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Rajkumar SV. Multiple myeloma: 2024 update on diagnosis, risk-stratification, and management. Am J Hematol 2024; 99:1802-1824. [PMID: 38943315 DOI: 10.1002/ajh.27422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2024] [Accepted: 06/11/2024] [Indexed: 07/01/2024]
Abstract
DISEASE OVERVIEW Multiple myeloma accounts for approximately 10% of hematologic malignancies. DIAGNOSIS The diagnosis requires ≥10% clonal bone marrow plasma cells or a biopsy proven plasmacytoma plus evidence of one or more multiple myeloma defining events (MDE): CRAB (hypercalcemia, renal failure, anemia, or lytic bone lesions) attributable to the plasma cell disorder, bone marrow clonal plasmacytosis ≥60%, serum involved/uninvolved free light chain (FLC) ratio ≥100 (provided involved FLC is ≥100 mg/L and urine monoclonal protein is ≥200 mg/24 h), or >1 focal lesion on magnetic resonance imaging. RISK STRATIFICATION The presence of del(17p), t(4;14), t(14;16), t(14;20), gain 1q, del 1p, or p53 mutation is considered high-risk multiple myeloma. Presence of any two high risk factors is considered double-hit myeloma; three or more high risk factors is triple-hit myeloma. RISK-ADAPTED INITIAL THERAPY In patients who are candidates for autologous stem cell transplantation, induction therapy consists of anti-CD38 monoclonal antibody plus bortezomib, lenalidomide, dexamethasone (VRd) followed by autologous stem cell transplantation (ASCT). Selected standard risk patients can delay transplant until first relapse. Frail patients who not candidates for transplant are treated with VRd for approximately 8-12 cycles followed by maintenance or alternatively with daratumumab, lenalidomide, dexamethasone (DRd) until progression. MAINTENANCE THERAPY Standard risk patients need lenalidomide maintenance, while bortezomib plus lenalidomide maintenance is needed for high-risk myeloma. MANAGEMENT OF RELAPSED DISEASE A triplet regimen is usually needed at relapse, with the choice of regimen varying with each successive relapse. Chimeric antigen receptor T (CAR-T) cell therapy and bispecific antibodies are additional options.
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Park K, Kwon SH. Monoclonal gammopathy of renal significance from the perspective of nephrologists. Blood Res 2024; 59:28. [PMID: 39133392 PMCID: PMC11319560 DOI: 10.1007/s44313-024-00027-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Accepted: 07/04/2024] [Indexed: 08/13/2024] Open
Abstract
Kidney disease is a frequent complication of multiple myeloma and other malignancies associated with monoclonal gammopathies. Additionally, dysproteinemia-related kidney disease can occur independently of overt multiple myeloma or hematologic malignancies. Monoclonal gammopathy of renal significance (MGRS) is a spectrum of disorders in which a monoclonal immunoglobulin produced by a benign or premalignant B-cell or plasma cell clone causes kidney damage. MGRS-associated renal disease manifests in various forms, including immunoglobulin-associated amyloidosis, monoclonal immunoglobulin deposition diseases (light chain, heavy chain, and combined light and heavy chain deposition diseases), proliferative glomerulonephritis with monoclonal immunoglobulin deposits, C3 glomerulopathy with monoclonal gammopathy, and light chain proximal tubulopathy. Although MGRS is a nonmalignant or premalignant hematologic condition, it has significant renal implications that often lead to progressive kidney damage and, eventually, end-stage kidney disease. This review discusses the epidemiology, pathogenesis, and management of MGRS and focuses on the perspective of nephrologists.
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Affiliation(s)
- Kootae Park
- Division of Nephrology, Hyonam Kidney Laboratory, Soonchunhyang University Hospital, 59 Daesagwan-Ro, Yongsan-Gu, Seoul, South Korea
| | - Soon Hyo Kwon
- Division of Nephrology, Hyonam Kidney Laboratory, Soonchunhyang University Hospital, 59 Daesagwan-Ro, Yongsan-Gu, Seoul, South Korea.
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Traub R, Qarni T, Cohen AD, Karam C. Paraproteinemic neuropathies. Muscle Nerve 2024; 70:173-179. [PMID: 38816958 DOI: 10.1002/mus.28164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 04/14/2024] [Accepted: 04/27/2024] [Indexed: 06/01/2024]
Abstract
The diagnostic evaluation of a peripheral neuropathy includes testing for the presence of monoclonal gammopathy, which can be found in about 10% of patients with peripheral neuropathy. Our role, as physicians, is to determine whether the neuropathy is directly related to the gammopathy or whether the co-occurrence of these two disorders is purely coincidental. The evaluating physician needs to be familiar with the different types of neuropathies associated with monoclonal gammopathies, their clinical and electrodiagnostic characteristics, and their appropriate diagnostic evaluation and management. Testing for monoclonal protein disorders includes serum protein electrophoresis (SPEP) and immunofixation of blood, and in some cases of urine, as well as measurement of free light chains and quantitative immunoglobulins. Specific antibody testing is directed by paraprotein type and neuropathy phenotype. Patients with abnormal free light chains in association with sensory and autonomic neuropathy should be evaluated for AL amyloidosis. When a lambda monoclonal protein is identified together with a clinical phenotype of chronic inflammatory demyelinating neuropathy (CIDP), a diagnosis of polyneuropathy, organomegaly, endocrinopathy, monoclonal plasma cell disorder, skin changes (POEMS) syndrome should be considered. Patients with IgM paraprotein associated neuropathy should be assessed for distal acquired demyelinating sensorimotor (DADS) neuropathy, with or without anti myelin associated glycoprotein (MAG) antibody or CANOMAD syndrome. In many cases, a monoclonal gammopathy of uncertain significance (MGUS) is incidental and unrelated to the neuropathy. Collaboration with oncology is critical in evaluating patients with monoclonal proteins to assess for underlying plasma cell neoplasms or B cell lymphomas.
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Affiliation(s)
- Rebecca Traub
- Department of Neurology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Taha Qarni
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Adam D Cohen
- Division of Hematology/Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Amyloidosis Program, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Chafic Karam
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Amyloidosis Program, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Frye Naharro E, Peterson D, Yohe SL, Linden MA. Application and pitfalls of immunophenotyping in challenging plasma cell neoplasms: A case series. Hum Pathol 2024; 150:86-96. [PMID: 38909710 DOI: 10.1016/j.humpath.2024.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 06/15/2024] [Accepted: 06/20/2024] [Indexed: 06/25/2024]
Abstract
Multiple myeloma (MM) is an incurable malignant plasma cell neoplasm, representing the second most common hematopoietic cancer. As plasma cell neoplasms are clonal and often secrete a monoclonal protein (M-spike), laboratory diagnosis is usually straightforward, especially when ancillary studies such as immunohistochemistry, flow cytometry, and protein electrophoresis are available in addition to microscopic examination. Despite the repertoire of diagnostic tools, rare cases pose diagnostic dilemmas, especially when reagent antibodies do not react as expected, extent of disease is patchy, or when disease occurs in unique age groups. In this retrospective study, we report a series of challenging diagnostic cases, discussing aberrant findings and comparing them to more classic counterparts. Twelve cases collected during routine clinical sign-out were reanalyzed and include examples of MGUS, classic multiple myeloma, t(11; 14) rearranged myeloma, minimal residual disease, AA and AL amyloidosis, truncated light chain, non-secretory and non-producer myeloma, biphenotypic myeloma, oligoclonal expansion after bone marrow transplant, and plasma cell leukemia in a young adult. This cohort showcases the diversity of atypical presentations of plasma cell neoplasms, and we highlight standardized approaches to workup to avoid diagnostic pitfalls.
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Affiliation(s)
- Elena Frye Naharro
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA.
| | - Daniel Peterson
- MHealth Fairview University of Minnesota Medical Center, USA
| | - Sophia L Yohe
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Michael A Linden
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
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Sverrisdottir I, Thorsteinsdottir S, Rognvaldsson S, Aspelund T, Vidarsson B, Onundarson PT, Agnarsson BA, Sigurdardottir M, Thorsteinsdóttir I, Sveinsdottir SV, Palmason R, Olafsson I, Sigurdsson F, Thordardóttir AR, Eythorsson E, Jonsson A, Palsson R, Indridason OS, Gislason GK, Olafsson A, Sigurdsson J, Steingrímsdóttir H, Einarsson Long T, Hultcrantz M, Durie BGM, Harding S, Landgren O, Kristinsson SY, Love TJ. Association Between Autoimmune Diseases and Monoclonal Gammopathy of Undetermined Significance : An Analysis From a Population-Based Screening Study. Ann Intern Med 2024; 177:711-718. [PMID: 38768457 DOI: 10.7326/m23-2867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND Monoclonal gammopathy of undetermined significance (MGUS) is a precursor of multiple myeloma (MM) and related conditions. In previous registry-based, retrospective studies, autoimmune diseases have been associated with MGUS. However, these studies were not based on a screened population and are therefore prone to ascertainment bias. OBJECTIVE To examine whether MGUS is associated with autoimmune diseases. DESIGN A cross-sectional study within iStopMM (Iceland Screens, Treats, or Prevents MM), a prospective, population-based screening study of MGUS. SETTING Icelandic population of adults aged 40 years or older. PATIENTS 75 422 persons screened for MGUS. MEASUREMENTS Poisson regression for prevalence ratios (PRs) of MGUS among persons with or without an autoimmune disease, adjusted for age and sex. RESULTS A total of 10 818 participants had an autoimmune disorder, of whom 599 had MGUS (61 with a prior clinical diagnosis and 538 diagnosed at study screening or evaluation). A diagnosis of an autoimmune disease was not associated with MGUS (PR, 1.05 [95% CI, 0.97 to 1.15]). However, autoimmune disease diagnoses were associated with a prior clinical diagnosis of MGUS (PR, 2.11 [CI, 1.64 to 2.70]). LIMITATION Registry data were used to gather information on autoimmune diseases, and the homogeneity of the Icelandic population may limit the generalizability of these results. CONCLUSION The study did not find an association between autoimmune disease and MGUS in a systematically screened population. Previous studies not done in systematically screened populations have likely been subject to ascertainment bias. The findings indicate that recommendations to routinely screen patients with autoimmune disease for MGUS may not be warranted. PRIMARY FUNDING SOURCE The International Myeloma Foundation and the European Research Council.
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Affiliation(s)
- Ingigerdur Sverrisdottir
- University of Iceland, Reykjavik, Iceland, and Sahlgrenska University Hospital, Gothenburg, Sweden (I.S.)
| | | | - Sæmundur Rognvaldsson
- University of Iceland and Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland (S.R., R.Palmason, S.Y.K., T.J.L.)
| | - Thor Aspelund
- University of Iceland, Reykjavik, Iceland (T.A., A.R.T., G.K.G., A.O., J.S.)
| | - Brynjar Vidarsson
- Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland (B.V., P.T.O., B.A.A., M.S., I.T., S.V.S., I.O., F.S., E.E., A.J., O.S.I., H.S.)
| | - Pall Torfi Onundarson
- Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland (B.V., P.T.O., B.A.A., M.S., I.T., S.V.S., I.O., F.S., E.E., A.J., O.S.I., H.S.)
| | - Bjarni A Agnarsson
- Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland (B.V., P.T.O., B.A.A., M.S., I.T., S.V.S., I.O., F.S., E.E., A.J., O.S.I., H.S.)
| | - Margret Sigurdardottir
- Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland (B.V., P.T.O., B.A.A., M.S., I.T., S.V.S., I.O., F.S., E.E., A.J., O.S.I., H.S.)
| | - Ingunn Thorsteinsdóttir
- Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland (B.V., P.T.O., B.A.A., M.S., I.T., S.V.S., I.O., F.S., E.E., A.J., O.S.I., H.S.)
| | - Signy Vala Sveinsdottir
- Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland (B.V., P.T.O., B.A.A., M.S., I.T., S.V.S., I.O., F.S., E.E., A.J., O.S.I., H.S.)
| | - Robert Palmason
- University of Iceland and Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland, and Skåne University Hospital, Lund, Sweden (R.Palsson)
| | - Isleifur Olafsson
- Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland (B.V., P.T.O., B.A.A., M.S., I.T., S.V.S., I.O., F.S., E.E., A.J., O.S.I., H.S.)
| | - Fridbjorn Sigurdsson
- Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland (B.V., P.T.O., B.A.A., M.S., I.T., S.V.S., I.O., F.S., E.E., A.J., O.S.I., H.S.)
| | | | - Elias Eythorsson
- Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland (B.V., P.T.O., B.A.A., M.S., I.T., S.V.S., I.O., F.S., E.E., A.J., O.S.I., H.S.)
| | - Asbjorn Jonsson
- Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland (B.V., P.T.O., B.A.A., M.S., I.T., S.V.S., I.O., F.S., E.E., A.J., O.S.I., H.S.)
| | - Runolfur Palsson
- University of Iceland and Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland (S.R., R.Palmason, S.Y.K., T.J.L.)
| | - Olafur Skuli Indridason
- Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland (B.V., P.T.O., B.A.A., M.S., I.T., S.V.S., I.O., F.S., E.E., A.J., O.S.I., H.S.)
| | | | - Andri Olafsson
- University of Iceland, Reykjavik, Iceland (T.A., A.R.T., G.K.G., A.O., J.S.)
| | - Jon Sigurdsson
- University of Iceland, Reykjavik, Iceland (T.A., A.R.T., G.K.G., A.O., J.S.)
| | - Hlif Steingrímsdóttir
- Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland (B.V., P.T.O., B.A.A., M.S., I.T., S.V.S., I.O., F.S., E.E., A.J., O.S.I., H.S.)
| | - Thorir Einarsson Long
- University of Iceland, Reykjavik, Iceland, and Skåne University Hospital, Lund, Sweden (T.E.L.)
| | - Malin Hultcrantz
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York (M.H.)
| | - Brian G M Durie
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Outpatient Cancer Center, Los Angeles, California (B.G.M.D.)
| | | | - Ola Landgren
- Myeloma Program, Department of Medicine, University of Miami, Sylvester Comprehensive Cancer Center, Miami, Florida (O.L.)
| | - Sigurdur Yngvi Kristinsson
- University of Iceland and Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland (S.R., R.Palmason, S.Y.K., T.J.L.)
| | - Thorvardur Jon Love
- University of Iceland and Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland (S.R., R.Palmason, S.Y.K., T.J.L.)
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Walzik D, Belen S, Wilisch K, Kupjetz M, Kirschke S, Esser T, Joisten N, Schenk A, Proschinger S, Zimmer P. Impact of exercise on markers of B cell-related immunity: A systematic review. JOURNAL OF SPORT AND HEALTH SCIENCE 2024; 13:339-352. [PMID: 37832643 PMCID: PMC11116964 DOI: 10.1016/j.jshs.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 08/17/2023] [Accepted: 09/08/2023] [Indexed: 10/15/2023]
Abstract
BACKGROUND B cells represent a crucial component of adaptive immunity that ensures long-term protection from infection by generating pathogen-specific immunoglobulins. Exercise alters B cell counts and immunoglobulin levels, but evidence-based conclusions on potential benefits for adaptive immunity are lacking. This systematic review assessed current literatures on the impact of acute exercise and exercise training on B cells, immunoglobulins, and markers of secretory immunity in human biofluids. METHODS According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, MEDLINE, Web of Science, and Embase were searched on March 8, 2023. Non-randomized controlled trials and crossover trials investigating the impact of acute exercise or exercise training on B cell counts and proportions, immunoglobulin levels, salivary flow rate, or secretory immunoglobulin A secretion rate were included. Quality and reporting of exercise training studies were assessed using the Tool for the Assessment of Study Quality and reporting in Exercise. Study characteristics, outcome measures, and statistically significant changes were summarized tabularly. RESULTS Of the 67 eligible studies, 22 applied acute exercise and 45 applied exercise training. All included outcomes revealed significant alterations over time in acute exercise and exercise training context, but only a few investigations showed significant differences compared to control conditions. Secretory and plasma immunoglobulin A levels were most consistently increased in response to exercise training. CONCLUSION B cell-related outcomes are altered by acute exercise and exercise training, but evidence-based conclusions cannot be drawn with high confidence due to the large heterogeneity in populations and exercise modalities. Well-designed trials with large sample sizes are needed to clarify how exercise shapes B cell-related immunity.
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Affiliation(s)
- David Walzik
- Division of Performance and Health (Sports Medicine), Institute for Sport and Sport Science, TU Dortmund University, Dortmund 44227, Germany
| | - Sergen Belen
- Division of Performance and Health (Sports Medicine), Institute for Sport and Sport Science, TU Dortmund University, Dortmund 44227, Germany
| | - Karen Wilisch
- Division of Performance and Health (Sports Medicine), Institute for Sport and Sport Science, TU Dortmund University, Dortmund 44227, Germany
| | - Marie Kupjetz
- Division of Performance and Health (Sports Medicine), Institute for Sport and Sport Science, TU Dortmund University, Dortmund 44227, Germany
| | - Silvana Kirschke
- Division of Performance and Health (Sports Medicine), Institute for Sport and Sport Science, TU Dortmund University, Dortmund 44227, Germany
| | - Tobias Esser
- Division of Performance and Health (Sports Medicine), Institute for Sport and Sport Science, TU Dortmund University, Dortmund 44227, Germany
| | - Niklas Joisten
- Division of Performance and Health (Sports Medicine), Institute for Sport and Sport Science, TU Dortmund University, Dortmund 44227, Germany
| | - Alexander Schenk
- Division of Performance and Health (Sports Medicine), Institute for Sport and Sport Science, TU Dortmund University, Dortmund 44227, Germany
| | - Sebastian Proschinger
- Division of Performance and Health (Sports Medicine), Institute for Sport and Sport Science, TU Dortmund University, Dortmund 44227, Germany
| | - Philipp Zimmer
- Division of Performance and Health (Sports Medicine), Institute for Sport and Sport Science, TU Dortmund University, Dortmund 44227, Germany.
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Dekeyser C, De Kesel P, Cambron M, Vanopdenbosch L, Van Hijfte L, Vercammen M, Laureys G. Inter-assay diagnostic accuracy of cerebrospinal fluid kappa free light chains for the diagnosis of multiple sclerosis. Front Immunol 2024; 15:1385231. [PMID: 38745673 PMCID: PMC11091388 DOI: 10.3389/fimmu.2024.1385231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 04/12/2024] [Indexed: 05/16/2024] Open
Abstract
Background Cerebrospinal fluid (CSF) kappa free light chain (κFLC) measures gained increasing interest as diagnostic markers in multiple sclerosis (MS). However, the lack of studies comparing assay-dependent diagnostic cutoff values hinders their use in clinical practice. Additionally, the optimal κFLC parameter for identifying MS remains a subject of ongoing debate. Objectives The aim of this study was to compare same-sample diagnostic accuracies of the κFLC index, κIgG index, CSF κFLC/IgG ratio, and isolated CSF κFLC (iCSF-κFLC) between two reference centers using different methods. Methods Paired serum and CSF samples were analyzed for κFLC and albumin concentrations by Freelite®-Optilite (Sint-Jan Bruges hospital) and N Latex®-BNII (Ghent University hospital). Diagnostic performance to differentiate MS from controls was assessed using ROC curve analysis. Results A total of 263 participants were included (MS, n = 80). Optimal diagnostic cutoff values for the κFLC index (Freelite®-Optilite: 7.7; N Latex®-BNII: 4.71), κIgG index (Freelite®-Optilite: 14.15, N Latex®-BNII: 12.19), and CSF κFLC/IgG ratio (Freelite®-Optilite: 2.27; N Latex®-BNII: 1.44) differed between the two methods. Sensitivities related to optimal cutoff values were 89.9% (Freelite®-Optilite) versus 94.6% (N Latex®-BNII) for the κFLC index, 91% (Freelite®-Optilite) versus 92.2% (N Latex®-BNII) for the κIgG index, and 81.3% (Freelite®-Optilite) versus 91.4% (N Latex®-BNII) for the CSF κFLC/IgG ratio. However, for iCSF-κFLC, optimal diagnostic cutoff values (0.36 mg/L) and related specificities (81.8%) were identical with a related diagnostic sensitivity of 89.9% for Freelite®-Optilite and 90.5% for N Latex®-BNII. The diagnostic performance of the κFLC index [area under the curve (AUC) Freelite®-Optilite: 0.924; N Latex®-BNII: 0.962] and κIgG index (AUC Freelite®-Optilite: 0.929; N Latex®-BNII: 0.961) was superior compared to CSF oligoclonal bands (AUC: 0.898, sensitivity: 83.8%, specificity: 95.9%). Conclusions The κFLC index and the κIgG index seem to be excellent markers for identifying MS, irrespective of the method used for κFLC quantification. Based on the AUC, they appear to be the measures of choice. For all measures, optimal cutoff values differed between methods except for iCSF-κFLC. iCSF-κFLC might therefore serve as a method-independent, more cost-efficient, initial screening measure for MS. These findings are particularly relevant for clinical practice given the potential future implementation of intrathecal κFLC synthesis in MS diagnostic criteria and for future multicentre studies pooling data on κFLC measures.
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Affiliation(s)
| | - Pieter De Kesel
- Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Melissa Cambron
- Department of Neurology, AZ Sint-Jan Brugge, Bruges, Belgium
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | | | | | - Martine Vercammen
- Department of Laboratory Medicine, Algemeen Ziekenhuis (AZ) Sint-Jan Brugge, Bruges, Belgium
- Basic Biomedical Sciences, Vrije Universiteit Brussel, Brussels, Belgium
| | - Guy Laureys
- Department of Neurology, Ghent University Hospital, Ghent, Belgium
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Gao Y, Feng X, Song W, Li Z, Zhao Z, Zhang J, Zhang L, Zhang M. Prognostic significance of serum monoclonal proteins based on immunofixation electrophoresis in B-cell non-Hodgkin lymphoma. Ann Hematol 2024; 103:1261-1271. [PMID: 38114824 DOI: 10.1007/s00277-023-05584-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 12/06/2023] [Indexed: 12/21/2023]
Abstract
The presence of serum monoclonal components has been associated with poor outcomes in various hematological malignancies. The current study focused on exploring its prognostic role in B-cell non-Hodgkin lymphoma. Our study represented 314 patients with information on serum immunofixation electrophoresis at diagnosis that were available with B-cell non-Hodgkin lymphoma. IFE was positive in 61 patients (19%). Baseline features were comparable between pairs of groups, poor ECOG PS, B symptoms, advanced stage, and high-risk IPI score were significantly more frequent in the + IFE group. Shorter PFS and OS of B-NHL patients were observed in patients who presented at diagnosis with a + IFE, and IFE was the independent predictor of PFS and OS in multivariate analysis. Moreover, integrating IFE into the IPI-M1, IPI-M2, and IPI-M3 models improved the area under the curve for more accurate survival prediction and prognosis. Serum monoclonal proteins are significant prognostic indicators for newly diagnosed B-cell non-Hodgkin lymphoma that can early identify patients with poor prognosis and guide clinical treatment decisions.
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Affiliation(s)
- Yuyang Gao
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe East Road, Zhengzhou, Henan, 450052, China
- Academy of Medical Sciences of Zhengzhou University, Zhengzhou, 450052, Henan, China
- State Key Laboratory of Esophageal Cancer Prevention & Treatment and Henan Key Laboratory for Esophageal Cancer Research, Zhengzhou University, Zhengzhou, Henan, 450052, China
| | - Xiaoyan Feng
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe East Road, Zhengzhou, Henan, 450052, China
| | - Wenting Song
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe East Road, Zhengzhou, Henan, 450052, China
- Academy of Medical Sciences of Zhengzhou University, Zhengzhou, 450052, Henan, China
- State Key Laboratory of Esophageal Cancer Prevention & Treatment and Henan Key Laboratory for Esophageal Cancer Research, Zhengzhou University, Zhengzhou, Henan, 450052, China
| | - Zhaoming Li
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe East Road, Zhengzhou, Henan, 450052, China
- State Key Laboratory of Esophageal Cancer Prevention & Treatment and Henan Key Laboratory for Esophageal Cancer Research, Zhengzhou University, Zhengzhou, Henan, 450052, China
| | - Zhanzheng Zhao
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe East Road, Zhengzhou, Henan, 450052, China
| | - Jianxiang Zhang
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe East Road, Zhengzhou, Henan, 450052, China
| | - Lei Zhang
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe East Road, Zhengzhou, Henan, 450052, China
| | - Mingzhi Zhang
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe East Road, Zhengzhou, Henan, 450052, China.
- State Key Laboratory of Esophageal Cancer Prevention & Treatment and Henan Key Laboratory for Esophageal Cancer Research, Zhengzhou University, Zhengzhou, Henan, 450052, China.
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Giles HV, Karunanithi K. Performance Characteristics and Limitations of the Available Assays for the Detection and Quantitation of Monoclonal Free Light Chains and New Emerging Methodologies. Antibodies (Basel) 2024; 13:19. [PMID: 38534209 DOI: 10.3390/antib13010019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 02/26/2024] [Accepted: 03/05/2024] [Indexed: 03/28/2024] Open
Abstract
Light chain measurements form an essential component of the testing strategy for the detection and monitoring of patients with suspected and/or proven plasma cell disorders. Urine-based electrophoretic assays remain at the centre of the international guidelines for response assessment but the supplementary role of serum-free light chain (FLC) assays in response assessment and the detection of disease progression due to their increased sensitivity has been increasingly recognised since their introduction in 2001. Serum FLC assays have also been shown to be prognostic across the spectrum of plasma cell disorders and are now incorporated into risk stratification scores for patients with monoclonal gammopathy of undetermined significance (MGUS), smouldering multiple myeloma, and light chain amyloidosis (AL amyloidosis), as well as being incorporated into the criteria for defining symptomatic multiple myeloma. There are now multiple different commercially available serum FLC assays available with differing performance characteristics, which are discussed in this review, along with the implications of these for patient monitoring. Finally, newer methodologies for the identification and characterisation of monoclonal FLC, including modifications to electrophoretic techniques, mass spectrometry-based assays and Amylite, are also described along with the relevant published data available regarding the performance of each assay.
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Affiliation(s)
- Hannah V Giles
- Department of Clinical Haematology, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2SY, UK
- Instute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
| | - Kamaraj Karunanithi
- Department of Clinical Haematology, University Hospitals North Midlands NHS Trust, Royal Stoke Hospital, Newcastle Road, Stoke-on-Trent ST4 6QG, UK
- School of Medicine, Keele University, Keele, Newcastle-under-Lyme ST5 5BG, UK
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10
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Lim SM, Wijeratne N, Choy KW, Nguyen TTH, Setiawan L, Loh TP. A review of clinical guidelines, laboratory recommendations and external quality assurance programs for monoclonal gammopathy testing. Crit Rev Clin Lab Sci 2024; 61:107-126. [PMID: 37776896 DOI: 10.1080/10408363.2023.2257306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 09/06/2023] [Indexed: 10/02/2023]
Abstract
Monoclonal gammopathy (MG) is a spectrum of diseases ranging from the benign asymptomatic monoclonal gammopathy of undetermined significance to the malignant multiple myeloma. Clinical guidelines and laboratory recommendations have been developed to inform best practices in the diagnosis, monitoring, and management of MG. In this review, the pathophysiology, relevant laboratory testing recommended in clinical practice guidelines and laboratory recommendations related to MG testing and reporting are examined. The clinical guidelines recommend serum protein electrophoresis, serum immunofixation and serum free light chain measurement as initial screening. The laboratory recommendations omit serum immunofixation as it offers limited additional diagnostic value. The laboratory recommendations offer guidance on reporting findings beyond monoclonal protein, which was not required by the clinical guidelines. The clinical guidelines suggested monitoring total IgA concentration by turbidimetry or nephelometry method if the monoclonal protein migrates in the non-gamma region, whereas the laboratory recommendations make allowance for involved IgM and IgG. Additionally, several external quality assurance programs for MG protein electrophoresis and free light chain testing are also appraised. The external quality assurance programs show varied assessment criteria for protein electrophoresis reporting and unit of measurement. There is also significant disparity in reported monoclonal protein concentrations with wide inter-method analytical variation noted for both monoclonal protein quantification and serum free light chain measurement, however this variation appears smaller when the same method was used. Greater harmonization among laboratory recommendations and reporting format may improve clinical interpretation of MG testing.
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Affiliation(s)
| | - Nilika Wijeratne
- Dorevitch Pathology, Melbourne, Australia
- School of Clinical Sciences at Monash Health, Department of Medicine, Nursing and Health Sciences, Monash University, Clayton, Australia
- Eastern Health Pathology, Eastern Health, Box Hill, Australia
- Dorevitch Pathology, Heidelberg, Australia
| | | | | | - Lyana Setiawan
- Dharmais Hospital National Cancer Centre, West Jakarta, Indonesia
| | - Tze Ping Loh
- National University Hospital, Singapore, Singapore
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11
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Borai A, Ichihara K, Tamimi W, Masaud A, Sobki S. Establishment of reference intervals for free light chains and immunoglobulins in Saudi population. Clin Chem Lab Med 2024; 62:522-529. [PMID: 37787915 DOI: 10.1515/cclm-2023-0774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 09/21/2023] [Indexed: 10/04/2023]
Abstract
OBJECTIVES Testing of serum-free light chains kappa (κ) and lambda (λ), along with ratio (FLCR) is essential for the diagnosis and management of monoclonal gammopathies. Accurate clinical diagnosis depends upon appropriate local population reference intervals (RIs). This study examined the Saudi population for serum-free light chains and other immunoglobulins to establish RIs and to explore variations in the test results by using the International Federation for Clinical Chemistry and Laboratory Medicine's global protocol for harmonized implementation of RI study. METHODS A total of 180 healthy Saudi adults were recruited. All serum samples were assayed using the Freelite reagents from the Binding Site. The variation in reference values attributable to sex, age, BMI, and region was calculated by ANOVA as a standard deviation ratio (SDR). The RIs for the FLCR were derived by the parametric method and validated by using samples from patients with hypo- and hypergammaglobulinemia. RESULTS The new RIs for free κ and FLCR were shifted to a higher side from the manufacturer-adapted RIs. Based on the SDR cutoff value (>0.4), between-sex partition RIs were not required for all analytes except IgM. Validation using patients with hypo- or hypergammaglobulinemia and without multiple myeloma, was all within the new RI. BMI, smoking, and exercise were not relevant sources of variation for any analyte. CONCLUSIONS Locally derived RIs for free light chains and immunoglobulins analytes specific for Saudis were established after careful consideration of various factors. These RIs were more reliable than those provided as guidance by the manufacturer, or from other countries, for appropriate classification and prediction of disease progression for Saudi patients.
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Affiliation(s)
- Anwar Borai
- King Abdullah International Medical Research Center (KAIMRC), King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), King Abdulaziz Medical City, Ministry of National Guard, Riyadh, Saudi Arabia
| | - Kiyoshi Ichihara
- Faculty of Health Sciences, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Waleed Tamimi
- King Abdullah International Medical Research Center (KAIMRC), King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), King Abdulaziz Medical City, Ministry of National Guard, Riyadh, Saudi Arabia
| | - Abdulaziz Masaud
- King Abdullah International Medical Research Center (KAIMRC), King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), King Abdulaziz Medical City, Ministry of National Guard, Riyadh, Saudi Arabia
| | - Samia Sobki
- Central Military Laboratory & Blood Bank, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
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12
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Drayson M, Jennis T, Laketic-Ljubojevic I, Patel D, Pratt G, Renwick S, Richter A, Wheeler R, Sheldon J, Sadler R, Stapleton M, Willis F, Whiston M. Laboratory practice is central to earlier myeloma diagnosis: Utilizing a primary care diagnostic tool and laboratory guidelines integrated into haematology services. Br J Haematol 2024; 204:476-486. [PMID: 38168756 DOI: 10.1111/bjh.19224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 10/13/2023] [Accepted: 11/13/2023] [Indexed: 01/05/2024]
Abstract
Treatment advances have greatly improved survival, but myeloma is among the worst of all cancers for delayed diagnosis, causing serious morbidities and early deaths. This delay is largely because the symptom profile of myeloma has very low specificity, and in primary care, myeloma is rare. However, initiating the journey to diagnosis simply requires considering myeloma and sending blood to test for monoclonal immunoglobulin. Laboratory tests reliably detect monoclonal immunoglobulin, which is present in 99% of myeloma cases, so why do health care systems have such a problem with delayed diagnosis? The Myeloma UK early diagnosis programme has brought together diverse expertise to investigate this problem, and this article was prepared by the programme's working group for laboratory best practice. It reviews evidence for test requesting, analysis and reporting, for which there is large variation in practice across the United Kingdom. It presents a 'GP Myeloma diagnostic tool' and how it can be integrated into laboratory practice alongside a laboratory best practice tool. It proposes improved requesting and integration with haematology services for reporting and interpretation. Here the laboratory has a central role in creating efficient and cost-effective pathways for appropriate and timely bone marrow examination for myeloma diagnosis.
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Affiliation(s)
- Mark Drayson
- Clinical Immunology Service, University of Birmingham, Birmingham, UK
| | | | | | - Dina Patel
- UK NEQAS Immunology, Immunochemistry & Allergy, Sheffield Teaching Hospitals, Sheffield, UK
| | - Guy Pratt
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | | | - Alex Richter
- Clinical Immunology Service, University of Birmingham, Birmingham, UK
| | - Rachel Wheeler
- Protein Reference Unit, South West London Pathology, St Georges Hospital, London, UK
| | - Joanna Sheldon
- Protein Reference Unit, South West London Pathology, St Georges Hospital, London, UK
| | - Ross Sadler
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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13
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Cárdenas MC, García-Sanz R, Puig N, Pérez-Surribas D, Flores-Montero J, Ortiz-Espejo M, de la Rubia J, Cruz-Iglesias E. Recommendations for the study of monoclonal gammopathies in the clinical laboratory. A consensus of the Spanish Society of Laboratory Medicine and the Spanish Society of Hematology and Hemotherapy. Part I: Update on laboratory tests for the study of monoclonal gammopathies. Clin Chem Lab Med 2023; 61:2115-2130. [PMID: 37477188 DOI: 10.1515/cclm-2023-0326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/29/2023] [Indexed: 07/22/2023]
Abstract
Monoclonal gammopathies (MG) are characterized by the proliferation of plasma cells that produce identical abnormal immunoglobulins (intact or some of their subunits). This abnormal immunoglobulin component is called monoclonal protein (M-protein), and is considered a biomarker of proliferative activity. The identification, characterization and measurement of M-protein is essential for the management of MG. We conducted a systematic review of the different tests and measurement methods used in the clinical laboratory for the study of M-protein in serum and urine, the biochemistry and hematology tests necessary for clinical evaluation, and studies in bone marrow, peripheral blood and other tissues. This review included literature published between 2009 and 2022. The paper discusses the main methodological characteristics and limitations, as well as the purpose and clinical value of the different tests used in the diagnosis, prognosis, monitoring and assessment of treatment response in MG. Included are methods for the study of M-protein, namely electrophoresis, measurement of immunoglobulin levels, serum free light chains, immunoglobulin heavy chain/light chain pairs, and mass spectrometry, and for the bone marrow examination, morphological analysis, cytogenetics, molecular techniques, and multiparameter flow cytometry.
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Affiliation(s)
- María C Cárdenas
- Department of Clinical Analysis, Hospital Clinico San Carlos, Madrid, Spain
- Protein Commission, Spanish Society of Laboratory Medicine (SEQCML), Barcelona, Spain
| | - Ramón García-Sanz
- Hematology Department, University Hospital of Salamanca, Research Biomedical Institute of Salamanca (IBSAL), CIBERONC and Center for Cancer Research-IBMCC (University of Salamanca-CSIC), Salamanca, Spain
- Spanish Society of Hematology and Hemotherapy (SEHH), Madrid, Spain
| | - Noemí Puig
- Hematology Department, University Hospital of Salamanca, Research Biomedical Institute of Salamanca (IBSAL), CIBERONC and Center for Cancer Research-IBMCC (University of Salamanca-CSIC), Salamanca, Spain
- Spanish Society of Hematology and Hemotherapy (SEHH), Madrid, Spain
| | - David Pérez-Surribas
- Laboratori Pasteur, Andorra La Vella, Andorra
- Protein Commission, Spanish Society of Laboratory Medicine (SEQCML), Barcelona, Spain
| | - Juan Flores-Montero
- Hematology Department, University Hospital of Salamanca, Research Biomedical Institute of Salamanca (IBSAL), CIBERONC and Center for Cancer Research-IBMCC (University of Salamanca-CSIC), Salamanca, Spain
- Spanish Society of Hematology and Hemotherapy (SEHH), Madrid, Spain
| | - María Ortiz-Espejo
- Department of Clinical Analysis, Hospital Universitario Marqués de Valdecilla, Santander, Spain
- Protein Commission, Spanish Society of Laboratory Medicine (SEQCML), Barcelona, Spain
| | - Javier de la Rubia
- Hematology Department, Hospital Universitario y Politécnico La Fe & Universidad Católica de Valencia, Instituto de Investigación Sanitaria La Fe Centro de Investigación Biomédica en Red de Cáncer, CIBERONC CB16/12/00284, Instituto de Salud Carlos III, Valencia, Spain
- Spanish Society of Hematology and Hemotherapy (SEHH), Madrid, Spain
| | - Elena Cruz-Iglesias
- Department of Laboratory Medicine, Osakidetza Basque Health Service, Basurto University Hospital, Bilbao, Spain
- Protein Commission, Spanish Society of Laboratory Medicine (SEQCML), Barcelona, Spain
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14
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Wijnands C, Noori S, Donk NWCJVD, VanDuijn MM, Jacobs JFM. Advances in minimal residual disease monitoring in multiple myeloma. Crit Rev Clin Lab Sci 2023; 60:518-534. [PMID: 37232394 DOI: 10.1080/10408363.2023.2209652] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 04/07/2023] [Accepted: 04/28/2023] [Indexed: 05/27/2023]
Abstract
Multiple myeloma (MM) is characterized by the clonal expansion of plasma cells and the excretion of a monoclonal immunoglobulin (M-protein), or fragments thereof. This biomarker plays a key role in the diagnosis and monitoring of MM. Although there is currently no cure for MM, novel treatment modalities such as bispecific antibodies and CAR T-cell therapies have led to substantial improvement in survival. With the introduction of several classes of effective drugs, an increasing percentage of patients achieve a complete response. This poses new challenges to traditional electrophoretic and immunochemical M-protein diagnostics because these methods lack sensitivity to monitor minimal residual disease (MRD). In 2016, the International Myeloma Working Group (IMWG) expanded their disease response criteria with bone marrow-based MRD assessment using flow cytometry or next-generation sequencing in combination with imaging-based disease monitoring of extramedullary disease. MRD status is an important independent prognostic marker and its potential as a surrogate endpoint for progression-free survival is currently being studied. In addition, numerous clinical trials are investigating the added clinical value of MRD-guided therapy decisions in individual patients. Because of these novel clinical applications, repeated MRD evaluation is becoming common practice in clinical trials as well as in the management of patients outside clinical trials. In response to this, novel mass spectrometric methods that have been developed for blood-based MRD monitoring represent attractive minimally invasive alternatives to bone marrow-based MRD evaluation. This paves the way for dynamic MRD monitoring to allow the detection of early disease relapse, which may prove to be a crucial factor in facilitating future clinical implementation of MRD-guided therapy. This review provides an overview of state-of-the-art of MRD monitoring, describes new developments and applications of blood-based MRD monitoring, and suggests future directions for its successful integration into the clinical management of MM patients.
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Affiliation(s)
- Charissa Wijnands
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Somayya Noori
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | | | - Martijn M VanDuijn
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | - Joannes F M Jacobs
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
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15
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Singh G, Arinze N, Manthei DM, Plapp FV, Bollag RJ. Urine Protein Immunofixation Electrophoresis: Free Light Chain Urine Immunofixation Electrophoresis Is More Sensitive than Conventional Assays for Detecting Monoclonal Light Chains and Could Serve as a Marker of Minimal Residual Disease. Lab Med 2023; 54:527-533. [PMID: 36857478 DOI: 10.1093/labmed/lmac155] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Immunoglobulin monoclonal light chains (MLCs) in serum and urine are markers for monoclonal gammopathy and could serve as markers of minimal residual disease (MRD) in multiple myeloma (MM). Excretion of MLCs in urine is known to result in renal damage and shorter survival in patients with LC-predominant MM. METHODS Retrospective review of urine immunofixation in 1738 specimens at 3 medical centers was conducted to assess the utility of urinalysis for diagnosis and monitoring of monoclonal gammopathy. We tested 228 stored urine specimens via the modified urine immunofixation method, using antisera to assay free LCs (FLCs). RESULTS Our review of urine immunofixation results and medical records validated the theory that the only meaningful value-added finding was detection of monoclonal free light chains. Examination of 228 urine specimens using our novel method revealed 18.4% additional positive results. The rate of incremental findings for lambda LCs was nearly 3-fold higher than for kappa LCs. CONCLUSIONS The new method of urine immunofixation is significantly more sensitive and more efficient than the conventional method for detecting MLCs in urine. The new assay appears to be sensitive enough to prove that MLCs serve as a marker of MRD in MM.
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Affiliation(s)
- Gurmukh Singh
- Department of Pathology Medical College of Georgia at Augusta University, Augusta, GA
| | - Nkechi Arinze
- Department of Pathology Medical College of Georgia at Augusta University, Augusta, GA
| | | | | | - Roni J Bollag
- Department of Pathology Medical College of Georgia at Augusta University, Augusta, GA
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16
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Moore AR, Brown K, Chapman C, Broeckling C. Mass spectrometric-based assessment of the serum kappa to lambda immunoglobulin light chain ratio (κ:λ) in dogs with immunoglobulin secretory diseases. Vet Comp Oncol 2023; 21:460-468. [PMID: 37154287 DOI: 10.1111/vco.12905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 04/21/2023] [Accepted: 04/25/2023] [Indexed: 05/10/2023]
Abstract
The ratio of κ light chains to λ light chains (κ:λ) in serum is used as a biomarker of immunoglobulin secreting neoplasia in humans but has not been evaluated in dogs. A mass-spectrometry based method for determining the canine serum κ:λ was developed and used to evaluate samples from control dogs, dogs with an infectious aetiology, dogs with secretory plasma cell tumours (sPCT) and dogs with non-secretory B cell neoplasia. A human-targeted immunoturbidometric κ:λ assay and immunofixation using antisera targeting human κ light chain or λ light chain was also performed on all samples. Using whole serum samples, the MS-based κ:λ method identified 5 sPCT as κ-predominant (mean κ:λ = 3.307) and 5 sPCT as λ-predominant (mean κ:λ = 0.023) and documented differences between these groups and all other groups (p < 0.05 for all). The infectious aetiology group had a lower mean κ:λ ratio (mean κ:λ = 0.069) than control samples (mean κ:λ = 0.103, p = 0.035). Similar results were obtained when samples were enriched for proteins between 10 and 50 kDa using size exclusion chromatography, except for the statistical difference between the control and infectious aetiology group. All λ-predominant cases had only anti-human λ light chain labelling by immunofixation. Three κ-predominant cases had only anti-human κ-light chain labelling and the remaining two cases did not label with either antisera by immunofixation. The immunoturbidometric method had high analytical CV% (λ light chain CV = 13%, κ light chain CV = 50%), was unable to measure light chains in 20.5% of samples and did not distinguish groups. The data suggests that the human-targeted immunoturbidometric method would not be diagnostically useful and that the MS-derived serum κ:λ may be a useful biomarker of canine immunoglobulin secretory neoplasia which may have the ability to distinguish neoplasia from infectious causes of immunoglobulin secretion.
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Affiliation(s)
- A Russell Moore
- Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, Colorado, USA
| | - Kitty Brown
- Analytical Resources Core-Bioanalysis and Omics, Colorado State University, Fort Collins, Colorado, USA
| | - Cecelia Chapman
- Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, Colorado, USA
| | - Corey Broeckling
- Analytical Resources Core-Bioanalysis and Omics, Colorado State University, Fort Collins, Colorado, USA
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17
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Azimi V, Fiala MA, Zaydman MA. Use of the Current Standard of Practice Serum Free Light Chains (sFLC) Reference Interval Puts Black Patients at 5 Times Higher Odds for Light Chain Monoclonal Gammopathy of Undetermined Significance (LC-MGUS). Clin Chem 2023; 69:1084-1086. [PMID: 37366327 DOI: 10.1093/clinchem/hvad083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 05/22/2023] [Indexed: 06/28/2023]
Affiliation(s)
- Vahid Azimi
- Department of Pathology and Immunology, Division of Laboratory and Genomic Medicine, Washington University School of Medicine, St. Louis, MO, United States
| | - Mark A Fiala
- Department of Medicine, Division of Hematology & Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Mark A Zaydman
- Department of Pathology and Immunology, Division of Laboratory and Genomic Medicine, Washington University School of Medicine, St. Louis, MO, United States
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18
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Suresh J, Wu Y, Sabaratnam R, Brijlall S, Kyle B, Torlakovic EE. Dual Expression of Immunoglobulin Light Chains in Plasma Cell Myeloma: A Case Report and Literature Review. Appl Immunohistochem Mol Morphol 2023; 31:447-451. [PMID: 36314594 DOI: 10.1097/pai.0000000000001069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 08/19/2022] [Indexed: 11/25/2022]
Abstract
Typically, myeloma cells express a monoclonal immunoglobulin (Ig), either heavy or light chain. Here, we present a case of multiple myeloma with clonal dual expression of kappa and lambda light chain in a 74-year-old woman. Awareness of rare biphenotypic myeloma is important for proper diagnostic workup. A 74-year-old woman underwent hip replacement with an incidental finding of 20% plasma cells in the femoral head. Subsequent bone marrow biopsy also showed about 30% of plasma cells negative for CD20, CD56, and CD117. Immunohistochemistry (IHC) and in situ hybridization studies showed a mixture of kappa and lambda plasma cells. Flow cytometry showed ambiguous results for cytoplasmic Ig light chains kappa and lambda. However, cyclin D1 was highly expressed by plasma cells, and increased free kappa light chains were identified in serum. Further investigation by double IHC demonstrated co-expression of kappa and lambda light chains in the same cells. Fluoresces in situ hybridization studies were positive for t(11;14)(q13;q32) and the deletion 13q. Since its first description by Taylor and Burns in 1974, the demonstration of restricted cytoplasmic Ig light chain expression by immunohistochemistry is 1 of the basic tools for corroborating clonality of the plasma cells in tissue biopsy. IHC results in myeloma with dual expression of Ig light chains may suggest polyclonal plasma cell population, especially when plasma cells do not form sheets in the bone marrow. In an appropriate clinical setting, other investigations are needed to exclude plasma cell neoplasm, even with seemingly "polytypic" results by IHC.
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Affiliation(s)
- Janarthanee Suresh
- Department of Pathology and Laboratory Medicine, College of Medicine, University of Saskatchewan
| | - Yue Wu
- Department of Pathology and Laboratory Medicine, College of Medicine, University of Saskatchewan
- Saskatchewan Health Authority, Saskatoon
| | | | - Shashi Brijlall
- Department of Pathology
- Department of Orthopedic, Victoria Hospital, Prince Albert Parkland Health Region, SK, Canada
| | - Barry Kyle
- Department of Pathology and Laboratory Medicine, College of Medicine, University of Saskatchewan
- Saskatchewan Health Authority, Saskatoon
| | - Emina E Torlakovic
- Department of Pathology and Laboratory Medicine, College of Medicine, University of Saskatchewan
- Saskatchewan Health Authority, Saskatoon
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19
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Solimando AG, Krebs M, Desantis V, Marziliano D, Caradonna IC, Morizio A, Argentiero A, Shahini E, Bittrich M. Breaking through Multiple Myeloma: A Paradigm for a Comprehensive Tumor Ecosystem Targeting. Biomedicines 2023; 11:2087. [PMID: 37509726 PMCID: PMC10377041 DOI: 10.3390/biomedicines11072087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/29/2023] [Accepted: 07/12/2023] [Indexed: 07/30/2023] Open
Abstract
Multiple myeloma (MM) is a cancerous condition characterized by the proliferation of plasma cells within the hematopoietic marrow, resulting in multiple osteolytic lesions. MM patients typically experience bone pain, kidney damage, fatigue due to anemia, and infections. Historically, MM was an incurable disease with a life expectancy of around three years after diagnosis. However, over the past two decades, the development of novel therapeutics has significantly improved patient outcomes, including response to treatment, remission duration, quality of life, and overall survival. These advancements include thalidomide and its derivatives, lenalidomide and pomalidomide, which exhibit diverse mechanisms of action against the plasma cell clone. Additionally, proteasome inhibitors such as bortezomib, ixazomib, and carfilzomib disrupt protein degradation, proving specifically toxic to cancerous plasma cells. Recent advancements also involve monoclonal antibodies targeting surface antigens, such as elotuzumab (anti-CS1) and daratumumab (anti-CD38), bispecific t-cell engagers such as teclistamab (anti-BCMA/CD3) and Chimeric antigen receptor T (CAR-T)-based strategies, with a growing focus on drugs that exhibit increasingly targeted action against neoplastic plasma cells and relevant effects on the tumor microenvironment.
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Affiliation(s)
- Antonio G Solimando
- Unit of Internal Medicine and Clinical Oncology "G. Baccelli", Department of Precision and Regenerative Medicine and Ionian Area, University of Bari Aldo Moro Medical School, 70124 Bari, Italy
| | - Markus Krebs
- Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, 97080 Würzburg, Germany
- Department of Urology and Pediatric Urology, University Hospital Würzburg, 97080 Würzburg, Germany
| | - Vanessa Desantis
- Department of Precision and Regenerative Medicine and Ionian Area, Pharmacology Section, University of Bari Aldo Moro Medical School, 70124 Bari, Italy
| | - Donatello Marziliano
- Unit of Internal Medicine and Clinical Oncology "G. Baccelli", Department of Precision and Regenerative Medicine and Ionian Area, University of Bari Aldo Moro Medical School, 70124 Bari, Italy
| | - Ingrid Catalina Caradonna
- Department of Precision and Regenerative Medicine and Ionian Area, Pharmacology Section, University of Bari Aldo Moro Medical School, 70124 Bari, Italy
| | - Arcangelo Morizio
- Orthopedics and Traumatology Unit ASL BA-Ospedale della Murgia "Fabio Perinei", 70022 Altamura, Italy
| | | | - Endrit Shahini
- Gastroenterology Unit, National Institute of Gastroenterology-IRCCS "Saverio de Bellis", 70013 Castellana Grotte, Italy
| | - Max Bittrich
- Department of Internal Medicine II, University Hospital Würzburg, 97080 Würzburg, Germany
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20
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Rozenova K, Willrich M, Snyder M, Dasari S, Kourelis T, Rajkumar SV, Kumar S, Dispenzieri A, Murray DL. Kappa Free Light Chain Drift Prompts the Need for a New Upper Limit of Normal Free Light Chain Ratio to Avoid an Epidemic of Kappa Light Chain Monoclonal Gammopathy of Undermined Significance. J Appl Lab Med 2023; 8:742-750. [PMID: 37232112 DOI: 10.1093/jalm/jfad027] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 03/08/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Multiple laboratory tests are employed for detection of monoclonal proteins in patients and include serum protein electrophoresis (SPEP), immunofixation electrophoresis, free light chain (FLC) immunoassay, and mass spectrometry (Mass-Fix). Recently, reports on a drift in FLC quantitation results have been brought to light. METHODS We studied a cohort of 16 887 patients whose sera were tested for a monoclonal protein by a FLC assay, serum protein electrophoresis, and Mass-Fix. This is a retrospective study designed to assess the impact of a drift on the performance of FLC ratio (rFLC) in groups of patients with and without detectable plasma cell disorders (PCDs). RESULTS The results demonstrated that 63% of patients with monoclonal protein equal or higher than 2 g/L (by SPEP) had an abnormal rFLC (reference range 0.26-1.65). Conversely, 16% of patients with undetectable monoclonal protein by other methods (i.e., SPEP and Mass-Fix) who also had no record of treated PCD had an abnormal rFLC. In these cases, there was an imbalance in the number of kappa high rFLCs to lambda low rFLCs of 201 to 1. CONCLUSIONS The results of this study suggest decreased specificity of rFLC for a monoclonal kappa FLC in the 1.65 to 3.0 range.
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Affiliation(s)
- Krasimira Rozenova
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Maria Willrich
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Melissa Snyder
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Surendra Dasari
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, United States
| | | | | | - Shaji Kumar
- Division of Hematology, Mayo Clinic, Rochester, MN, United States
| | - Angela Dispenzieri
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
- Division of Hematology, Mayo Clinic, Rochester, MN, United States
| | - David L Murray
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
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21
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Schroeder LF. Retrospective Analysis of Serum Free Light Chain Reference Intervals and Risk for Monoclonal Gammopathy Suggests Different Limits Than Those in International Guidelines. Clin Biochem 2023:110604. [PMID: 37394225 DOI: 10.1016/j.clinbiochem.2023.110604] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 06/03/2023] [Accepted: 06/23/2023] [Indexed: 07/04/2023]
Abstract
OBJECTIVES Recent reference interval studies of the serum free light chain (FLC) test using contemporary instruments display divergence with the diagnostic range generally adopted as the international standard. In this study, we perform a retrospective reference interval analysis with risk predictions for monoclonal gammopathy. METHODS Retrospective laboratory and clinical data for 8,986 patients were included in the study. Reference intervals were generated against a set of inclusion/exclusion criteria for two time periods representing the use of different instruments. The presence of monoclonal gammopathy was established from diagnostic test interpretations and EHR diagnosis codes in the patient problem lists and medical history. RESULTS The 95% FLC ratio reference intervals were 0.76-2.38 for SPAPLUS®, and 0.68-1.82 for Optilite® instruments. These intervals varied considerably from the current diagnostic range of 0.26-1.65 and mapped approximately to the FLC ratios beyond which risk of monoclonal gammopathy substantially increased. CONCLUSIONS These findings corroborate recent reference interval studies and support recommendations for independent re-evaluation of intervals by institutions as well as an update of international guidelines.
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22
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Basile U, Santini G, Napodano C, Macis G, Pocino K, Gulli F, Malerba M, Bush A, Adcock IM, Montuschi P. Elevated serum polyclonal immunoglobulin free light chains in patients with severe asthma. Front Pharmacol 2023; 14:1126535. [PMID: 37397489 PMCID: PMC10311563 DOI: 10.3389/fphar.2023.1126535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 05/09/2023] [Indexed: 07/04/2023] Open
Abstract
Background: Inflammation plays a pivotal role in the pathophysiology of asthma. Free light chains (FLC) can cause inflammation by mast cell antigen-activation. Serum immunoglobulin (Ig) FLC κ, but not λ, were shown elevated in adult males with asthma. We sought to investigate if serum Ig FLC concentrations are affected by asthma severity and their relationships with inflammatory outcomes. Methods: By using immunoassays, we measured serum κ and λ Ig FLCs in 24 severe persistent asthma patients, 15 patients with moderate persistent asthma, 15 steroid-naïve mild persistent asthma patients and 20 healthy control subjects in a cross-sectional observational study. Total and specific serum IgE concentrations, fractional exhaled nitric oxide (FENO), lung function, peripheral blood eosinophils and neutrophils, and C reactive protein (CRP) were also measured. Results: Serum κ FLC concentrations were elevated in severe asthma patients compared mild asthma patients (p < 0.05) and healthy subjects (p < 0.05). Serum λ FLCs were higher in severe asthma patients than in healthy subjects (p < 0.05) and correlated with blood eosinophil counts (percentage, κ: r = 0.51, p = 2.9678-6; λ: r = 0.42, p = 1.7377-4; absolute values, κ: r = 0.45, p = 6.1284-5; λ: r = 0.38, p = 7.8261-4), but not with total or specific serum IgE. In severe asthma patients, serum Ig FLC correlated with serum CRP (κ: r = 0.33; p = 0.003; λ: r = 0.38, p = 8.8305-4) and blood neutrophil cell counts (percentage, κ: r = 0.31; p = 0.008; λ: r = 0.29, p = 0.01; absolute values, κ: r = 0.40; p = 3.9176-4; λ: r = 0.40, p = 4.5479-4), were elevated in subjects with blood eosinophilia (≥300 cells/µL) (n = 13) compared with non-eosinophilic subjects (n = 10) (κ: 19.2 ± 1.2 mg/L versus 12.1 ± 1.3 mg/L, p < 0.001; λ: 27.2 ± 2.6 mg/L versus 16.8 ± 2.5 mg/L, p < 0.01), but were similar in atopic (n = 15) versus nonatopic subjects (n = 9) (κ: p = 0.20; λ: p = 0.80). Serum FLC were negatively correlated with lung function tests, including forced expiratory volume in one second (FEV1) (κ: r = -0.33; p = 0.0034; λ: r = -0.33; p = 0.0035), and FEV1/forced vital capacity ratio (κ: r = -0.33; p = 0.0034; λ: r = -0.33; p = 0.0036). Conclusion: Serum Ig FLCs are elevated in severe asthma adults and might represent new surrogate markers of inflammation. The pathophysiological implications of these findings require further research. This study was approved by the ethics committee of the University Hospital Agostino Gemelli Foundation and Catholic University of the Sacred Heart (approval number P/1034/CE2012).
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Affiliation(s)
- Umberto Basile
- Department of Translational Medicine, Catholic University of the Sacred Heart, University Hospital Agostino Gemelli Foundation IRCCS, Rome, Italy
- Clinical Pathology Unit, Santa Maria Goretti Hospital, ASL, Latina, Italy
| | - Giuseppe Santini
- Pharmacology, Faculty of Medicine, Catholic University of the Sacred Heart, Rome, Italy
- Clinical Pathology Unit, Belcolle Hospital, ASL Viterbo, Rome, Italy
| | - Cecilia Napodano
- Department of Laboratory Medicine and Pathology, S. Agostino Estense Hospital, Modena, Italy
| | - Giuseppe Macis
- Department of Radiological Sciences, University Hospital Agostino Gemelli Foundation IRCCS, Rome, Italy
| | - Krizia Pocino
- Clinical Pathology Unit, San Pietro Fatebenefratelli Hospital, Rome, Italy
| | - Francesca Gulli
- Clinical Biochemistry Laboratory, IRCCS, Bambino Gesù Children’s Hospital, Rome, Italy
| | - Mario Malerba
- Respiratory Unit, S. Andrea Hospital, University of Piemonte Orientale, Vercelli, Italy
| | - Andrew Bush
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Ian M. Adcock
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Paolo Montuschi
- Pharmacology, Faculty of Medicine, Catholic University of the Sacred Heart, Rome, Italy
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom
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23
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McCormack S, Hamad E, Hamad A. Solitary Plasmacytoma of the Breast: A Case of an Uncommon Breast Neoplasm. Case Rep Hematol 2023; 2023:9622042. [PMID: 37303483 PMCID: PMC10257539 DOI: 10.1155/2023/9622042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/15/2023] [Accepted: 05/27/2023] [Indexed: 06/13/2023] Open
Abstract
Plasmacytoma is a rare cancer that originates from a single plasma cell and is characterized by the abnormal proliferation of monoclonal plasma cells. It is typically localized in a single area of the body, most commonly in the bone or soft tissue. Solitary plasmacytoma can be further classified as either solitary plasmacytoma of bone (SPB) or solitary extramedullary plasmacytoma (SEP or EMP). Diagnosis may be delayed in symptomatically silent plasmacytomas, but early diagnosis and prompt treatment are crucial for the management of this disease. The mean age for patients with plasmacytoma varies depending on the specific type of plasmacytoma, but generally, it is more common in older adults. Soft tissue plasmacytomas are uncommon, and plasmacytomas manifesting within the breast are extremely rare, especially when they are not a manifestation of multiple myeloma (MM). This report presents a case of SEP of the breast in a 79-year-old female patient. This rare disease needs to be studied further in terms of long-term survival and disease progression to MM. By raising awareness and understanding of plasmacytoma, we aim to improve outcomes and quality of life for patients affected by this disease.
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Affiliation(s)
- Sean McCormack
- Saint James School of Medicine, Cane Hall Road, Arnos Vale, Saint Vincent and the Grenadines
| | - Eyad Hamad
- Northwestern School of Medicine, 10604 SW Hwy Ste 200, Chicago Ridge, IL 60415, USA
| | - Amar Hamad
- Christ Hospital, 10604 SW Hwy Ste 200, Chicago Ridge, IL 60415, USA
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24
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Azimi V, Slade M, Fiala M, Fortier JM, Stockerl-Goldstein K, Frater JL, Brestoff JR, Jackups R, Zaydman MA. A Single Reference Interval for Interpreting Serum Free Light Chains across Patients with Varying Renal Function. Clin Chem 2023:7153471. [PMID: 37147848 DOI: 10.1093/clinchem/hvad043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 03/13/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND Serum free light chain (sFLC) assays are interpreted using a sFLC-ratio-based reference interval (manufacturer's interval) that was defined using a cohort of healthy patients. However, renal impairment elevates the sFLC-ratio, leading to a high false positive rate when using the manufacturer's interval. Prior studies have developed renal-specific reference intervals; however, this approach has not been widely adopted due to practical limitations. Thus, there remains a critical need for a renally robust sFLC interpretation method. METHODS Retrospective data mining was used to define patient cohorts that reflect the spectrum of renal function seen in clinical practice. Two new reference intervals, one based on the sFLC-ratio and one based on a novel principal component analysis (PCA)-based metric, were developed for the FREELITE assay (Binding Site) on the Roche Cobas c501 instrument (Roche). RESULTS Compared to the manufacturer's reference interval, both new methods exhibited significantly lower false positive rates and greater robustness to renal function while maintaining equivalent sensitivity for monoclonal gammopathy (MG) diagnosis. While not significantly different, the point estimate for sensitivity was highest for the PCA-based approach. CONCLUSION Renally robust sFLC interpretation using a single reference interval is possible given a reference cohort that reflects the variation in renal function observed in practice. Further studies are needed to achieve sufficient power and determine if the novel PCA-based metric offers superior sensitivity for MG diagnosis. These new methods offer the practical advantages of not requiring an estimated glomerular filtration rate result or multiple reference intervals, thereby lowering practical barriers to implementation.
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Affiliation(s)
- Vahid Azimi
- Department of Pathology and Immunology, Washington University in St. Louis, School of Medicine, St. Louis, MO, United States
| | - Michael Slade
- Department of Medicine, Division of Oncology, Washington University in St. Louis, School of Medicine, St. Louis, MO, United States
| | - Mark Fiala
- Department of Medicine, Division of Oncology, Washington University in St. Louis, School of Medicine, St. Louis, MO, United States
| | - Julie M Fortier
- Department of Medicine, Division of Oncology, Washington University in St. Louis, School of Medicine, St. Louis, MO, United States
| | - Keith Stockerl-Goldstein
- Department of Medicine, Division of Oncology, Washington University in St. Louis, School of Medicine, St. Louis, MO, United States
| | - John L Frater
- Department of Pathology and Immunology, Washington University in St. Louis, School of Medicine, St. Louis, MO, United States
| | - Jonathan R Brestoff
- Department of Pathology and Immunology, Washington University in St. Louis, School of Medicine, St. Louis, MO, United States
| | - Ronald Jackups
- Department of Pathology and Immunology, Washington University in St. Louis, School of Medicine, St. Louis, MO, United States
| | - Mark A Zaydman
- Department of Pathology and Immunology, Washington University in St. Louis, School of Medicine, St. Louis, MO, United States
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25
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Choudhuri S, Rainone F. Assessment of current clinical practice throughout the UK for the diagnosis and management of monoclonal gammopathy of renal significance. EJHAEM 2023; 4:410-418. [PMID: 37206284 PMCID: PMC10188446 DOI: 10.1002/jha2.658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 01/31/2023] [Indexed: 05/21/2023]
Abstract
Since the inception of the term monoclonal gammopathy of renal significance (MGRS) in 2012 by the International Kidney and Monoclonal Gammopathy Research Group, there have been no consensus guidelines specifically pertaining to the UK regarding to patient management. We aimed to identify both regional and cross-discipline variation in current clinical practice, to provide insight and rationale for a potential standardised pathway in the future. A national survey of 88 consultants from the disciplines of haematology and nephrology was conducted between June 2020 and July 2021. Agreement was evident for aspects of the diagnostic pathway, including presenting features likely to raise suspicion of MGRS and the most pertinent confounding factors to consider before renal biopsy. However, significant variability was identified in both the cohort of diagnostic tests used, as well as urinary work-up for patients with suspected MGRS. Treatment and monitoring frequency was also an aspect of management identified as variable. Despite differences in clinical practice across the UK, MGRS diagnosis was widely regarded to be the joint responsibility of both disciplines. The results provide an indication of inter-regional and interdisciplinary differences in practice, highlighting the need for improved awareness and standardised protocol for management of MGRS that applies to the UK population.
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26
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Natsuhara KH, Huang CY, Knoche J, Arora S, Chung A, Martin T, Wolf J, Wong SW, Shah N, Banerjee R. Significance of the pee-value: relevance of 24-hour urine studies for patients with myeloma. Leuk Lymphoma 2023:1-8. [PMID: 37096638 DOI: 10.1080/10428194.2023.2201365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Abstract
International Myeloma Working Group (IMWG) response criteria require refrigerated 24-hour urine specimens for most patients. However, given that serum free light chain testing has been shown to outperform 24-hour urine immunofixation as a prognostic marker, the importance of maintaining urine testing options or requirements within each level of IMWG response criteria has not been investigated. We analyzed responses to induction therapy for all transplant-eligible patients with multiple myeloma at our institution over a 3-year period using traditional versus 'urine-free' IMWG response criteria (where references to urine were removed from the descriptions for every depth of response). Of 281 evaluable patients, responses changed for only 4% of patients (95% confidence interval 2-7%) using urine-free criteria. Our results call into question the continued requirement for 24-hour urine measurements as part of IMWG response assessments for all patients. Research into the prognostic performance of urine-free IMWG criteria is ongoing.
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Affiliation(s)
- Kelsey H Natsuhara
- Division of Hematology & Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Chiung-Yu Huang
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Jennifer Knoche
- Division of Hematology & Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Shagun Arora
- Division of Hematology & Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Alfred Chung
- Division of Hematology & Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Thomas Martin
- Division of Hematology & Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Jeffrey Wolf
- Division of Hematology & Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Sandy W Wong
- Division of Hematology & Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Nina Shah
- Division of Hematology & Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Rahul Banerjee
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
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27
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Kropivsek K, Kachel P, Goetze S, Wegmann R, Festl Y, Severin Y, Hale BD, Mena J, van Drogen A, Dietliker N, Tchinda J, Wollscheid B, Manz MG, Snijder B. Ex vivo drug response heterogeneity reveals personalized therapeutic strategies for patients with multiple myeloma. NATURE CANCER 2023; 4:734-753. [PMID: 37081258 DOI: 10.1038/s43018-023-00544-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 03/17/2023] [Indexed: 04/22/2023]
Abstract
Multiple myeloma (MM) is a plasma cell malignancy defined by complex genetics and extensive patient heterogeneity. Despite a growing arsenal of approved therapies, MM remains incurable and in need of guidelines to identify effective personalized treatments. Here, we survey the ex vivo drug and immunotherapy sensitivities across 101 bone marrow samples from 70 patients with MM using multiplexed immunofluorescence, automated microscopy and deep-learning-based single-cell phenotyping. Combined with sample-matched genetics, proteotyping and cytokine profiling, we map the molecular regulatory network of drug sensitivity, implicating the DNA repair pathway and EYA3 expression in proteasome inhibitor sensitivity and major histocompatibility complex class II expression in the response to elotuzumab. Globally, ex vivo drug sensitivity associated with bone marrow microenvironmental signatures reflecting treatment stage, clonality and inflammation. Furthermore, ex vivo drug sensitivity significantly stratified clinical treatment responses, including to immunotherapy. Taken together, our study provides molecular and actionable insights into diverse treatment strategies for patients with MM.
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Affiliation(s)
- Klara Kropivsek
- Institute of Molecular Systems Biology, Department of Biology, ETH Zurich, Zurich, Switzerland
- Swiss Institute of Bioinformatics, Lausanne, Switzerland
| | - Paul Kachel
- Department of Medical Oncology and Hematology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Sandra Goetze
- Swiss Institute of Bioinformatics, Lausanne, Switzerland
- Institute of Translational Medicine, Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland
- Swiss Multi-Omics Center, PHRT-CPAC, ETH Zurich, Zurich, Switzerland
| | - Rebekka Wegmann
- Institute of Molecular Systems Biology, Department of Biology, ETH Zurich, Zurich, Switzerland
- Swiss Institute of Bioinformatics, Lausanne, Switzerland
| | - Yasmin Festl
- Institute of Molecular Systems Biology, Department of Biology, ETH Zurich, Zurich, Switzerland
- Swiss Institute of Bioinformatics, Lausanne, Switzerland
| | - Yannik Severin
- Institute of Molecular Systems Biology, Department of Biology, ETH Zurich, Zurich, Switzerland
- Swiss Institute of Bioinformatics, Lausanne, Switzerland
| | - Benjamin D Hale
- Institute of Molecular Systems Biology, Department of Biology, ETH Zurich, Zurich, Switzerland
- Swiss Institute of Bioinformatics, Lausanne, Switzerland
| | - Julien Mena
- Institute of Molecular Systems Biology, Department of Biology, ETH Zurich, Zurich, Switzerland
- Swiss Institute of Bioinformatics, Lausanne, Switzerland
| | - Audrey van Drogen
- Swiss Institute of Bioinformatics, Lausanne, Switzerland
- Institute of Translational Medicine, Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland
- Swiss Multi-Omics Center, PHRT-CPAC, ETH Zurich, Zurich, Switzerland
| | - Nadja Dietliker
- Department of Medical Oncology and Hematology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Joëlle Tchinda
- Pediatric Oncology, Children's Research Centre, University Children's Hospital Zurich, Zurich, Switzerland
| | - Bernd Wollscheid
- Swiss Institute of Bioinformatics, Lausanne, Switzerland
- Institute of Translational Medicine, Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland
- Swiss Multi-Omics Center, PHRT-CPAC, ETH Zurich, Zurich, Switzerland
| | - Markus G Manz
- Department of Medical Oncology and Hematology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Comprehensive Cancer Center Zurich (CCCZ), Zurich, Switzerland
| | - Berend Snijder
- Institute of Molecular Systems Biology, Department of Biology, ETH Zurich, Zurich, Switzerland.
- Swiss Institute of Bioinformatics, Lausanne, Switzerland.
- Comprehensive Cancer Center Zurich (CCCZ), Zurich, Switzerland.
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28
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Karam S, Haidous M, Dalle IA, Dendooven A, Moukalled N, Van Craenenbroeck A, Bazarbachi A, Sprangers B. Monoclonal gammopathy of renal significance: Multidisciplinary approach to diagnosis and treatment. Crit Rev Oncol Hematol 2023; 183:103926. [PMID: 36736510 DOI: 10.1016/j.critrevonc.2023.103926] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 01/13/2023] [Accepted: 01/20/2023] [Indexed: 02/05/2023] Open
Abstract
Monoclonal gammopathy of renal significance (MGRS) is a hemato-nephrological term referring to a heterogeneous group of kidney disorders characterized by direct or indirect kidney injury caused by a monoclonal immunoglobulin (MIg) produced by a B cell or plasma cell clone that does not meet current hematologic criteria for therapy. MGRS-associated kidney diseases are diverse and can result in the development of end stage kidney disease (ESKD). The diagnosis is typically made by nephrologists through a kidney biopsy. Many distinct pathologies have been identified and they are classified based on the site or composition of the deposited Mig, or according to histological and ultrastructural findings. Therapy is directed towards the identified underlying clonal population and treatment decisions should be coordinated between hematologists and nephrologists in a multidisciplinary fashion, depend on the type of MGRS, the degree of kidney function impairment and the risk of progression to ESKD.
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Affiliation(s)
- Sabine Karam
- Division of Nephrology and Hypertension, University of Minnesota, Minneapolis, MN, United States
| | - Mohammad Haidous
- Department of Medicine, Saint Vincent Charity Medical Center, Cleveland, OH, United States
| | - Iman Abou Dalle
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Amélie Dendooven
- Department of Pathology, University Hospital Ghent, Ghent, Belgium
| | - Nour Moukalled
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Amaryllis Van Craenenbroeck
- Department of Microbiology, Immunology and Transplantation, Laboratory of Nephrology, KU Leuven, Leuven, Belgium; Division of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Ali Bazarbachi
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon; Department of Anatomy, Cell Biology and Physiological Sciences, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ben Sprangers
- Biomedical Research Institute, Department of Immunology and Infection, University Hasselt, Diepenbeek, Belgium; Department of Nephrology, Ziekenhuis Oost-Limburg, Genk, Belgium.
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29
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Absmeier RM, Rottenaicher GJ, Svilenov HL, Kazman P, Buchner J. Antibodies gone bad - the molecular mechanism of light chain amyloidosis. FEBS J 2023; 290:1398-1419. [PMID: 35122394 DOI: 10.1111/febs.16390] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 01/19/2022] [Accepted: 02/03/2022] [Indexed: 12/19/2022]
Abstract
Light chain amyloidosis (AL) is a systemic disease in which abnormally proliferating plasma cells secrete large amounts of mutated antibody light chains (LCs) that eventually form fibrils. The fibrils are deposited in various organs, most often in the heart and kidney, and impair their function. The prognosis for patients diagnosed with AL is generally poor. The disease is set apart from other amyloidoses by the huge number of patient-specific mutations in the disease-causing and fibril-forming protein. The molecular mechanisms that drive the aggregation of mutated LCs into fibrils have been enigmatic, which hindered the development of efficient diagnostics and therapies. In this review, we summarize our current knowledge on AL amyloidosis and discuss open issues.
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Affiliation(s)
- Ramona M Absmeier
- Center for Functional Protein Assemblies and Department of Chemistry, Technische Universität München, Garching, Germany
| | - Georg J Rottenaicher
- Center for Functional Protein Assemblies and Department of Chemistry, Technische Universität München, Garching, Germany
| | - Hristo L Svilenov
- Center for Functional Protein Assemblies and Department of Chemistry, Technische Universität München, Garching, Germany
| | - Pamina Kazman
- Center for Functional Protein Assemblies and Department of Chemistry, Technische Universität München, Garching, Germany
| | - Johannes Buchner
- Center for Functional Protein Assemblies and Department of Chemistry, Technische Universität München, Garching, Germany
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30
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Noori S, Wijnands C, Langerhorst P, Bonifay V, Stingl C, Touzeau C, Corre J, Perrot A, Moreau P, Caillon H, Luider TM, Dejoie T, Jacobs JFM, van Duijn MM. Dynamic monitoring of myeloma minimal residual disease with targeted mass spectrometry. Blood Cancer J 2023; 13:30. [PMID: 36828828 PMCID: PMC9957984 DOI: 10.1038/s41408-023-00803-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 02/10/2023] [Accepted: 02/16/2023] [Indexed: 02/26/2023] Open
Affiliation(s)
- Somayya Noori
- Department of Neurology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Charissa Wijnands
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Pieter Langerhorst
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Christoph Stingl
- Department of Neurology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Jill Corre
- Unite de Genomique du Myelome, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | - Aurore Perrot
- Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | | | - Hélène Caillon
- Biochemistry Laboratory, Hospital of Nantes, Nantes, France
| | - Theo M Luider
- Department of Neurology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Thomas Dejoie
- Biochemistry Laboratory, Hospital of Nantes, Nantes, France
| | - Joannes F M Jacobs
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Martijn M van Duijn
- Department of Neurology, Erasmus University Medical Center, Rotterdam, the Netherlands.
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Weight-Based Bisphosphonate Administration for Multiple Myeloma Patients and the Risks of Skeletal Complications. J Clin Med 2023; 12:jcm12041637. [PMID: 36836169 PMCID: PMC9961848 DOI: 10.3390/jcm12041637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 01/31/2023] [Accepted: 02/15/2023] [Indexed: 02/22/2023] Open
Abstract
High-dose bisphosphonate for multiple myeloma patients might elevate risks of skeletal complications earlier than general expectations. This study aims to find incidences of atypical femoral fracture (AFF) and medication-related osteonecrosis of the jaw (MRONJ), elucidate their risk factors, and suggest cut-off values for the safer dosing of high-dose bisphosphonate treatment. By using the clinical data warehouse of a single institute, retrospective cohort data of multiple myeloma-diagnosed patients with high-dose bisphosphonate (pamidronate or zoledronate) treatment from 2009 to 2019 was extracted. Among 644 patients, the incidence of prominent AFF requiring surgery was 0.93% (6/644) and MRONJ was diagnosed in 11.8% (76/644) of the study population. For both AFF and MRONJ, the total potency-weighted sum of total dose per body weight (OR = 1.010, p = 0.005) were significant on logistic regression. Cutoffs of the potency-weighted total dose (mg) per body weight (kg) for AFF and MRONJ were 77.00 and 57.70 mg/kg, respectively. After roughly one year of treatment with high-dose zoledronate (about four years for pamidronate), an earlier thorough re-evaluation of skeletal complications should be taken. Body weight adjustments for accumulative dose calculation in terms of permissible dosing should be taken into consideration.
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32
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Pearson DS, McEvoy DS, Murali MR, Dighe AS. Use of Clinical Decision Support to Improve the Laboratory Evaluation of Monoclonal Gammopathies. Am J Clin Pathol 2023; 159:192-204. [PMID: 36622340 DOI: 10.1093/ajcp/aqac151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 11/03/2022] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES There is considerable variation in ordering practices for the initial laboratory evaluation of monoclonal gammopathies (MGs) despite clear society guidelines to include serum free light chain (sFLC) testing. We assessed the ability of a clinical decision support (CDS) alert to improve guideline compliance and analyzed its clinical impact. METHODS We designed and deployed a targeted CDS alert to educate and prompt providers to order an sFLC assay when ordering serum protein electrophoresis (SPEP) testing. RESULTS The alert was highly effective at increasing the co-ordering of SPEP and sFLC testing. Preimplementation, 62.8% of all SPEP evaluations included sFLC testing, while nearly 90% of evaluations included an sFLC assay postimplementation. In patients with no prior sFLC testing, analysis of sFLC orders prompted by the alert led to the determination that 28.9% (800/2,769) of these patients had an abnormal κ/λ ratio. In 452 of these patients, the sFLC assay provided the only laboratory evidence of a monoclonal protein. Moreover, within this population, there were numerous instances of new diagnoses of multiple myeloma and other MGs. CONCLUSIONS The CDS alert increased compliance with society guidelines and improved the diagnostic evaluation of patients with suspected MGs.
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Affiliation(s)
- Daniel S Pearson
- Department of Pathology Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - Mandakolathur R Murali
- Department of Pathology Medicine, Massachusetts General Hospital, Boston, MA, USA.,Medicine, Massachusetts General Hospital, Boston, MA, USAand
| | - Anand S Dighe
- Department of Pathology Medicine, Massachusetts General Hospital, Boston, MA, USA.,Massachuscetts General Brigham, Somerville, MA, USA
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Hegen H, Arrambide G, Gnanapavan S, Kaplan B, Khalil M, Saadeh R, Teunissen C, Tumani H, Villar LM, Willrich MAV, Zetterberg H, Deisenhammer F. Cerebrospinal fluid kappa free light chains for the diagnosis of multiple sclerosis: A consensus statement. Mult Scler 2023; 29:182-195. [PMID: 36527368 PMCID: PMC9925908 DOI: 10.1177/13524585221134217] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Cerebrospinal fluid (CSF) analysis is of utmost importance for diagnosis and differential diagnosis of patients with suspected multiple sclerosis (MS). Evidence of intrathecal immunoglobulin G (IgG) synthesis proves the inflammatory nature of the disease, increases diagnostic certainty and substitutes for dissemination in time according to current diagnostic criteria. The gold standard to determine intrathecal IgG synthesis is the detection of CSF-restricted oligoclonal bands (OCBs). However, advances in laboratory methods brought up κ-free light chains (FLCs) as a new biomarker, which are produced in excess over intact immunoglobulins and accumulate in CSF in the case of central nervous system-derived inflammation. Overwhelming evidence showed a high diagnostic accuracy of intrathecal κ-FLC synthesis in MS with sensitivity and specificity of approximately 90% similar to OCB. κ-FLCs have advantages as its detection is fast, easy, cost-effective, reliable, rater-independent and returning quantitative results which might also improve the value of predicting MS disease activity. An international panel of experts in MS and CSF diagnostics developed a consensus of all participants. Six recommendations are given for establishing standard CSF evaluation in patients suspected of having MS. The panel recommended to include intrathecal κ-FLC synthesis in the next revision of MS diagnostic criteria as an additional tool to measure intrathecal immunoglobulin synthesis.
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Affiliation(s)
- Harald Hegen
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Georgina Arrambide
- Servei de Neurologia-Neuroimmunologia, Centre d'Esclerosi Múltiple de Catalunya (Cemcat), Vall d'Hebron Hospital Universitari, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Sharmilee Gnanapavan
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Batia Kaplan
- Laboratory of Hematology, Sheba Medical Center, Ramat Gan, Israel
| | - Michael Khalil
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Ruba Saadeh
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA/Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Charlotte Teunissen
- Neurochemistry Laboratory, Department of Clinical Chemistry, Amsterdam Neuroscience, Program Neuroinflammation, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Hayrettin Tumani
- CSF Laboratory, Department of Neurology, University of Ulm, Ulm, Germany
| | - Luisa Maria Villar
- Biostatistics Unit, Department of Immunology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden/Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Gothenburg, Sweden/Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, London, UK/UK Dementia Research Institute at UCL, London, UK/Hong Kong Center for Neurodegenerative Diseases, Hong Kong, China
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Das N, Dahiya M, Gupta R, Kumar L, Rani L, Gupta A, Farswan A, Sharma A, Sharma OD. Graded Depth of Response and Neoplastic Plasma Cell Index as Indicators of Survival Outcomes in Patients With Multiple Myeloma Following Autologous Stem Cell Transplant. Am J Clin Pathol 2023; 159:69-80. [PMID: 36317501 DOI: 10.1093/ajcp/aqac129] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 09/13/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES With a substantial number of patients with multiple myeloma (MM) experiencing disease relapse, the quest for more sensitive methods to assess deeper responses indicative of cure continues. METHODS In this prospective analysis of 170 patients with MM at day 100 after autologous stem cell transplant, we evaluated the predictive value of conventional response, measurable residual disease (MRDTOTAL: the aberrant percentage of plasma cells [PC%] among total bone marrow cells), and neoplastic plasma cell index scores (NPCI: the aberrant PC% of total PCs). RESULTS Significantly better progression-free survival (PFS) and overall survival (OS) were observed with deepening conventional response. Conventional response-based stratification within the MRD-positive and MRD-negative subgroups showed a significantly higher PFS (hazard ratio [HR], 3.11; P < .005) and OS (HR, 3.08; P = .01) in the conventional response-positive/MRD-positive group compared with the conventional response-negative/MRD-positive group. Using K-adaptive partitioning to find the optimum threshold for MRD, patients achieving less than 0.001% MRDTOTAL had superior PFS (MRDTOTAL 0.001% to <0.1%: HR, 6.66, P < .005; MRDTOTAL ≥0.1%: HR, 11.52, P < .005) and OS (MRDTOTAL 0.001% to <0.1%: HR, 5.3, P < .05; MRDTOTAL ≥0.1%: HR = 9.21, P < .005). The C index and Akaike information criterion metrics demonstrated the superior performance of the NPCI compared with MRDTOTAL in predicting treatment outcome. CONCLUSIONS Progressive deepening of response, conventional as well as MRD, correlates with superior survival outcomes. The NPCI proved to be a superior determinant of survival and can be explored as a better statistic than MRD.
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Affiliation(s)
- Nupur Das
- Laboratory Oncology Unit, Dr. B.R.A. IRCH, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Meetu Dahiya
- Laboratory Oncology Unit, Dr. B.R.A. IRCH, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Ritu Gupta
- Laboratory Oncology Unit, Dr. B.R.A. IRCH, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Lalit Kumar
- Department of Medical Oncology, Dr. B.R.A. IRCH, AIIMS, New Delhi, India
| | - Lata Rani
- Laboratory Oncology Unit, Dr. B.R.A. IRCH, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Anubha Gupta
- SBI Lab, Department of ECE, Indraprastha Institute of Information Technology, New Delhi, India
| | - Akanksha Farswan
- SBI Lab, Department of ECE, Indraprastha Institute of Information Technology, New Delhi, India
| | - Atul Sharma
- Department of Medical Oncology, Dr. B.R.A. IRCH, AIIMS, New Delhi, India
| | - Om Dutt Sharma
- Laboratory Oncology Unit, Dr. B.R.A. IRCH, All India Institute of Medical Sciences (AIIMS), New Delhi, India
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Claveau JS, Murray DL, Dispenzieri A, Kapoor P, Binder M, Buadi F, Dingli D, Fonder A, Gertz M, Gonsalves W, Hayman S, Hobbs M, Hwa YL, Kourelis T, Lacy M, Leung N, Lin Y, Warsame R, Kyle RA, Rajkumar V, Kumar SK. Value of bone marrow examination in determining response to therapy in patients with multiple myeloma in the context of mass spectrometry-based M-protein assessment. Leukemia 2023; 37:1-4. [PMID: 36482129 DOI: 10.1038/s41375-022-01779-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 11/21/2022] [Accepted: 11/23/2022] [Indexed: 12/14/2022]
Affiliation(s)
| | - David L Murray
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
- Department of Laboratory, Mayo Clinic, Rochester, MN, USA
| | | | | | - Moritz Binder
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Francis Buadi
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - David Dingli
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Amie Fonder
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Morie Gertz
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Miriam Hobbs
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Yi Lisa Hwa
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | | | - Martha Lacy
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Nelson Leung
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Yi Lin
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Rahma Warsame
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Robert A Kyle
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | | | - Shaji K Kumar
- Division of Hematology, Mayo Clinic, Rochester, MN, USA.
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36
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Naum R, Gwathmey KG. Autoimmune polyneuropathies. HANDBOOK OF CLINICAL NEUROLOGY 2023; 195:587-608. [PMID: 37562888 DOI: 10.1016/b978-0-323-98818-6.00004-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
The autoimmune peripheral neuropathies with prominent motor manifestations are a diverse collection of unusual peripheral neuropathies that are appreciated in vast clinical settings. This chapter highlights the most common immune-mediated, motor predominant neuropathies excluding acute, and chronic inflammatory demyelinating polyradiculoneuropathy (AIDP and CIDP, respectively). Other acquired demyelinating neuropathies such as distal CIDP and multifocal motor neuropathy will be covered. Additionally, the radiculoplexus neuropathies, resulting from microvasculitis-induced injury to nerve roots, plexuses, and nerves, including diabetic and nondiabetic lumbosacral radiculoplexus neuropathy and neuralgic amyotrophy (i.e., Parsonage-Turner syndrome), will be included. Finally, the motor predominant peripheral neuropathies encountered in association with rheumatological disease, particularly Sjögren's syndrome and rheumatoid arthritis, are covered. Early recognition of these distinct motor predominant autoimmune neuropathies and initiation of immunomodulatory and immunosuppressant treatment likely result in improved outcomes.
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Affiliation(s)
- Ryan Naum
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, United States
| | - Kelly Graham Gwathmey
- Neuromuscular Division, Department of Neurology, Virginia Commonwealth University, Richmond, VA, United States.
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37
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Arneth B, Kraus J. The Use of Kappa Free Light Chains to Diagnose Multiple Sclerosis. Medicina (B Aires) 2022; 58:medicina58111512. [PMID: 36363469 PMCID: PMC9698214 DOI: 10.3390/medicina58111512] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 10/10/2022] [Accepted: 10/20/2022] [Indexed: 11/06/2022] Open
Abstract
Background: The positive implications of using free light chains in diagnosing multiple sclerosis have increasingly gained considerable interest in medical research and the scientific community. It is often presumed that free light chains, particularly kappa and lambda free light chains, are of practical use and are associated with a higher probability of obtaining positive results compared to oligoclonal bands. The primary purpose of the current paper was to conduct a systematic review to assess the up-to-date methods for diagnosing multiple sclerosis using kappa and lambda free light chains. Method: An organized literature search was performed across four electronic sources, including Google Scholar, Web of Science, Embase, and MEDLINE. The sources analyzed in this systematic review and meta-analysis comprise randomized clinical trials, prospective cohort studies, retrospective studies, controlled clinical trials, and systematic reviews. Results: The review contains 116 reports that includes 1204 participants. The final selection includes a vast array of preexisting literature concerning the study topic: 35 randomized clinical trials, 21 prospective cohort studies, 19 retrospective studies, 22 controlled clinical trials, and 13 systematic reviews. Discussion: The incorporated literature sources provided integral insights into the benefits of free light chain diagnostics for multiple sclerosis. It was also evident that the use of free light chains in the diagnosis of clinically isolated syndrome (CIS) and multiple sclerosis is relatively fast and inexpensive in comparison to other conventional state-of-the-art diagnostic methods, e.g., using oligoclonal bands (OCBs).
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Affiliation(s)
- Borros Arneth
- Institute of Laboratory Medicine and Pathobiochemistry, Molecular Diagnostics, Justus Liebig University, Feulgenstr. 12, 35392 Giessen, Germany
- Correspondence:
| | - Jörg Kraus
- Department of Laboratory Medicine, Paracelsus Medical University and Salzburger Landeskliniken, Strubergasse 21, 5020 Salzburg, Austria
- Department of Neurology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Bergische Landstraße 2, 40629 Düsseldorf, Germany
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38
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Singh MK, Paswan V, Dwivedi S, Gupta R, Rahman K, Chandra D, Yadav S, Gupta A, Kashyap R, Nityanand S. An Analysis of M-protein in Plasma cell Dyscrasia Patients Identifies that IgG Lambda Subtype is More Commonly Associated with Normal Serum Free Light Chain (SFLC) Ratio. Indian J Clin Biochem 2022; 37:466-472. [PMID: 36262785 PMCID: PMC9573842 DOI: 10.1007/s12291-021-01017-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 11/17/2021] [Indexed: 10/26/2022]
Abstract
The determination of monoclonal protein (M-protein) by SPE, IFE and SFLC assay is fundamental in the diagnosis of Plasma cell proliferative disorder (PCPD). In the present study, we seek to assess the diagnostic performance and concordance of these three techniques in un-treated PCPD patients. All new patients with dysproteinemia and/or suspected PCPD were included in this retrospective observational study. The baseline parameters were retrieved from electronic medical records. SPE was performed on gel electrophoresis system; monoclonal component was identified by IFE. SFLC assays were performed by nephelometry using a latex-enhanced immunoassay. Total 402 patients of PCPD were included (10.9% of MGUS/SMM and 89.1% of multiple myeloma). The combination of SPE + rSFLC (ratio of kappa/lambda light chain) and SPE + IFE + rSFLC was able to detect M-protein across all subgroups of patients. In 61 patients, rSFLC values were within normal range (54.5% of MGUS/SMM and 10.3% of MM) and was more commonly seen with IgG lambda M-protein (57.4% vs. all-others). The median dFLC value, among these patients, was higher for MM than MGUS/SMM patients (23.8 vs. 14.4 mg/L, respectively). The combination of SPE and rSFLC can be reliably used to detect M-protein in PCPD patients. In a small subgroup of MM patients, despite the presence of an intact immunoglobulin (M-protein), the rSFLC is not abnormal. Historically, these patients should respond better to treatment. However, a further follow-up analysis with more number of such patients would be advantageous for better understanding.
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Affiliation(s)
- Manish K. Singh
- Department of Hematology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, U.P. 226014 India
| | - Vinita Paswan
- Department of Hematology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, U.P. 226014 India
| | - Sonal Dwivedi
- Department of Hematology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, U.P. 226014 India
| | - Ruchi Gupta
- Department of Hematology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, U.P. 226014 India
| | - Khaliqur Rahman
- Department of Hematology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, U.P. 226014 India
| | - Dinesh Chandra
- Department of Hematology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, U.P. 226014 India
| | - Sanjeev Yadav
- Department of Hematology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, U.P. 226014 India
| | - Anshul Gupta
- Department of Hematology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, U.P. 226014 India
| | - Rajesh Kashyap
- Department of Hematology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, U.P. 226014 India
| | - Soniya Nityanand
- Department of Hematology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, U.P. 226014 India
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A method to obtain purified free light chain monomers and dimers from urine samples of patients with multiple myeloma. Immunol Res 2022; 70:844-849. [DOI: 10.1007/s12026-022-09314-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 08/20/2022] [Indexed: 11/05/2022]
Abstract
AbstractAntibody light chains are synthesized in excess by plasma cells, and this excess can be secreted into biological fluids as dimers or monomers in various proportions. Structural differences between monomers or dimers of free light chains (FLC) can affect their biological functions and possibly their pathogenicity. They also may exhibit differential immune reactivity, perhaps explaining discrepant quantifications when measured by different immunoreagents. Having purified FLC monomers and dimers available can be useful for studying their properties. Here we propose a simple preparatory procedure to purify FLC monomers and dimers from urine samples of patients with plasma cell disorders. Two representative urine samples containing lambda or kappa FLC were loaded into a nonreducing sodium dodecyl sulfate–polyacrylamide gel electrophoresis (SDS-PAGE). The gel strips containing separate monomers and dimers were excised, electroeluted, and the FLC recovered. The FLC were recovered from SDS-PAGE gel in sufficient amounts to be quantified by UV and two automated nephelometric assays immunochemical. The procedure was found to be simple, reproducible, and with a high yield, thus offering the opportunity to compare different assays. Not all urine samples are suitable for this procedure, but this approach allows for the purification of FLC monomers and dimers from many selected urine samples which maintain their oligomeric organization.
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40
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Defining new reference intervals for serum free light chains in individuals with chronic kidney disease: Results of the iStopMM study. Blood Cancer J 2022; 12:133. [PMID: 36100605 PMCID: PMC9470548 DOI: 10.1038/s41408-022-00732-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/31/2022] [Accepted: 09/01/2022] [Indexed: 11/08/2022] Open
Abstract
Serum free light chain (FLC) concentration is greatly affected by kidney function. Using a large prospective population-based cohort, we aimed to establish a reference interval for FLCs in persons with chronic kidney disease (CKD). A total of 75422 participants of the iStopMM study were screened with serum FLC, serum protein electrophoresis and immunofixation. Estimated glomerular filtration rate (eGFR) was calculated from serum creatinine. Central 99% reference intervals were determined, and 95% confidence intervals calculated. Included were 6461 (12%) participants with measured FLCs, eGFR < 60 mL/min/1.73 m2, not receiving renal replacement therapy, and without evidence of monoclonality. Using current reference intervals, 60% and 21% had kappa and lambda FLC values outside the normal range. The FLC ratio was outside standard reference interval (0.26-1.65) in 9% of participants and outside current kidney reference interval (0.37-3.10) in 0.7%. New reference intervals for FLC and FLC ratio were established. New reference intervals for the FLC ratio were 0.46-2.62, 0.48-3.38, and 0.54-3.30 for eGFR 45-59, 30-44, and < 30 mL/min/1.73 m2 groups, respectively. The crude prevalence of LC-MGUS in CKD patients was 0.5%. We conclude that current reference intervals for FLC and FLC ratio are inaccurate in CKD patients and propose new eGFR based reference intervals to be implemented.
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41
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Cho H, Lee JJ, Kim M, Oh EJ, Kim Y, Chae H. Laboratory characteristics of IgG4-related disease: A retrospective study from a single tertiary medical center. Medicine (Baltimore) 2022; 101:e30387. [PMID: 36086780 PMCID: PMC10980491 DOI: 10.1097/md.0000000000030387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/22/2022] [Indexed: 11/25/2022] Open
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is an immune-mediated fibroinflammatory condition with unique histopathological features that can affect most organs, making diagnosis challenging. This study characterized detailed laboratory characteristics of IgG4-RD. Baseline clinical and laboratory features of 33 patients with IgG4-RD were reviewed, including serum IgG4 concentrations, serum free light chains (sFLCs), IgGĸ- and IgGλ-heavy/light chains (HLCs), capillary serum protein electrophoresis (SPE), and immunofixation electrophoresis (IFE) of IgG4 subclass. The cohort of 33 patients showed male predominance (94%), with 8 (24%) exhibiting multiple organ involvement. Most patients (88%) had an elevated IgG4 concentration, and 67% had elevated erythrocyte sedimentation rate and IgE levels. Median IgG4 concentration at baseline was significantly higher in patients with >2 organs involved than those with ≤2. Furthermore, erythrocyte sedimentation rate was significantly correlated with serum IgG4 concentrations at baseline. SPE results demonstrated polyclonal gammopathy in most patients. Half of the patients had an increased κ/λ sFLC ratio, 42% had an increased IgGκ/IgGλ HLC ratio. Most patients exhibited hypergammaglobulinemia in the anodal end of the ɤ region on SPE. This study describes detailed laboratory features of IgG4-RD. Although none of these tests are considered diagnostically sufficient by itself, the provided laboratory characteristics can increase awareness of this disorder and help distinguish it from other IgG4-RD mimics.
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Affiliation(s)
- Hanwool Cho
- Department of Laboratory Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jeong Joong Lee
- Department of Laboratory Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Myungshin Kim
- Department of Laboratory Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Eun-Jee Oh
- Department of Laboratory Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yonggoo Kim
- Department of Laboratory Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyojin Chae
- Department of Laboratory Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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42
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Singh G, Whitaker BM, Wu AHB, Xu H, Bollag RJ. Serum Free Light Chain Quantification Testing: Comparison of Two Methods for Disease Monitoring. J Appl Lab Med 2022; 7:1290-1301. [DOI: 10.1093/jalm/jfac068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 07/01/2022] [Indexed: 11/13/2022]
Abstract
Abstract
Background
Levels of free immunoglobulin light chains in serum and urine are a sensitive measure of dysregulated immunoglobulin synthesis. The development of an assay for free light chains in serum was a major advance in laboratory testing for monoclonal gammopathies. The original assay by The Binding Site, called Freelite®, has been in common use in laboratory monitoring of monoclonal gammopathies. Two clinical entities, myeloma-defining condition and light chain-predominant multiple myeloma, rely on quantitative measurements of serum free light chains.
Methods
Using polyclonal antisera specific to free light chains, Diazyme Laboratories developed a latex immunoturbidimetric assay for quantification of human kappa and lambda serum free light chains. We evaluated the Diazyme assay by comparing the results of kappa and lambda free light chain quantification, and kappa/lambda ratio with the results on the same specimens by the Freelite method. We also compared the correlation of the 2 methods to evaluate response to treatment and to changes in clinical status of patients with multiple myeloma.
Results
The results of Freelite and Diazyme methods are comparable. There was no statistically significant difference in the performance of the 2 assays for quantification of light chains, kappa/lambda ratio, or correlation of clinical parameters from patients with multiple myeloma at various stages of monitoring the disease in 2 geographically diverse laboratory and clinical environments.
Conclusions
The Diazyme method is comparable to Freelite and provides an opportunity to add the test to front-end automation and improvement in efficiency of the assay.
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Affiliation(s)
- Gurmukh Singh
- Department of Pathology, Medical College of Georgia at Augusta University , Augusta, GA 30912 , USA
| | - Brooke M Whitaker
- Department of Pathology, Medical College of Georgia at Augusta University , Augusta, GA 30912 , USA
| | - Alan H B Wu
- Department of Laboratory Medicine, University of California at San Francisco, 1001 Potrero Ave., SFGH 5 , San Francisco CA 94110 , USA
| | - Hongyan Xu
- Department of Population Health Sciences, Medical College of Georgia at Augusta University , Augusta, GA 30912 , USA
| | - Roni J Bollag
- Department of Pathology, Medical College of Georgia at Augusta University , Augusta, GA 30912 , USA
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Calorimetric Markers for Detection and Monitoring of Multiple Myeloma. Cancers (Basel) 2022; 14:cancers14163884. [PMID: 36010876 PMCID: PMC9405568 DOI: 10.3390/cancers14163884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/05/2022] [Accepted: 08/09/2022] [Indexed: 11/17/2022] Open
Abstract
Simple Summary This review highlights the potential of differential scanning calorimetry for multiple myeloma diagnosis and monitoring of the treatment outcome. The thermodynamic signatures of blood sera from patients with multiple myeloma are strongly dependent on the concentration and isotype of the secreted monoclonal immunoglobulins. Mathematical methods developed to analyze the biocalorimetry data and distinguish “diseased” from “healthy” thermogram to stratify plasma calorimetric profiles and determine specific interrelations between calorimetric and biochemical/clinical data are discussed. Abstract This review summarizes data obtained thus far on the application of differential scanning calorimetry (DSC) for the analysis of blood sera from patients diagnosed with multiple myeloma (MM) with the secretion of the most common isotypes of monoclonal proteins (M-proteins), free light chains (FLC) and non-secretory MM, as well as Waldenström macroglobulinemia and the premalignant state monoclonal gammopathy of undetermined significance. The heterogeneous nature of MM is reflected in the thermal stability profiles of the blood serum proteome of MM patients found to depend on both the level and the isotype of the secreted M-proteins or FLC. Common calorimetric markers feature the vast majority of the different myeloma types, i.e., stabilization of the major serum proteins and decrease in the albumin/globulin heat capacity ratio. A unique calorimetric fingerprint of FLC molecules forming amorphous aggregates is the low-temperature transition centered at 57 °C for a calorimetric set of FLC MM and at 46–47 °C for a single FLC MM case for which larger aggregates were formed. The calorimetric assay proved particularly advantageous for non-secretory MM and is thus a suitable tool for monitoring such patients during treatment courses. Thus, DSC provides a promising blood-based approach as a complementary tool for MM detection and monitoring.
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[The consensus of the diagnosis of monoclonal gammopathies of clinical significance in China (2022)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2022; 43:631-635. [PMID: 36709146 PMCID: PMC9593018 DOI: 10.3760/cma.j.issn.0253-2727.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Yu H, He D, Zhang Q, Cao B, Liu W, Wu Y. Case Report: Monoclonal Gammopathies of Clinical Significance-Associated Myopathy: A Case-Based Review. Front Oncol 2022; 12:914379. [PMID: 35912259 PMCID: PMC9333131 DOI: 10.3389/fonc.2022.914379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 05/24/2022] [Indexed: 12/27/2022] Open
Abstract
Monoclonal gammopathies of clinical significance (MGCS)-associated myopathy is a group of muscular MGCS-based rare manifestations. It mainly includes amyloid light chain (AL) amyloidosis and sporadic late-onset nemaline myopathy with monoclonal gammopathy of undetermined significance. When myopathy manifests as the initial or sole clinical symptom, it can often be delayed or misdiagnosed as other myopathies. We report the case of a 60-year-old man who initially presented with fatigue and muscle weakness of the symmetric proximal lower limbs. Muscle biopsy did not reveal mononuclear cell infiltration, atrophy, necrosis, or positive Congo red staining results. The results of serum protein electrophoresis and immunofixation electrophoresis were negative. No specific diagnosis was established. After 1 year, the patient was diagnosed with AL amyloidosis after myocardial and fat pad biopsies were performed and myopathy was diagnosed as AL amyloidosis-associated myopathy after reassessment. The patient received CyBorD regime chemotherapy and achieved hematological and organ remission. Therefore, we reviewed the clinical and pathological manifestations of MGCS-associated myopathies. Based on published articles and the present case, we conclude that comprehensive screening for MGCS in unexplained myopathy is essential to avoid misdiagnosis or delayed diagnosis.
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Affiliation(s)
- Hongbin Yu
- Department of Hematology, West China Hospital, Sichuan University, Chengdu, China
| | - Du He
- Department of Pathology, West China Hospital, Sichuan University, Chengdu, China
| | - Qing Zhang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Bei Cao
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Weiping Liu
- Department of Pathology, West China Hospital, Sichuan University, Chengdu, China
| | - Yu Wu
- Department of Hematology, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Yu Wu,
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Serum Free Light-Chain Ratio at Diagnosis Is Associated with Early Renal Damage in Multiple Myeloma: A Case Series Real-World Study. Biomedicines 2022; 10:biomedicines10071657. [PMID: 35884962 PMCID: PMC9313319 DOI: 10.3390/biomedicines10071657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 06/29/2022] [Accepted: 07/08/2022] [Indexed: 11/17/2022] Open
Abstract
The serum free light-chain (FLC) ratio is a sensitive tool for the differential diagnosis of plasma cell disorders and is biomarker of multiple myeloma (MM) progression from premalignant conditions. Here, we investigate the potential role of FLC ratio at diagnosis in identifying early renal damage in MM patients and other correlations with clinical, laboratory, and molecular findings. A total of 34 MM patients who had undergone autologous stem cell transplantation were included in this retrospective case series study, and FLC quantification was performed with nephelometric assays. In our study, sFLC ratio was significantly associated with light-chain MM and β-2 microglobulin levels, likely indicating a high disease burden at diagnosis, especially in patients without heavy chain M-protein at serum electrophoresis. Moreover, the sFLC ratio was inversely correlated with glomerular filtration rate, possibly identifying early renal damage in MM patients. Our preliminary results confirm the importance of early sFLC evaluation, especially in patients with the light-chain MM type and low disease burden, to minimize the risk of late renal failure.
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Ferreira BV, Carneiro EA, Pestana C, Barahona F, Caetano J, Lopes R, Lúcio P, Neves M, Beck HC, Carvalho AS, Matthiesen R, Costa-Silva B, João C. Patient-Derived Extracellular Vesicles Proteins as New Biomarkers in Multiple Myeloma - A Real-World Study. Front Oncol 2022; 12:860849. [PMID: 35800053 PMCID: PMC9254863 DOI: 10.3389/fonc.2022.860849] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 05/16/2022] [Indexed: 12/14/2022] Open
Abstract
Multiple myeloma (MM) is a hematological malignancy of clonal antibody–secreting plasma cells (PCs). MM diagnosis and risk stratification rely on bone marrow (BM) biopsy, an invasive procedure prone to sample bias. Liquid biopsies, such as extracellular vesicles (EV) in peripheral blood (PB), hold promise as new minimally invasive tools. Real-world studies analyzing patient-derived EV proteome are rare. Here, we characterized a small EV protein content from PB and BM samples in a cohort of 102 monoclonal gammopathies patients routinely followed in the clinic and 223 PB and 111 BM samples were included. We investigated whether EV protein and particle concentration could predict an MM patient prognosis. We found that a high EV protein/particle ratio, or EV cargo >0.6 µg/108 particles, is related to poorer survival and immune dysfunction. These results were supported at the protein level by mass spectrometry. We report a set of PB EV-proteins (PDIA3, C4BPA, BTN1A1, and TNFSF13) with a new biomarker potential for myeloma patient outcomes. The high proteomic similarity between PB and BM matched pairs supports the use of circulating EV as a counterpart of the BM EV proteome. Overall, we found that the EV protein content is related to patient outcomes, such as survival, immune dysfunction, and possibly treatment response.
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Affiliation(s)
- Bruna Velosa Ferreira
- Myeloma Lymphoma Research Group, Champalimaud Experimental Clinical Research Programme, Champalimaud Foundation, Lisbon, Portugal
- NOVA Medical School (NMS), NOVA University Lisbon, Lisbon, Portugal
- Hemato-Oncology Unit, Champalimaud Clinical Centre, Champalimaud Foundation, Lisbon, Portugal
| | - Emilie Arnault Carneiro
- Myeloma Lymphoma Research Group, Champalimaud Experimental Clinical Research Programme, Champalimaud Foundation, Lisbon, Portugal
| | - Carolina Pestana
- Myeloma Lymphoma Research Group, Champalimaud Experimental Clinical Research Programme, Champalimaud Foundation, Lisbon, Portugal
- Centre of Statistics and its Applications, Faculty of Sciences, University of Lisbon, Lisbon, Portugal
| | - Filipa Barahona
- Myeloma Lymphoma Research Group, Champalimaud Experimental Clinical Research Programme, Champalimaud Foundation, Lisbon, Portugal
- NOVA Medical School (NMS), NOVA University Lisbon, Lisbon, Portugal
| | - Joana Caetano
- Myeloma Lymphoma Research Group, Champalimaud Experimental Clinical Research Programme, Champalimaud Foundation, Lisbon, Portugal
- NOVA Medical School (NMS), NOVA University Lisbon, Lisbon, Portugal
- Hemato-Oncology Unit, Champalimaud Clinical Centre, Champalimaud Foundation, Lisbon, Portugal
| | - Raquel Lopes
- Myeloma Lymphoma Research Group, Champalimaud Experimental Clinical Research Programme, Champalimaud Foundation, Lisbon, Portugal
- Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Paulo Lúcio
- Hemato-Oncology Unit, Champalimaud Clinical Centre, Champalimaud Foundation, Lisbon, Portugal
| | - Manuel Neves
- Hemato-Oncology Unit, Champalimaud Clinical Centre, Champalimaud Foundation, Lisbon, Portugal
| | - Hans Christian Beck
- Centre for Clinical Proteomics, Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | - Ana Sofia Carvalho
- NOVA Medical School (NMS), Faculdade de Ciências Médicas (FCM), Universidade Nova de Lisboa, Lisboa, Portugal
| | - Rune Matthiesen
- NOVA Medical School (NMS), Faculdade de Ciências Médicas (FCM), Universidade Nova de Lisboa, Lisboa, Portugal
| | - Bruno Costa-Silva
- Systems Oncology Group, Champalimaud Physiology and Cancer Programme, Champalimaud Foundation, Lisbon, Portugal
- *Correspondence: Bruno Costa-Silva, ; Cristina João,
| | - Cristina João
- Myeloma Lymphoma Research Group, Champalimaud Experimental Clinical Research Programme, Champalimaud Foundation, Lisbon, Portugal
- NOVA Medical School (NMS), NOVA University Lisbon, Lisbon, Portugal
- Hemato-Oncology Unit, Champalimaud Clinical Centre, Champalimaud Foundation, Lisbon, Portugal
- *Correspondence: Bruno Costa-Silva, ; Cristina João,
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Napodano C, Pocino K, Gulli F, Rossi E, Rapaccini GL, Marino M, Basile U. Mono/polyclonal free light chains as challenging biomarkers for immunological abnormalities. Adv Clin Chem 2022; 108:155-209. [PMID: 35659060 DOI: 10.1016/bs.acc.2021.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Free light chain (FLC) kappa (k) and lambda (λ) consist of low molecular weight proteins produced in excess during immunoglobulin synthesis and secreted into the circulation. In patients with normal renal function, over 99% of FLCs are filtered and reabsorbed. Thus, the presence of FLCs in the serum is directly related to plasma cell activity and the balance between production and renal clearance. FLCs are bioactive molecules that may exist as monoclonal (m) and polyclonal (p) FLCs. These have been detected in several body fluids and may be key indicators of ongoing damage and/or illness. International guidelines now recommend mFLC for screening, diagnosis and monitoring multiple myeloma and other plasma cell dyscrasias. In current clinical practice, FLCs in urine indicate cast nephropathy and other renal injury, whereas their presence in cerebrospinal fluid is important for identifying central nervous system inflammatory diseases such as multiple sclerosis. Increased pFLCs have also been detected in various conditions characterized by B cell activation, i.e., chronic inflammation, autoimmune disease and HCV infection. Monitoring the coronavirus (COVID-19) pandemic by analysis of salivary FLCs presents a significant opportunity in clinical immunology worthy of scientific pursuit.
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Affiliation(s)
- Cecilia Napodano
- Dipartimento di Scienze Mediche e Chirurgiche, UOC Gastroenterologia Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Krizia Pocino
- Dipartimento di Scienze Mediche e Chirurgiche, UOC Gastroenterologia Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesca Gulli
- Laboratorio di Patologia Clinica, Ospedale Madre Giuseppina Vannini, Rome, Italy
| | - Elena Rossi
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gian Ludovico Rapaccini
- Dipartimento di Scienze Mediche e Chirurgiche, UOC Gastroenterologia Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Mariapaola Marino
- Dipartimento di Medicina e Chirurgia Traslazionale, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Umberto Basile
- Dipartimento di Scienze di laboratorio e Infettivologiche, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.
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Heaney JLJ, Faustini S, Evans L, Rapson A, Collman E, Emery A, Campbell JP, Moore S, Goodall M, Afzal Z, Chapple IL, Pratt G, Drayson MT. Investigating the utility of saliva immunoglobulins for the detection of myeloma and using myeloma proteins to clarify partition between oral and systemic immunity. Eur J Haematol Suppl 2022; 108:493-502. [PMID: 35184331 PMCID: PMC9314979 DOI: 10.1111/ejh.13758] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/14/2022] [Accepted: 02/16/2022] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Myeloma is characterised by the presence of monoclonal immunoglobulin (M-protein) and the free light chain (FLC) in blood. We investigated whether these M-proteins and FLC are detectable in myeloma patients' saliva to evaluate its utility for non-invasive screening and monitoring of haematological malignancies. METHODS A total of 57 patients with monoclonal gammopathy and 26 age-matched healthy participants provided paired serum and saliva samples for immunoglobulin characterisation and quantification. RESULTS Myeloma patients had IgG or IgA M-protein levels ranging up to five times and FLC levels up to a thousand times normal levels of polyclonal immunoglobulins. Despite these highly elevated levels, only two IgG and no IgA M-proteins or FLC could be detected in paired saliva samples. Most patients had reduced levels of serum polyclonal immunoglobulins, but all had normal levels of salivary IgA. CONCLUSIONS Immunoglobulin transfer from blood is not determined by levels in the systemic circulation and more likely dictated by periodontal inflammation and the integrity of the oral epithelium. Immunoglobulins secreted by bone marrow plasma cells do not substantially enter saliva, which represents a poor medium for myeloma diagnosis. These findings, along with normal salivary IgA levels despite systemic immunoparesis, support a strong partitioning of oral from systemic humoral immunity.
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Affiliation(s)
- Jennifer L J Heaney
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Sian Faustini
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Lili Evans
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Alec Rapson
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Emily Collman
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | | | | | - Sally Moore
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Margaret Goodall
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Zaheer Afzal
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Iain L Chapple
- Periodontal Research Group, School of Dentistry, Institute of Clinical Sciences, University of Birmingham, and Birmingham Community Health Trust, Birmingham, UK
| | - Guy Pratt
- University Hospitals Birmingham NHS Trust, Birmingham, UK
| | - Mark T Drayson
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
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Rajkumar SV. Multiple myeloma: 2022 update on diagnosis, risk stratification, and management. Am J Hematol 2022; 97:1086-1107. [PMID: 35560063 DOI: 10.1002/ajh.26590] [Citation(s) in RCA: 229] [Impact Index Per Article: 114.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/05/2022] [Accepted: 05/06/2022] [Indexed: 12/22/2022]
Abstract
DISEASE OVERVIEW Multiple myeloma accounts for approximately 10% of hematologic malignancies. DIAGNOSIS The diagnosis requires ≥10% clonal bone marrow plasma cells or a biopsy-proven plasmacytoma plus evidence of one or more multiple myeloma defining events (MDE): CRAB (hypercalcemia, renal failure, anemia, or lytic bone lesions) attributable to the plasma cell disorder, bone marrow clonal plasmacytosis ≥60%, serum involved/uninvolved free light chain (FLC) ratio ≥ 100 (provided involved FLC is ≥100 mg/L), or >1 focal lesion on magnetic resonance imaging. RISK STRATIFICATION The presence of del(17p), t(4;14), t(14;16), t(14;20), gain 1q, or p53 mutation is considered high-risk multiple myeloma. The presence of any two high risk factors is considered double-hit myeloma, and three or more high risk factors is triple-hit myeloma. RISK-ADAPTED INITIAL THERAPY In patients who are candidates for autologous stem cell transplantation, induction therapy consists of bortezomib, lenalidomide, dexamethasone (VRd) given for approximately 3-4 cycles followed by autologous stem cell transplantation (ASCT). In high-risk patients, daratumumab, bortezomib, lenalidomide, dexamethasone (Dara-VRd) is an alternative to VRd. Selected standard-risk patients can collect stem cells, get additional cycles of induction therapy, and delay transplant until first relapse. Patients who are not candidates for transplant are treated with VRd for approximately 8-12 cycles followed by maintenance or alternatively with daratumumab, lenalidomide, dexamethasone (DRd) until progression. MAINTENANCE THERAPY Standard-risk patients need lenalidomide maintenance, while bortezomib plus lenalidomide maintenance is needed for high-risk myeloma. MANAGEMENT OF RELAPSED DISEASE A triplet regimen is usually needed at relapse, with the choice of regimen varying with each successive relapse.
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