Discrepancies in Serum Free Light Chain Assays and Immunofixation for Response Evaluation and Prognostication in Plasma Cell Proliferative Disorders

Blood ◽  
2011 ◽  
Vol 118 (21) ◽  
pp. 5099-5099
Author(s):  
Nasir Bakshi ◽  
Nahlah AlGhasham ◽  
Maha Alharbi ◽  
Jalaluddin Bhuiyan ◽  
Ghada Elgohary ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Complete Remission ◽  
Plasma Cell ◽  
Light Chain ◽  
Free Light Chain ◽  
Response To Therapy ◽  
Oligoclonal Bands ◽  
M Spike ◽  
Serial Samples

Abstract Abstract 5099 Plasma cell proliferative disorders are monitored by a variety of methods. Serum protein electrophoresis (SPE), M-spike quantitation and Immunoelectrophoresis (IFE) 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. sFLC quantitation provides a rapid indicator of response, detects the rare occurrence of FLC escape, and also allows disease monitoring in the absence of a measurable serum or urine M-spike. To improve sensitivity of response assessment in MM, the International Myeloma Working Group (IMWG) has recently introduced the stringent CR category. However, no formal studies have validated this criterion. Indeed, the role of the sFLC assay has recently been questioned because of the presence of discordant abnormal sFLC ratios in a significant proportion of patients in CR. This could be at least partly explained by the presence of oligoclonal bands in response to therapy, potentially leading to false-positive results. Accordingly it has been recommended that the serum M-spike be used to monitor disease, and that FLC quantitation be used only if there is no measurable disease by electrophoresis and if the monoclonal sFLC concentration is greater than 10 mg/dL in the context of an abnormal FLC ratio. By analyzing serial samples in our patient population we aim to help usefully interpret the sFLC results and in the long run validate the prognostic impact of attaining CR versus CR plus normal sFLC ratio (stringent CR) after therapy in MM. From a total of 566 samples submitted for FLC analysis over 24-month period at our institution, 94 cases were monoclonal (abnormal FLC ratio) with kappa being the involved chain in 63 and lambda in 31 cases. Serial data from 35 multiple myeloma patients were identified by the availability of 3 serum test results (SPE/IFE/sFLC) in at least 3 serial samples that were obtained 3 months to 6 months apart along with treatment outcome details. Kappa and lambda FLC were quantitated using a Siemens BNII® nephelometer and Freelite® reagent sets from The Binding Site, Birmingham, UK; M-spikes were quantitated Capillarys® system and reagent sets (Sebia Electrophoresis, Norcross, GA). 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). Treatment modalities included allogeneic, or autologous stem cell transplantation, conventional, bortezomib or lenalidomide containing chemotherapy. There were 16 (45%) cases in which discordance was observed between the three techniques (sFLC/SPE/IFE) during the follow-up. 11/16 (68%) patients were found to have abnormal sFLC with both abnormal FLC ratio and involved chain (FLCi), while no M-band was detected by SPE/IFE. In two cases (13%) the pattern of discrepancy was opposite with IFE found to be positive while rFLC results were within normal range of 0.26 – 1.65 mg/l. In three cases (19%) abnormal FLC ratio was detected with SPE/IFE being normal but the sFLC ratio did not match the myeloma isotype (sFLC ratio <0.26 for kappa and >1.65 for lambda isotype). In a subgroup of patients (n = 4) who relapsed during follow-up from complete remission sequential monitoring of immunofixation and free light chain assays revealed normalization of SPE/IFE with only faint/ doubtful band detected in one while FLC results were abnormal. The variability of the serum M-spike, IFE and FLC measurements confirm the IMWG recommendations for patient monitoring. The free light chain assay ratio is widely reported as a useful marker for a faster detection of remission or progression in myeloma patients. These techniques in reality complement each other and the FLC results need to be interpreted with caution in context of the electrophoresis results in order to determine the status of remission. More sensitive methods such as multiparametric imunophenotyping analysis for minimal residual disease by multiparametric flowcytometry or molecular primer assays may be useful to determine the depth of complete remission as choosing the type of screening test will likely have a relevant impact in clinical decision making in MM. Disclosures: No relevant conflicts of interest to declare.

The Natural History of Smoldering (Asymptomatic) Multiple Myeloma.

Blood ◽  
2005 ◽  
Vol 106 (11) ◽  
pp. 3396-3396 ◽  
Author(s):  
Robert Kyle ◽  
Ellen Remstein ◽  
Terry Therneau ◽  
Angela Dispenzieri ◽  
Paul Kurtin ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Bone Marrow ◽  
Plasma Cell ◽  
Light Chain ◽  
Plasma Cells ◽  
M Protein ◽  
Cell Content ◽  
Bone Marrow Plasma ◽  
M Spike

Abstract Smoldering multiple myeloma (SMM) is characterized by a serum M protein ≥ 3g/dL and/or 10% or more of plasma cells in the bone marrow. However, the definition is not standardized, and it is not known whether both serum M protein levels and bone marrow plasma cell counts are necessary for diagnosis or if one parameter is sufficient. We reviewed the medical records and bone marrows of all patients from Mayo Clinic seen within 30 days of recognition of an IgG or IgA M protein ≥ 3g/dL or a bone marrow containing ≥ 10% plasma cells from 1970 to 1995. This allows for a minimum potential follow-up of 10 years. Patients with end-organ damage at baseline from plasma cell proliferation, including active multiple myeloma (MM) and primary amyloidosis (AL) and those who had received chemotherapy were excluded. A differential of the bone marrow aspirate coupled with the bone marrow biopsy morphology and immunohistochemistry using antibodies directed against CD138, MUM-1 and Cyclin D1 were evaluated in every case in order to estimate the plasma cell content. In all, 301 patients fulfilled either of the criteria for SMM. Their median age was 64 years and only 3% were less than 40 years of age; 60% were male. The median hemoglobin value was 12.9 g/dL; 7% were less than 10 g/dL, but the anemia was unrelated to plasma cell proliferation. IgG accounted for 75%, IgA 22%, and biclonal proteins were found in 3%. The serum light-chain was κ in 67% and λ in 33%. The median serum M spike was 2.9 g/dL; 11% were at least 4.0 g/dL. Uninvolved serum immunoglobulins were reduced in 81%; only 1 immunoglobulin was reduced in 31% and both were decreased in 50%. The urine contained a monoclonal κ protein in 36% and λ in 18% and 46% were negative. The median size of the urine M spike was 0.04 g/24h; only 5 (3%) were &gt; 1 g/24h. The median bone marrow plasma cell content was 15 – 19%; 10% had less than 10% plasma cells, while 10% had at least 50% plasma cells in the bone marrow. Cyclin D-1 was expressed in 17%. Patients were categorized into 3 groups: Group 1, serum M protein ≥ 3g/dL and bone marrow containing ≥ 10% plasma cells (n= 113, 38%); Group 2, bone marrow plasma cells ≥ 10% but serum M protein &lt; 3g/dL (n= 158, 52%); Group 3, serum M protein ≥ 3g/dL but bone marrow plasma cells &lt; 10% (n= 30, 10%). During 2,204 cumulative years of follow-up 85% died (median follow-up of those still living 10.8 years), 155 (51%) developed MM, while 7 (2%) developed AL. The overall rate of progression at 10 years was 62%; median time to progression was 5.5 yrs. The median time to progression was 2.4, 9.2, and 19 years in groups 1, 2, and 3 respectively; correspondingly at 10 years, progression occurred in 76%, 59%, and 32% respectively. Significant risk factors for progression with univariate analysis were serum M spike ≥ 4g/dL (p &lt; 0.001), presence of IgA (p = 0.003), presence of urine light chain (p = 0.006), presence of λ urinary light chain (p = 0.002), bone marrow plasma cells ≥ 20% (p &lt; 0.001) and reduction of uninvolved immunoglobulins (p &lt; 0.001). The hemoglobin value, gender, serum albumin, and expression of cyclin D-1 were not of prognostic importance. On multivariate analysis, the percentage of bone marrow plasma cells was the only significant factor predicting progression to MM or AL.

Abnormal serum free light chain ratio in patients with multiple myeloma in complete remission has strong association with the presence of oligoclonal bands: implications for stringent complete remission definition

Blood ◽  
2009 ◽  
Vol 114 (24) ◽  
pp. 4954-4956 ◽  
Author(s):  
Carlos Fernández de Larrea ◽  
María Teresa Cibeira ◽  
Montserrat Elena ◽  
Juan Ignacio Arostegui ◽  
Laura Rosiñol ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Complete Remission ◽  
Confidence Interval ◽  
Light Chain ◽  
Free Light Chain ◽  
Oligoclonal Bands ◽  
Prognostic Impact ◽  
Hematopoietic Stem ◽  
Serum Free ◽  
Serum Free Light Chain

AbstractThe prevalence of an abnormal serum free light chain (FLC) ratio in 34 patients with multiple myeloma in complete response (CR) after hematopoietic stem cell transplantation was studied. Fourteen of 34 patients (41.2%) showed an abnormal FLC ratio. The frequency of abnormal FLC ratio in patients with or without oligoclonal bands was 72.7% versus 26%, respectively (P = .023). The median value of FLC ratio was 2.55 (95% confidence interval, 1.89-3.20) in patients with oligoclonal bands versus 0.87 (95% confidence interval, 0.70-1.04) for those with no oligoclonal bands (P = .011). This is the first report showing that the presence of oligoclonal bands in patients with multiple myeloma in CR frequently results in an abnormal FLC ratio. Because an oligoclonal immune response is associated with a good outcome, our results question the current definition of stringent CR and support that the prognostic impact of oligoclonal bands should be also assessed on multivariate analysis.

scholarly journals High serum-free light chain levels and their rapid reduction in response to therapy define an aggressive multiple myeloma subtype with poor prognosis

Blood ◽  
2007 ◽  
Vol 110 (3) ◽  
pp. 827-832 ◽  
Author(s):  
Frits van Rhee ◽  
Vanessa Bolejack ◽  
Klaus Hollmig ◽  
Mauricio Pineda-Roman ◽  
Elias Anaissie ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Light Chain ◽  
Prognostic Significance ◽  
Complete Response ◽  
High Serum ◽  
Free Light Chain ◽  
Response To Therapy ◽  
Rapid Reduction ◽  
Serum Free ◽  
Serum Free Light Chain

Abstract Serum-free light chain (SFLC) levels are useful for diagnosing nonsecretory myeloma and monitoring response in light-chain–only disease, especially in the presence of renal failure. As part of a tandem autotransplantation trial for newly diagnosed multiple myeloma, SFLC levels were measured at baseline, within 7 days of starting the first cycle, and before both the second induction cycle and the first transplantation. SFLC baseline levels higher than 75 mg/dL (top tertile) identified 33% of 301 patients with higher near-complete response rate (n-CR) to induction therapy (37% vs 20%, P = .002) yet inferior 24-month overall survival (OS: 76% vs 91%, P < .001) and event-free survival (EFS: 73% vs 90%, P < .001), retaining independent prognostic significance for both EFS (HR = 2.40, P = .008) and OS (HR = 2.43, P = .016). Baseline SFLC higher than 75 mg/dL was associated with light-chain–only secretion (P < .001), creatinine level 176.8 μM (2 mg/dL) or higher (P < .001), beta-2-microglobulin 297.5 nM/L (3.5 mg/L) or higher (P < .001), lactate dehydrogenase 190 U/L or higher (P < .001), and bone marrow plasmacytosis higher than 30% (P = .003). Additional independent adverse implications were conferred by top-tertile SFLC reductions before cycle 2 (OS: HR = 2.97, P = .003; EFS: HR = 2.56, P = .003) and before transplantation (OS: HR = 3.31, P = .001; EFS: HR = 2.65, P = .003). Unlike baseline and follow-up analyses of serum and urine M-proteins, high SFLC levels at baseline—reflecting more aggressive disease—and steeper reductions after therapy identified patients with inferior survival.

IgM Multiple Myeloma: A Rare Subtype Highly Sensitive to Lenalidomide

Blood ◽  
2008 ◽  
Vol 112 (11) ◽  
pp. 5220-5220
Author(s):  
Alvaro Moreno-Aspitia ◽  
Antony Charles ◽  
Tejal Patel ◽  
Celine Bueno ◽  
Abba Zubair ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Transient Response ◽  
Low Dose ◽  
Plasma Cells ◽  
Poor Response ◽  
Response To Therapy ◽  
Bone Lesions ◽  
Best Response ◽  
M Spike

Abstract Background: IgM multiple myeloma (MM) are very rare plasmaproliferative disorders representing 0.5–1.2% of all cases of MM and &lt; 0.2% of all IgM monoclonal gammopathies. Clinical criterion are not always helpful in differentiating IgM MM from Waldenstrom macroglobulinemia. However, the presence of lytic bone lesions, absence of lymphadenopathy and/or hepatosplenomegaly, presence of translocation of the immunoglobulin heavy chain locus at 14q32 [t(11;14), t(14;16), t(4;14)], and strong expression of CD138 by the plasma cells are useful in the diagnosis of IgM MM. It has been our experience and of others that these cases have an aggressive behavior at presentation, shorter survival than IgG and IgA MM and poor response to therapy for lymphoplasmacytoid lymphomas. We present here 2 cases of IgM MM with a dramatic response to Lenalidomide and low dose dexamethasone (Rev/Dex) Results: Baseline patient characteristics at time of diagnosis of IgM MM and therapy outcome are presented in the following 2 tables: Table 1. Case 1 2 Age and sex 72 (F) 73 (F) Serum M-spike (g/dL) 5.3 6.2 Urine M-spike (mg/dl/24 hrs) 72 412 Serum IgM (mg/dL) 8,590 11,000 BM plasma cells percentage 90 20 Plasma cell immunophenotyping CD138+++, partial CD20, CD56− CD138+++, partial CD20, CD56− Cytogenetics (Standard and/or FISH) Standard: normal FISH: not done on initial biopsy. On follow up there were insufficient number of plasma cells to perform test Standard: of 20 metaphases, 6 had a complex hypotetraploid karyotype with relative loss of 13q, 14, 15, 16, 20, and 22, and numerous unbalanced rearrangements. FISH: a plasma cell clone with monosomy 13 and IGH/c-MAF fusion, t(14;16). In addition, approximately 60% of plasma cells had a tetraploid clone with the same anomalies as well as relative loss of p53 Bone lesions Multiple non-traumatic spinal fractures and of stenum Several lytic lesions of long bones Renal insufficiency No No Anemia (Hbg g/dL) Yes (8.7) Yes (8.1) Hypercalcemia (Ca mg/dL) Yes (12.5) Yes (11.4) Beta 2 microglobulin (mg/dL) 5.79 8.51 Serum viscosity (cpoise) 5.9 4.8 Table 2. Best Response to therapy Case Therapy Best Response Comments 1 Rituxan, then Fludarabine based therapy Transient response Rapid progression after partial and transient response to each therapy 1 Lenalidomide + LD-Dex sCR after cycle #6. Currently on CR 18 months later IgM declined from 8,590 to 43 mg/dL after 4 cycles of Rev/Dex. 2 Lenalidomide + LD-Dex VGPR after cycle #2 IgM declined from 11,000 to 463 mg/dL after cycle 3. Complete disappearance of M-spike in serum; BM to be done after cycle #4 Conclusions: This is the first report that we are aware of a rapid and dramatic response to lenalidomide and low dose dexamethasone in these rare cases of IgM MM with poor response to NHL-type treatment. Lenalidomide-based therapy might abrogate poor prognosis cytogenetics in this unusual subtype of MM (case #2), however, follow up for this patient is still very short.

Laboratory testing requirements for diagnosis and follow-up of multiple myeloma and related plasma cell dyscrasias

2016 ◽  
Vol 54 (6) ◽  
Author(s):  
Maria A.V. Willrich ◽  
Jerry A. Katzmann
Keyword(s):  
Multiple Myeloma ◽  
Serum Protein ◽  
Plasma Cell ◽  
Light Chain ◽  
Cell Clone ◽  
Protein Electrophoresis ◽  
Free Light Chain ◽  
Molecular Weights ◽  
Immunofixation Electrophoresis ◽  
Monoclonal Proteins

AbstractMonoclonal immunoglobulins are markers of plasma cell proliferative diseases and have been described as the first (and perhaps best) serological tumor marker. The unique structure of each monoclonal protein makes them highly specific for each plasma cell clone. The difficulties of using monoclonal proteins for diagnosing and monitoring multiple myeloma, however, stem from the diverse disease presentations and broad range of serum protein concentrations and molecular weights. Because of these challenges, no single test can confidently diagnose or monitor all patients. Panels of tests have been recommended for sensitivity and efficiency. In this review we discuss the various disease presentations and the use of various tests such as protein electrophoresis and immunofixation electrophoresis as well as immunoglobulin quantitation, free light chain quantitation, and heavy-light chain quantitation by immuno-nephelometry. The choice of tests for inclusion in diagnostic and monitoring panels may need to be tailored to each patient, and examples are provided. The panel currently recommended for diagnostic screening is serum protein electrophoresis, immunofixation electrophoresis, and free light chain quantitation.

Assessment of Serum Free Light Chain Assay for Screening for Plasma Cell Disorders.

Blood ◽  
2005 ◽  
Vol 106 (11) ◽  
pp. 2563-2563
Author(s):  
David E. Smith ◽  
Jude Abadie ◽  
Daniel Bankson ◽  
Graham Mead
Keyword(s):  
Multiple Myeloma ◽  
Positive Predictive Value ◽  
Negative Predictive Value ◽  
Plasma Cell ◽  
Light Chain ◽  
Predictive Value ◽  
Free Light Chain ◽  
Serum Free ◽  
Serum Free Light Chain ◽  
Plasma Cell Disorders

Abstract Introduction and Methods: The purpose of this study was to evaluate the serum free light chain (FLC) assay in its ability to improve performance of protocols designed to screen for plasma cell disorders. We measured M-protein levels using serum protein electrophoresis (SPEP) in 312 consecutive patients being screened for plasma cell disorders at the Veterans Administration Medical Center - Puget Sound. The serum kappa and lambda free light chain levels were quantitated using the serum FLC assay in these same patients. The kappa/lambda ratio was calculated using the free kappa and free lambda results from the serum FLC assay. Results: SPEP results indicated the presence of a possible monoclonal gammopathy in 77 of the 312 patients in this study. In this group of 77 patients, a plasma cell disorder was diagnosed in 27 of them. The serum FLC assay showed an abnormal kappa/lambda ratio in 20 of these 77 patients, all 20 of whom were diagnosed with multiple myeloma. In the group of 235 patients with normal SPEP results, 17 were found to have an abnormal kappa/lambda ratio. Of these 17 patients, 15 were diagnosed with multiple myeloma, one with lymphoma, and one with bladder cancer. Conclusions: Because a number of disorders and diseases can increase production of immunoglobulins, there were a significant number of false positives in the SPEP results. At the same time, there were also several false negative SPEP results. The number of both false positives and false negatives was smaller for the serum FLC assay. Further, use of SPEP and the serum FLC assay together resulted in significantly improved sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). (See Table 1.) These results indicate an important role for the serum FLC assay in screening for monoclonal gammopathies. Table 1. Performance of SPEP, sFLC, and both assays in screening for plasma cell disorders SPEP Alone sFLC Alone Both SPEP and sFLC Sensitivity 64% 88% 100% Specificity 81% 98% 99% Positive Predictive Value 35% 88% 89% Negative Predictive Value 94% 98% 100%

Significance of Serum Free Light Chain Estimation with Detectable Serum Monoclonal Protein on Immunofixation Electrophoresis.

Blood ◽  
2006 ◽  
Vol 108 (11) ◽  
pp. 5048-5048
Author(s):  
Jayesh Mehta ◽  
Regina Stein ◽  
Eric Vickrey ◽  
William Resseguie ◽  
Seema Singhal
Keyword(s):  
Light Chain ◽  
Free Light Chain ◽  
Response To Therapy ◽  
Oligoclonal Bands ◽  
Serum Samples ◽  
Serum Free ◽  
Monoclonal Protein ◽  
Serum Free Light Chain ◽  
Small Series ◽  
Immunofixation Electrophoresis

Abstract The serum free light chain (SFLC) assay is useful in detecting monoclonal protein when there no detectable M protein on immunofixation electrophoresis (IFE). There are limited data on its value when IFE is positive. In a small series of 5 patients achieving CR, normalization of SFKLR was found to precede IFE negativity by a few weeks (Moesbauer et al. ASH 2005). Results on 231 serum samples from myeloma patients (most on therapy) where serum IFE showed IgA κ (n=33), IgA λ (n=13), IgG κ (n=153), or IgG λ (n=32), and where simultaneous SFLC and immunoglobulin (Ig) estimation had been performed were analyzed. Samples with &gt;1 monoclonal band or multiple oligoclonal bands were excluded. The serum free κ:λ ratio (SFKLR; normal 0.26–1.65) was abnormal in 113 (49%) and normal in 118 (51%). IgG and IgA levels were compared in the context of normal versus abnormal SFKLR within each of the 4 isotypes (IgA κ, IgAλ, IgG κ, IgG λ). The table below shows that involved Ig levels were higher with abnormal than with normal SFKLR. However, uninvolved Ig levels were higher with normal than with abnormal SFKLR suggesting that normalization of SFKLR may mark a response to therapy - improved uninvolved Ig levels being evidence of response. Monoclonal protein Immunoglobulin Abnormal SFKLR Normal SFKLR P IgA kappa IgA 1640 (190–4000) 515 (102–2230) 0.048 IgA kappa IgG 419 (118–1120) 404 (197–1740) 0.39 IgA lambda IgA 408 (159–696) 704 (180–779) 0.17 IgA lambda IgG 619 (495–1510) 1530 (533–1700) 0.025 IgG kappa IgA 42 (7–225) 94 (7–642) 0.0009 IgG kappa IgG 1490 (585–5560) 1260 (327–2690) 0.004 IgG lambda IgA 32 (7–121) 96 (19–562) 0.047 IgG lambda IgG 2060 (555–12300) 1050 (432–2830) 0.018 However, does normalization of SFKLR universally herald IFE negativity? This is an important unanswered question because SFKLR is normal in a high proportion of samples which still show monoclonal protein on IFE. The figures below show scatter plots of IgG and IgA for each of the 4 isotypes for normal vs abnormal SFKLR. Within each plot, there is no obvious pattern distinguishing normal (x) from abnormal (o) SFKLR. However, there are a number of normal SFKLR points with high involved and low uninvolved Ig levels where a normal SFKLR is difficult to explain. Figure Figure Figure Figure We conclude that the SFLC assay often reveals normal SFKLR even when there is a detectable monoclonal protein in the serum. Whether this always predicts eventual paraprotein clearance and achievement of IFE negativity in patients on therapy is unknown, and needs to be studied prospectively.

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