The Biologic and Analytic Variability of Serum Protein Electrophoresis M-Spike, Nephelometric Ig Quantitation, Serum FLC Quantitation, and Urine M-Spike in Monoclonal Gammopathies.

Blood ◽  
2009 ◽  
Vol 114 (22) ◽  
pp. 1803-1803
Author(s):  
Melissa Snyder ◽  
Angela Dispenzieri ◽  
S.Vincent Rajkumar ◽  
Robert Kyle ◽  
Joanne Benson ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Serum Protein ◽  
Protein Electrophoresis ◽  
Serum Protein Electrophoresis ◽  
Monoclonal Gammopathies ◽  
Number Of Patients ◽  
Measurable Disease ◽  
M Spike ◽  
Serial Samples ◽  
Serum And Urine

Abstract Abstract 1803 Poster Board I-829 Background Plasma cell proliferative disorders are monitored by a variety of methods. Serum protein electrophoresis (SPEP) and/or urine PEP M-spike quantitation are commonly assessed in patients with monoclonal gammopathy of undetermined significance (MGUS), smoldering multiple myeloma (SMM), and multiple myeloma (MM) to determine disease progression, response, or relapse. Serum immunoglobin (Ig) concentrations can be quantitated when the M-spike is large or if the migration is obscured within the SPEP beta fraction. Serum FLC quantitation provides a rapid indicator of response, will detect the rare occurrence of FLC escape, and will allow disease monitoring in the absence of a measurable serum or urine M-spike. The International Myeloma Working Group (IMWG) has recommended that the serum and urine M-spike should be used to monitor disease, and that FLC quantitation should be used only if there is no measurable disease by electrophoresis and if the monoclonal FLC concentration is greater than 10 mg/dL in the context of an abnormal FLC K/L ratio. We have studied serial samples in clinically stable patients in order to assess the total variability (analytic and biologic) of these assays and to confirm the IMWG recent recommendations. Methods Serial data from stable MGUS patients (n=35) were identified by the availability of all 3 serum test results (M-spike, Ig, FLC) in at least 4 serial samples that were obtained 9 months to 5 years apart and whose serum M-spikes varied by less than 25%. For MM (n=60) and SMM (n=48) the samples were within 9-15 months and serum M-spikes varied by less than 0.5 g/dL. Among the 60 MM, 48 SMM, and 35 MGUS patients, there were 23, 41, and 18 patients with measurable disease by serum M-spike (i.e. M-spike >1 g/dL); 19, 10, and 10 patients with an evaluable FLC (i.e. monoclonal FLC > 10 mg/dL and an abnormal FLC ratio); and 5, 5, and 1 patient with an evaluable urine (i.e. M-spike > 200mg/24 hr). The FLC data was analyzed as the involved FLC concentration (iFLC), the difference between the involved and uninvolved FLC concentration (dFLC), and the FLC K/L ratio (rFLC). The coefficients of variability (CV) were determined for each methodology in each patient sample set, and the average CVs were determined. Igs were quantitated by immunonephelometry using a Siemens BNII and Siemens reagent sets; kappa and lambda FLC were quantitated using a Siemens BNII and Freelite reagent sets from The Binding Site; M-spikes were quantitated using Helena SPIFE SPE and reagent sets. Results The CVs for the Ig quantitation, SPEP M-spike, FLC quantitation, and urine M-spike in each of the patient groups are listed in the table: Our laboratory's interassay analytic CV for replicate samples are 4-5% for Ig quantitation, 6-8% for SPEP M-spikes, 6-7% for FLC quantitation, and 5-7% for urine M-spikes. The analytic CVs of the methods are similar, but the total (analytic + biologic) CVs are very different. The samples have been selected by restricting the variability of serum M-spike values; when we apply the same criteria to the IgG quantitation, the IgG total CV comes closer to the serum M-spike CVs. The remaining differences, however, may be due to biologic variability contributed by polyclonal Ig. The total CV for iFLC is similar to the urine M-spike CV and suggests a previously unrecognized large biologic CV for serum FLC. The iFLC and dFLC CVs were comparable but were smaller than the rFLC CV. Conclusion The variability of the serum and urine M-spike, Ig, and FLC measurements confirm the IMWG recommendations for patient monitoring. If a patient has a measurable M-spike >1 g/dL, then the serum M-spike should be followed. If there is no measurable disease, then the iFLC can be monitored, provided that the rFLC is abnormal and the iFLC concentration is >10 mg/dL. Although the number of patients with evaluable urine M-spikes in this study is small, larger studies may confirm the utility of serum FLC compared to urine M-spike for monitoring patients with monoclonal gammopathies. Disclosures No relevant conflicts of interest to declare.

scholarly journals Long-Term Biological Variation of Serum Protein Electrophoresis M-Spike, Urine M-Spike, and Monoclonal Serum Free Light Chain Quantification: Implications for Monitoring Monoclonal Gammopathies

2011 ◽  
Vol 57 (12) ◽  
pp. 1687-1692 ◽  
Author(s):  
Jerry A Katzmann ◽  
Melissa R Snyder ◽  
S Vincent Rajkumar ◽  
Robert A Kyle ◽  
Terry M Therneau ◽  
...  
Keyword(s):  
Serum Protein ◽  
Light Chain ◽  
Protein Electrophoresis ◽  
Free Light Chain ◽  
Serum Protein Electrophoresis ◽  
Serum Free ◽  
Serum Free Light Chain ◽  
Measurable Serum ◽  
M Spike ◽  
Serial Samples

BACKGROUND We analyzed serial data in patients with clinically stable monoclonal gammopathy to determine the total variation of serum M-spikes [measured with serum protein electrophoresis (SPEP)], urine M-spikes [measured with urine protein electrophoresis (UPEP)], and monoclonal serum free light chain (FLC) concentrations measured with immunoassay. METHODS Patients to be studied were identified by (a) no treatment during the study interval, (b) no change in diagnosis and <5 g/L change in serum M-spike over the course of observation; (c) performance of all 3 tests (SPEP, UPEP, FLC immunoassay) in at least 3 serial samples that were obtained 9 months to 5 years apart; (d) serum M-spike ≥10 g/L, urine M-spike ≥200 mg/24 h, or clonal FLC ≥100 mg/L. The total CV was calculated for each method. RESULTS Among the cohort of 158 patients, 90 had measurable serum M-spikes, 25 had urine M-spikes, and 52 had measurable serum FLC abnormalities. The CVs were calculated for serial SPEP M-spikes (8.1%), UPEP M-spikes (35.8%), and serum FLC concentrations (28.4%). Combining these CVs and the interassay analytical CVs, we calculated the biological CV for the serum M-spike (7.8%), urine M-spike (35.5%), and serum FLC concentration (27.8%). CONCLUSIONS The variations in urine M-spike and serum FLC measurements during patient monitoring are similar and are larger than those for serum M-spikes. In addition, in this group of stable patients, a measurable serum FLC concentration was available twice as often as a measurable urine M-spike.

Sequence of Testing for Monoclonal Gammopathies

1999 ◽  
Vol 123 (2) ◽  
pp. 114-118 ◽  
Author(s):  
Robert A. Kyle
Keyword(s):  
Multiple Myeloma ◽  
Serum Protein ◽  
Protein Electrophoresis ◽  
Serum Protein Electrophoresis ◽  
Primary Amyloidosis ◽  
Waldenström’S Macroglobulinemia ◽  
Related Disorder ◽  
Monoclonal Gammopathies ◽  
Waldenstrom's Macroglobulinemia ◽  
Waldenström's Macroglobulinemia

Abstract The first test for recognition of monoclonal gammopathies should be serum protein electrophoresis with high-resolution agarose gel. Serum protein electrophoresis should be performed whenever multiple myeloma, Waldenström’s macroglobulinemia, primary amyloidosis, or a related disorder is suspected. Immunofixation is critical for the differentiation of a monoclonal from a polyclonal increase in immunoglobulins. Quantitation of immunoglobulins should be performed with a rate nephelometer. The viscosity of serum should be measured if the patient has signs or symptoms of hyperviscosity syndrome. A 24-hour urine specimen should be obtained for determination of the total amount of protein excreted each day. Immunofixation of the urine should be performed on every patient who has an M-protein level greater than 1.5 g/dL (15 g/L) in the serum or in whom multiple myeloma, Waldenström’s macroglobulinemia, primary amyloidosis, or a related disorder is suspected.

scholarly journals Usefulness of serum globulin levels for discriminating patients with monoclonal gammopathies/ paraproteinemias

Biomedicine ◽  
2021 ◽  
Vol 41 (1) ◽  
pp. 31-35
Author(s):  
Neelam M Pawar ◽  
Anupama Hegde
Keyword(s):  
Serum Protein ◽  
Total Protein ◽  
Monoclonal Gammopathy ◽  
Protein Electrophoresis ◽  
Serum Protein Electrophoresis ◽  
Serum Globulin ◽  
Protein Ratio ◽  
Monoclonal Gammopathies ◽  
Median Serum ◽  
Control Study

Introduction and Aim: The confirmatory step in diagnosis of monoclonal gammopathies is bone marrow biopsy and presence of M-protein in serum protein electrophoresis. These tests are relatively expensive & invasive for screening and unavailable in low resource settings. Increased levels of serum globulin are clue to the diagnosis of monoclonal gammopathy. The aim of this study was to assess the relevance of serum globulin levels in discriminating between patients with & without monoclonal gammopathies/ paraproteinemia. Materials and Methods: We retrospectively reviewed serum protein electrophoresis (SPE) and related investigations of patients suspected of monoclonal gammopathy. Reports with an M-band were considered as paraproteinemias, and those without as controls. ROC for sensitivities & specificities for serum globulin levels were computed. Results: For the case-control study, median serum globulin values in cases were 4.4 (3.5-6.3) g/dL in males and 3.65 (3.33-5.0) g/dL in females. They were significantly higher than those with normal SPE pattern, with a p <0.001. A cut-off value of 3.25 g/dL of globulin could distinguish between paraproteinemias and controls with a sensitivity of 82.1% and specificity of 85.4% in males; a sensitivity of 79.2%, a specificity of 76.7% for females. At a cut-off value of 3.4 g/dL, sensitivity was 77% and specificity 92.7% for males; sensitivity was 75% and specificity 83.7% for females. Alternatively, a cut-off value of 0.458 of globulin/total protein ratio could distinguish at a best sensitivity & specificity of 80% and 89% in males; 83.3% and 83.7% in females. Conclusion: Serum globulin values and globulin/total protein ratio can reliably differentiate patients with paraproteinemias.

Test Utilization of Serum Protein Electrophoresis and Immunofixation Electrophoresis

2019 ◽  
Vol 152 (Supplement_1) ◽  
pp. S146-S147
Author(s):  
Roula Katerji ◽  
Tamera Paczos ◽  
Li Liu
Keyword(s):  
Multiple Myeloma ◽  
Serum Protein ◽  
Active Treatment ◽  
Cost Effective ◽  
Protein Electrophoresis ◽  
Serum Protein Electrophoresis ◽  
Efficient Test ◽  
Testing Frequency ◽  
Immunofixation Electrophoresis ◽  
Changes Over Time

Abstract Objectives Serum protein electrophoresis (SPE) and immunofixation electrophoresis (IFE) are commonly used to screen and monitor monoclonal gammopathies. Currently, there are no consensus guidelines on optimal testing frequency leading to overutilization. Here we examined the testing frequencies of SPE and IFE in our institution to provide an evidence-based perspective on efficient test utilization. Methods We retrospectively reviewed all SPE and IFE tests performed in 2018. Ordering patterns and testing frequencies were analyzed. In cases with more than monthly repeats, electronic medical records were reviewed to follow the result changes over time. Results There were 10,054 SPE and 4,248 IFE orders in 2018. The 4,248 IFE cases represented 2,439 patients, among whom 104 patients (4.3%) had IFE repeated more frequently than every 2 months and 50 patients (2%) more frequently than monthly. The 10,054 SPE cases represented 5,472 patients; 127 patients (2.3%) had SPE performed more than 12 times. Rare cases (0.1%) had SPE and IFE repeated every 1 to 2 weeks. Most IFE tests were ordered together with SPE (89% of all IFE orders), among which 28% of cases had normal SPE findings. Among the cases with more than monthly SPE and IFE tests, IFE results showed meaningful interpretation changes in a minimum period of 2 to 3 months; 35% cases had no IFE interpretation changes throughout the year. In contrast, during active treatment period of multiple myeloma, SPE detected paraprotein level change weekly. Conclusion IFE is overutilized and monthly monitoring does not add value even during active treatment of multiple myeloma. Our results support the need for the development of testing frequency guidelines to avoid overutilization and provide more cost-effective patient care.

A comparison between high resolution serum protein electrophoresis and screening immunofixation for the detection of monoclonal gammopathies in serum

2018 ◽  
Vol 56 (2) ◽  
pp. 256-263 ◽  
Author(s):  
Joel Smith ◽  
Geoffrey Raines ◽  
Hans-Gerhard Schneider
Keyword(s):  
High Resolution ◽  
Sensitivity And Specificity ◽  
Serum Protein ◽  
Light Chain ◽  
Monoclonal Gammopathy ◽  
Protein Electrophoresis ◽  
Serum Protein Electrophoresis ◽  
Agarose Gel ◽  
Serum Free ◽  
Monoclonal Gammopathies

Abstract Background: There are a variety of initial laboratory tests or combinations of tests that can be performed when a monoclonal gammopathy is suspected including serum protein electrophoresis (SPEP), urine protein electrophoresis (UPEP), serum immunofixation (IFE) and serum free light chain assays. Some groups have recently used simplified “screening” IFE methods for the detection of monoclonal gammopathies leveraging the greater sensitivity of IFE over SPEP alone to improve the detection of monoclonal gammopathies. These screening techniques have been predominantly evaluated against lower resolution agarose gel electrophoresis techniques. Methods: In this study we evaluated the diagnostic performance of the combined κ and λ light chain screening immunofixation (CLIF) in comparison to serum protein electrophoresis on a high-resolution (Sebia Hydragel 15 HR) agarose gel system. Each gel was interpreted by three adjudicators. A total of 156 patient samples were analysed. Adjudicated diagnoses based on the screening techniques were compared against the results of high resolution serum protein electrophoresis and high resolution standard immunofixation performed during routine laboratory operation. Where standard immunofixation was not performed a combination of a review of medical records, serum free light chains, UPEP and bone marrow aspirate and trephine and subsequent standard immunofixation and protein electrophoresis results where available were used to confirm the absence of a monoclonal gammopathy. Results: In this cohort a total of 65 (41%) patients had a paraprotein confirmed by standard immunofixation. HR SPEP had a sensitivity and specificity of 95% and 85%, respectively, while CLIF had a sensitivity and specificity of 88% and 97%, respectively. Conclusions: Overall we found that high-resolution gel serum protein electrophoresis using a Sebia Hydragel 15 HR system was more sensitive than a screening immunofixation method (CLIF) for the detection of paraproteins in patient serum in this patient cohort. The drawback of the greater sensitivity of HR SPEP was a higher false positive rate requiring an increased utilisation of follow up immunofixation electrophoresis.

Overcoming the Interference of Daratumumab with Immunofixation Electrophoresis (IFE) Using an Industry-Developed Dira Test : Hydrashift 2/4 Daratumumab

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 2063-2063 ◽  
Author(s):  
Helene Caillon ◽  
Alix Irimia ◽  
Jason S. Simon ◽  
Amy Axel ◽  
Kate Sasser ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Clinical Trials ◽  
Monoclonal Antibodies ◽  
Serum Protein ◽  
Working Group ◽  
Protein Electrophoresis ◽  
Globulin Fraction ◽  
M Spike ◽  
International Myeloma Working Group ◽  
Monoclonal Component

Abstract Background : Detection and quantification of monoclonal component (M-spike) by serum protein electrophoresis (SPE) and immunofixation (IFE) are essential for response evaluation in multiple myeloma (MM) according to the International Myeloma Working Group (IMWG) criteria. Recent clinical trials on daratumumab, an IgG Kappa anti-CD38 monoclonal antibody, have shown impressive results with deep responses. However daratumumab may be detected on serum protein electrophoresis (SPE) and immunofixation (IFE) assays used for monitoring disease monoclonal immunoglobulins (M protein). This can lead to false positive SPE and IFE assay results for patients with IgG kappa myeloma protein impacting initial assessment of complete responses (CR) by International Myeloma Working Group (IMWG) criteria. Differentiating therapeutic monoclonal antibodies, such as daratumumab, from endogenous monoclonal protein can be challenging when both molecules co-migrate or migrate closely on electrophoresis. The availability of a specific, anti-daratumumab antibody has provided the opportunity to overcome this interference and to correctly assess biochemical response. Indeed, Mc Cudden and al. in collaboration with Janssen developed a technique, the Daratumumab Interference Reflex Assay (DIRA) test, which has been utilised in daratumumab clinical trials. Given the need for a commercially available automated and standardized test, we evaluated a new commercial DIRA kit test being developed by Sebia (Lisses, France): the Hydrashift 2/4 daratumumab. Objective: The aim of this study is to evaluate the Hydrashift 2/4 daratumumab in comparison with our laboratory developed DIRA test for the displacement of daratumumab on IFE. Design and methods: The Hydrashift 2/4 daratumumab assay was prepared by Sebia using the anti-daratumumab antibody produced by Janssen and modified to allow a migration of daratumumab/anti-daratumumab complexes toward the α-globulin fraction on IFE. IFE technical procedures, migration, and staining programs were performed according to the manufacturer instructions, and run on the standard Sebia, Hydrasys plateform, with the HYDRAGEL 4 IF kit. In addition to the regular procedure, an additional applicator to apply the anti-daratumumab antibody was used. Analytical performances including sensitivity, specificity and comparisons with the original DIRA test were assessed on 31 samples from ongoing daratumumab clinical trials. Results: Serum samples from 309/324 (95.4%) patients assessed demonstrated a positive IFE at diagnosis. In 119/309 (38,5%) of cases, the M-spike partially or totally co-migrated with daratumumab detected in serum. Of these, MM cases displayed an isotype other than IgG Kappa or Kappa light chains did not require a DIRA test during follow-up for response assessment as a standard IFE could clearly show if initial monoclonal component was still detectable or not. From our experience, an anti-daratumumab displacement assay was only required for IgG Kappa MM or Kappa Light Chain MM (LCMM) when standard IFE could not distinguish daratumumab from endogenous M-spike. This situation represented 66 cases (21,4 %, i.e. 66 on 309). The Hydrashift 2/4 daratumumab assay showed excellent concordance (100%) with the laboratory developed test on the 31 samples tested (i.e. 17 negative DIRA, 10 positive DIRA and 4 doubtful DIRA). Daratumumab/anti-daratumumab complexes were detected in the α-globulin fraction with a sensibility of 200 mg/L. Daratumumab/anti-daratumumab complex was difficult to visualize when daratumumab concentrations were less than 200 mg/L but daratumumab was shown to be completely removed from the gamma globulin fraction with no trace left for all tested patients. For 48 samples tested on diagnosis, the anti-daratumumab shifted specifically the daratumumab with no effect on the patients' M-spike (100% specificity). Conclusion: With the growing application of monoclonal antibodies such as daratumumab in the treatment of multiple myeloma, the development of validated, widely available assays to overcome antibody interference will become increasingly important. The Hydrashift 2/4 daratumumab test provides the opportunity to automate and standardize the displacement of daratumumab interference and help with the correct interpretation of IFE results for clinical outcome measures. Disclosures Simon: Janssen: Employment. Axel:Janssen Pharmaceuticals Research and Development: Employment. Sasser:Johnson & Johnson: Equity Ownership; Janssen Pharmaceuticals R&D: Employment. Scullion:Janssen: Employment. Ligneel:Sebia: Employment. Nouadje:Sebia: Employment. Moreau:Bristol-Myers Squibb: Honoraria; Amgen: Honoraria; Janssen: Honoraria, Speakers Bureau; Novartis: Honoraria; Takeda: Honoraria; Celgene: Honoraria.

The Detection by Immunofixation Electrophoresis (IFE) of Monoclonal Proteins in Veteran Patients with Hypogammaglobulinemia on Negative Serum Protein Electrophoresis, the Veteran Affairs Medical Center (VAMC) Experience

2020 ◽  
Vol 154 (Supplement_1) ◽  
pp. S89-S89
Author(s):  
J M Petersen ◽  
M Litman ◽  
R Millili ◽  
D Jhala
Keyword(s):  
Serum Protein ◽  
Medical Center ◽  
Protein Electrophoresis ◽  
Serum Protein Electrophoresis ◽  
Time Analysis ◽  
Improvement Project ◽  
Immunofixation Electrophoresis ◽  
M Spike ◽  
Monoclonal Proteins ◽  
First Time

Abstract Introduction/Objective Serum protein electrophoresis (SPEP) is the backbone laboratory test for the detection of abnormal monoclonal proteins. However, IFE is a sensitive assay that can sometimes detect monoclonal proteins even when the corresponding SPEP is negative. The fact that IFE is more sensitive than SPEP combined with the need to avoid overutilization of IFE has led to published algorithms for guidance. Hypogammaglobulinemia in a new patient has been recognized in these algorithms as a reason to reflex to IFE when SPEP is negative, though studies on veteran patients are sparse. Therefore, this QA study of the percentage of positive IFEs in negative new SPEP veteran patients with hypogammaglobulinemia was undertaken to ensure reflex IFEs would still be indicated. Methods As part of a quality assurance/quality improvement project, a retrospective Vista/Fileman search of all SPEPs with IFE performed from January 2017 to February 2019 was undertaken to identify cases of SPEPs showing hypogammaglobulinemia (&lt;0.7 g/dL). Diagnostic comments were then analyzed to identify cases of hypogammaglobulinemia along with the M-spike (&lt;0.1 g/dL) to identify negative SPEPs. Only those cases that were consistent with first time hypogammaglobulinemia without an obvious M-spike were included and tabulated for calculations. Any result that was not negative for a monoclonal band was considered as positive. Results There were a total of 194 specimens that met the criteria of SPEP with hypogammaglobulinemia and standard comments consistent with first time analysis and without an obvious M-spike on SPEP. Out of these 194 specimens, 45 had a positive result, either as a monoclonal band comigrating with the beta protein peak or as a very faint gamma or beta monoclonal band. This represented approximately 23% of the specimens, about double the literature published rate for the non-veteran population. Conclusion The performance of IFE on new hypogammaglobulinemia veteran patients appears to be indicated like previously published algorithms and is supported by the fact that about double (23%), compared to the non-veteran population, had positive IFEs despite negative SPEPs. IFE is a helpful tool for new hypogammaglobulinemia patients for the detection of monoclonal proteins despite negative SPEPs.

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