Challenges in Interpreting Multiple Monoclonal Bands on Serum Protein Electrophoresis and Serum Immunofixation Electrophoresis: An Illustrative Case Report

Abstract Background Protein concentration of monoclonal immunoglobulin in plasma-cell myeloma/multiple myeloma provides an estimate of the tumor mass and allows for monitoring of the response to treatment. Accurate and reproducible estimates of the monoclonal immunoglobulin concentration are important for patient care. Objective To address the optimum method for estimation of the concentration of monoclonal immunoglobulins. Methods Serum protein electrophoresis and immunofixation electrophoresis were conducted by using the Helena SPIFE Touch instrument. Estimation of the protein concentration of monoclonal immunoglobulin in the gamma region by computer-assisted reading was compared with the reading by technologists and pathology residents, in 300 gels. The data were compared using t-testing and analysis of variance. Results Computer-generated readings had a consistent positive bias. The correlation coefficient of the average reading by technologists and residents with the computer generated value was 0.997. The average positive bias by the computer reading was 0.29 g per dL. The intercept on the regression analysis was 0.22 g per dL. The reading by the computer was significantly higher than each of the human-interpreted readings. The readings by the 3 human groups were not significantly different amongst them. The main reason for the higher reading by the computer was inclusion of a greater area on the anodal size of the peak on the densitometric scan. Conclusions Human- and computer-interpreted readings of the protein concentration of monoclonal immunoglobulin have a high degree of correlation. The consistent positive bias by the computer reading occurred due to inclusion of a greater area of the densitometric scan on the anodal side of the peak. We suggest that vendors should adjust such computer programs to provide readings comparable to those generated by expert humans. We recommend manual delineation of the monoclonal peaks for measuring the concentration of monoclonal immunoglobulins.

Download Full-text

Test Utilization of Serum Protein Electrophoresis and Immunofixation Electrophoresis

American Journal of Clinical Pathology ◽

10.1093/ajcp/aqz130.011 ◽

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.

Download Full-text

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

American Journal of Clinical Pathology ◽

10.1093/ajcp/aqaa161.195 ◽

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 (<0.7 g/dL). Diagnostic comments were then analyzed to identify cases of hypogammaglobulinemia along with the M-spike (<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.

Download Full-text

Serum Protein Electrophoresis and Immunofixation Electrophoresis Detection in Multiple Myeloma

Journal of College of Physicians And Surgeons Pakistan ◽

10.29271/jcpsp.2021.07.864 ◽

2021 ◽

Vol 31 (07) ◽

pp. 864-867

Keyword(s):

Multiple Myeloma ◽

Serum Protein ◽

Protein Electrophoresis ◽

Serum Protein Electrophoresis ◽

Immunofixation Electrophoresis

Download Full-text

In vitro evaluation of potential interference of lokivetmab with protein electrophoresis and immunofixation

Tierärztliche Praxis Ausgabe K Kleintiere / Heimtiere ◽

10.1055/a-1519-3587 ◽

2021 ◽

Vol 49 (04) ◽

pp. 278-283

Author(s):

Neoklis Apostolopoulos ◽

Athanasia Mitropoulou ◽

Gesine Foerster ◽

Klaus Failing ◽

Andreas Moritz ◽

...

Keyword(s):

Monoclonal Antibodies ◽

Serum Protein ◽

Monoclonal Gammopathy ◽

Reference Interval ◽

Protein Electrophoresis ◽

Serum Protein Electrophoresis ◽

Before And After ◽

Immunofixation Electrophoresis ◽

Therapeutic Monoclonal Antibodies

Abstract Objective In humans, misdiagnoses of monoclonal gammopathy after use of therapeutic monoclonal antibodies has been documented. This triggers concerns for similar misdiagnoses in animals treated with monoclonal antibodies. The aim of this study was to evaluate if lokivetmab interferes with serum protein electrophoresis and immunofixation electrophoresis in dogs. Material and methods Residual sera from 25 client-owned, healthy blood donor dogs from 2 veterinary hospitals in Germany were used. The residual sera were analysed with serum protein electrophoresis and immunofixation electrophoresis before and after being spiked with lokivetmab at a concentration of 10 µg/ml (corresponding to the mean peak serum concentration after a subcutaneous injection of 2 mg/kg lokivetmab). Results No monoclonal gammopathy was observed on serum protein electrophoresis and all proteins had a normal distribution pattern without any pathologic bands on immunofixation electrophoresis. The absolute γ-globulin values of spiked samples, however, were significantly higher than in the native sera although they remained within the reference interval. No other globulin fractions were significantly different. Conclusion and clinical relevance This study suggests that lokivetmab at a dose of 2 mg/kg is not detected as a monoclonal peak on serum protein electrophoresis or immunofixation electrophoresis, and thus is unlikely to lead to a misdiagnosis of other diseases that are characterised by monoclonal gammopathies.

Download Full-text

Should routine laboratories stop doing screening serum protein electrophoresis and replace it with screening immune-fixation electrophoresis? No quick fixes: Counterpoint

Clinical Chemistry and Laboratory Medicine (CCLM) ◽

10.1515/cclm-2015-0806 ◽

2016 ◽

Vol 54 (6) ◽

Cited By ~ 2

Author(s):

Joel D. Smith ◽

Geoffrey Raines ◽

Hans G. Schneider

Keyword(s):

Serum Protein ◽

Cell Clone ◽

Protein Electrophoresis ◽

Serum Protein Electrophoresis ◽

Patient Anxiety ◽

Transient Phenomena ◽

Monoclonal Gammopathies ◽

Immunofixation Electrophoresis ◽

Chain Type

AbstractMonoclonal gammopathies are characterised by the production of a monoclonal immunoglobulin or free light chains by an abnormal plasma cell or B-cell clone and may indicate malignancy or a precursor (MGUS). There is currently no consensus on the initial test or combination of tests to be performed in suspected monoclonal gammopathies but serum protein electrophoresis and urine protein electrophoresis are commonly requested as initial investigations. If abnormal, immunofixation electrophoresis is then performed to confirm the presence of paraprotein and to determine its heavy and light chain type. Recently, some groups have developed simplified “screening” IFE methods for use in parallel to SPEP for the detection monoclonal gammopathies. We argue here that screening IFE may be of benefit in clinical laboratories using SPEP with poor resolution in the β-region, assisting in the detection of mainly IgA paraprotein, but may be of less benefit in laboratories utilising higher resolution gels. Further it may increase the detection of trace bands of questionable clinical significance, representing transient phenomena in infectious and auto-immune conditions or very low risk MGUS. The increased detection of these bands using screening IFE would require further patient follow up, possibly causing unnecessary patient anxiety and additional follow up healthcare costs.

Download Full-text

Superiority of Serum Immunofixation Electrophoresis over Serum Protein Electrophoresis in the Diagnosis of Multiple Myeloma

Journal of Bangladesh College of Physicians and Surgeons ◽

10.3329/jbcps.v36i3.37031 ◽

2018 ◽

Vol 36 (3) ◽

pp. 95-100

Author(s):

Mohammed Mosleh Uddin ◽

Md Mizanur Rahman ◽

Syeda Adib Sultana ◽

Debashish Saha

Keyword(s):

Multiple Myeloma ◽

Serum Protein ◽

Monoclonal Gammopathy ◽

Plasma Cells ◽

Cell Lineage ◽

Armed Forces ◽

Protein Electrophoresis ◽

Serum Protein Electrophoresis ◽

Suspected Case ◽

Immunofixation Electrophoresis

Background: Multiple Myeloma (MM) is a neoplasm of B cell lineage characterized by excessive proliferation of abnormal plasma cells, secreting abnormal immunoglobulin causing monoclonal gammopathy which can be detected by the presence of M protein in serum and urine electrophoresis.Aim: Present study is aimed to detect and quantify monoclonal gamma globulins by SPEP and IFE in suspected case of MM and other plasma cell dyscrasias and also to find out the discrepant findings between SPEP and IFE.Methods: A retrospective observational study was carried out on clinically highly suspected cases of Multiple Myeloma (MM) presenting with backache, asthenia and generalized weakness at Armed forces Institute of Pathology(AFIP), Dhaka cantonment from January 2015 to July 2016. A total of 140 blood samples were collected and subjected to serum protein electrophoresis (SPEP) and Immunofixation electrophoresis (IFE). IFE identifies the type of heavy (IgG, IgM or IgA) and light chain (either kappa or lambda in suspected cases of MMResults: Out of 140 cases, SPEP identified monoclonal band in 62 cases and either non-specific findings or polyclonal band in 78 cases. At the same time immunofixation electrophoresis (IFE) which was done on all samples detected another 14 cases of M-band in addition to earlier 62 cases of monoclonal gammopathy by SPEP. Among 140 cases, SPEP detected M-band in 62 cases, whereas IFE identified monoclonal band in 76 cases. So in the remaining 14 cases (10%) small sharp spikes of monoclonal band was found only by IFE whereas SPEP failed to detect those 14 cases.Conclusion: SPEP is an easy to perform laboratory test which can be used for detection and quantification of monoclonal gammopathy but there is some limitation in detecting monoclonal band by SPEP. IFE is more sensitive to detect the monoclonal band than SPEP. So both SPEP and IFE should be done simultaneously for precise diagnosis of MM and related disorders.J Bangladesh Coll Phys Surg 2018; 36(3): 95-100

Download Full-text

24 Resolution of Discrepant Results in Serum Protein Electrophoresis and Immunofixation Electrophoresis

American Journal of Clinical Pathology ◽

10.1093/ajcp/aqx115.023 ◽

2018 ◽

Vol 149 (suppl_1) ◽

pp. S10-S10

Author(s):

Randol Vick ◽

Katherine Blakely ◽

Sara Taylor ◽

Heping Han ◽

Sally Lewis

Keyword(s):

Serum Protein ◽

Protein Electrophoresis ◽

Serum Protein Electrophoresis ◽

Immunofixation Electrophoresis

Download Full-text

Serum free light chain immunoassay as an adjunct to serum protein electrophoresis and immunofixation electrophoresis in the detection of multiple myeloma and other B-cell malignancies

Clinical Chemistry and Laboratory Medicine (CCLM) ◽

10.1515/cclm.2009.084 ◽

2009 ◽

Vol 47 (3) ◽

Cited By ~ 13

Author(s):

Stephen J. Harding ◽

Graham P. Mead ◽

Arthur R. Bradwell ◽

Annie M. Berard

Keyword(s):

B Cell ◽

Serum Protein ◽

Light Chain ◽

Protein Electrophoresis ◽

Free Light Chain ◽

Serum Protein Electrophoresis ◽

B Cell Malignancies ◽

Serum Free ◽

Serum Free Light Chain ◽

Immunofixation Electrophoresis

Abstract: Protein and immunofixation electrophoresis of serum and urine are established as diagnostic aids for identifying monoclonal gammopathies. However, many patient sera sent to laboratories are not accompanied by urine samples and recent reports suggest the use of serum free light chain (sFLC) analysis in combination with serum protein electrophoresis (SPE) and immunofixation electrophoresis (IFE) could eliminate the need for urinalysis. The aim of the study was to assess the utility of sFLC measurement in addition to serum protein electrophoresis in the identification of patients with B-cell malignancies.: A total of 952 serum samples were analysed by serum protein electrophoresis and those with abnormal bands were analysed by immunofixation. sFLCs were measured in a retrospective manner by automated assay.: In our study of 952 patient sera, it was found that FLC analysis identified 23 additional cases of B-cell malignancies which were missed by SPE.: The additional malignancies identified by sFLC analysis add support for its inclusion in the routine screening protocol for B-cell malignancies.Clin Chem Lab Med 2009;47:302–4.

Download Full-text