow transplantation; and in comparison with the Durie/Salmon staging system. The prognostic importance of this staging system was confirmed in our study. Regarding the great variability of myeloma pathophysiology, there are additional prognostic factors, such as age, hemoglobin concentration, serum creatinine and calcium levels. But, this could not be confirmed in our investigation. Since the number of patients was relatively small, the test power was limited and we may have missed to demonstrate them as significant risk factors. Special attention was drawn to prognostic factors, which could improve a risk-stratification model able to define high-risk patients who can benefit from novel therapeutic strategies.