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Keren DF, McCudden CR, Booth RA. Editorial on laboratory diagnosis and management of plasma cell dyscrasias special issue. Clin Biochem 2017; 51:1-3. [PMID: 29111449 DOI: 10.1016/j.clinbiochem.2017.10.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Accepted: 10/25/2017] [Indexed: 11/16/2022]
Affiliation(s)
- David F Keren
- Division of Clinical Pathology, Department of Pathology, The University of Michigan Hospital and Health Systems, USA
| | - Christopher R McCudden
- Dept. of Pathology & Lab. Medicine, Division of Biochemistry, University of Ottawa, Canada.
| | - Ronald A Booth
- Dept. of Pathology & Lab. Medicine, Division of Biochemistry, University of Ottawa, Canada
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202
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Sachchithanantham S, Berlanga O, Alvi A, Mahmood SA, Lachmann HJ, Gillmore JD, Hawkins PN, Harding S, Wechalekar AD. Immunoparesis defined by heavy+light chain suppression is a novel marker of long-term outcomes in cardiac AL amyloidosis. Br J Haematol 2017; 179:575-585. [PMID: 28990174 DOI: 10.1111/bjh.14908] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 07/23/2017] [Indexed: 01/14/2023]
Abstract
Cardiac involvement and presenting dFLC (difference between involved and uninvolved free light chains) are independent predictors of outcome in systemic AL amyloidosis. These markers have limited prognostic utility in patients surviving the initial months following diagnosis. Here we assessed immunoparesis, as determined by novel heavy+light chain (HLC) immunoassays, as a prognostic marker for survival in AL amyloidosis. HLC measurements identified immunoparesis of at least one immunoglobulin (Ig) isotype in 145 (85%) patients; and severe immunoparesis (≥2 Ig isotypes suppressed by >50% below normal levels) in 29 (17%) patients. Median overall survival (OS) on intention to treat (ITT) analysis was 26·2 months. In the ITT cohort, dFLC >180 mg/l was associated with shorter OS (P = 0·05); whereas HLC immunoparesis was not prognostic. On a landmark analysis of 127 patients alive at 6 months, presenting dFLC was not prognostic for OS (P = 0·33) and severe HLC immunoparesis trended towards poorer survival (20·2 vs. 42·8 months; P = 0·09). In the subset of patients with cardiac involvement, severe HLC immunoparesis conferred very poor outcome (median OS 8·8 vs. 29·9 months, P = 0·007). In conclusion, severe HLC immunoparesis is an independent marker of long-term poor prognosis in AL patients with cardiac involvement. The pathophysiological significance of this observation needs further study.
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Affiliation(s)
- Sajitha Sachchithanantham
- Centre for Amyloidosis and Acute Phase Proteins, University College London (Royal Free Campus), London, UK
| | | | - Azra Alvi
- The Binding Site Group Ltd., Birmingham, UK
| | - Shameem A Mahmood
- Centre for Amyloidosis and Acute Phase Proteins, University College London (Royal Free Campus), London, UK
| | - Helen J Lachmann
- Centre for Amyloidosis and Acute Phase Proteins, University College London (Royal Free Campus), London, UK
| | - Julian D Gillmore
- Centre for Amyloidosis and Acute Phase Proteins, University College London (Royal Free Campus), London, UK
| | - Philip N Hawkins
- Centre for Amyloidosis and Acute Phase Proteins, University College London (Royal Free Campus), London, UK
| | | | - Ashutosh D Wechalekar
- Centre for Amyloidosis and Acute Phase Proteins, University College London (Royal Free Campus), London, UK
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203
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Clinical presentation and outcomes in light chain amyloidosis patients with non-evaluable serum free light chains. Leukemia 2017; 32:729-735. [PMID: 28919633 DOI: 10.1038/leu.2017.286] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 08/21/2017] [Accepted: 08/30/2017] [Indexed: 12/11/2022]
Abstract
Hematologic response criteria in light chain (AL) amyloidosis require the difference in involved and uninvolved free light chains (dFLC) to be at least 5 mg/dl. We describe the clinical presentation and outcomes of newly diagnosed amyloidosis patients with dFLC <5 mg/dl (non-evaluable dFLC; 14%, n=165) compared with patients with dFLC ⩾5 mg/dl (evaluable dFLC; 86%, n=975). Patients with non-evaluable dFLC had less cardiac involvement (40% vs 80%, P<0.001), less liver involvement (11% vs 17%, P=0.04) and a trend toward less gastrointestinal involvement (18% vs 25%, P=0.08). However, significantly higher renal involvement (72% vs 56%, P=0.0002) was observed in the non-evaluable dFLC cohort. Differences in treatment patterns were observed, with 51% of treated patients undergoing upfront stem cell transplantation in the non-evaluable cohort compared with 28% in the evaluable dFLC group (P<0.001). Progression-free survival (61 vs 13 months, P<0.001) and overall survival (OS; 101 vs 29 months, P<0.001) were significantly longer in the non-evaluable dFLC cohort. Normalization of involved light chain levels and decrease in dFLC <1 mg/dl (baseline at least 2 mg/dl) were predictive of OS and associated with better dialysis-free survival and may be used for response assessment in patients with non-evaluable FLC levels.
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204
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Basile U, Gulli F, Gragnani L, Napodano C, Pocino K, Rapaccini GL, Mussap M, Zignego AL. Free light chains: Eclectic multipurpose biomarker. J Immunol Methods 2017; 451:11-19. [PMID: 28931470 DOI: 10.1016/j.jim.2017.09.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 07/21/2017] [Accepted: 09/15/2017] [Indexed: 12/14/2022]
Abstract
The production of antibodies is accompanied by a slight excess of synthesis of κ and λ immunoglobulin light chains; small amounts of them are released in the peripheral blood and can also be found in various body fluids, such as synovial fluid, cerebrospinal fluid, urine and saliva. They are rapidly filtered by the glomerulus and >99% are reabsorbed from the cells of the proximal convoluted tubule, making them present in the urine in only trace amounts. The production of an excess of protein without a reason or a specific function in a biological system is rare. Free light chains, considered for years a waste product of Ig synthesis, are currently known to be very active molecules, able to bind antigens as well as whole immunoglobulin and helping to develop specific antibody affinity. The ability of free light chains to activate mast cells and then become an active part of the pathogenic mechanisms of chronic inflammatory diseases has increased interest in their clinical use, both as an attractive therapeutic target or as a biochemical marker of disease evolution or remission. This is an overview of relevant scientific interest that immunoglobulin light chains κ and λ have attracted over the years, a report on the progress in knowledge about their structure and function, with a special focus on their biological meaning and potential clinical utility in different diseases.
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Affiliation(s)
- Umberto Basile
- Department of Laboratory Medicine of the Catholic University of Sacred Heart, Rome, Italy.
| | - Francesca Gulli
- Department of Laboratory Medicine of the Catholic University of Sacred Heart, Rome, Italy
| | - Laura Gragnani
- Center for Systemic Manifestations of Hepatitis Viruses (MaSVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Cecilia Napodano
- Department of Laboratory Medicine of the Catholic University of Sacred Heart, Rome, Italy
| | - Krizia Pocino
- Department of Laboratory Medicine of the Catholic University of Sacred Heart, Rome, Italy
| | | | - Michele Mussap
- Department of Laboratory Medicine, IRCCS-AOU San Martino, Genoa, Italy
| | - Anna Linda Zignego
- Center for Systemic Manifestations of Hepatitis Viruses (MaSVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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205
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Abstract
There have been several advances in the diagnosis of multiple myeloma (MM) in recent years. Serum free light chains have improved the ability to diagnose light chain MM; however, there are still difficulties in the serologic diagnosis of MM in some cases, particularly IgA MM. A novel heavy/light chain assay is able to improve the accuracy of diagnosis in these cases. Free light chains may also improve the diagnosis of extramedullary disease in difficult cases such as disease involving the central nervous system, pleura, or ascites. Advances in imaging such as whole body low-dose computed tomography (CT) whole body magnetic resonance imaging (MRI), and positron emission tomography/computed tomography (PET/CT) have improved sensitivity in identifying lytic bone lesions, which would enable earlier treatment, and monitoring of osseous disease particularly in non- or oligosecretory disease. New techniques such as fused PET/MRI may further enhance the diagnosis of both bone lesions and extramedullary disease.
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Abstract
Solitary plasmacytoma is a rare disease characterized by a localized proliferation of neoplastic monoclonal plasma cells, without evidence of systemic disease. It can be subdivided into solitary bone plasmacytoma if the lesion originates in bone, or solitary extramedullary plasmacytoma if the lesion involves a soft tissue. The incidence of solitary bone plasmacytoma is higher than solitary extramedullary plasmacytoma. Also, the prognosis is different: even if both forms respond well to treatment, overall survival and progression-free survival of solitary bone plasmacytoma are poorer than solitary extramedullary plasmacytoma due to its higher rate of evolution in multiple myeloma. However, the recent advances in the diagnosis of multiple myeloma can better refine also the diagnosis of plasmacytoma. Flow cytometry studies and molecular analysis may reveal clonal plasma cells in the bone marrow; magnetic resonance imaging or 18 Fluorodeoxyglucose positron emission tomography could better define osteolytic bone lesions. A more explicit exclusion of possible occult systemic involvement can avoid cases of misdiagnosed multiple myeloma patients, which were previously considered solitary plasmacytoma and less treated, with an unavoidable poor prognosis. Due to the rarity of the disease, there is no uniform consensus about prognostic factors and treatment. Radiotherapy is the treatment of choice; however, some authors debate about the radiotherapy dose and the relationship with the response rate. Moreover, the role of surgery and chemotherapy is still under debate. Nevertheless, we must consider that the majority of studies include a small number of patients and analyze the efficacy of conventional chemotherapy; few cases are reported concerning the efficacy of novel agents.
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207
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Evaluation of a new free light chain ELISA assay: bringing coherence with electrophoretic methods. ACTA ACUST UNITED AC 2017; 56:312-322. [DOI: 10.1515/cclm-2017-0339] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 07/06/2017] [Indexed: 01/08/2023]
Abstract
Abstract
Background:
Serum free light chain (sFLC) measurements are increasingly important in the context of screening for monoclonal gammopathies, prognostic stratification, and monitoring of therapy responses. At the same time, analytical limitations have been reported with the currently available nephelometric and turbidimetric sFLC assays. We have evaluated a new quantitative sFLC ELISA for its suitability in routine clinical use.
Methods:
Reference ranges of the Sebia FLC assay were calculated from 208 controls. Assay interference, reproducibility, lot-to-lot variability, and linearity were assessed. Method comparison to the Freelite assay (Binding Site) was conducted by retrospective analysis of 501 patient sera.
Results:
Reference ranges of the Sebia κ/λFLC-ratio were 0.37–1.44. We observed good sensitivity (1.5 mg/L) and linearity in both polyclonal and monoclonal sFLC samples and never experienced antigen excess. Sebia FLC reproducibility varied between 6.7% and 8.1% with good lot-to-lot consistency. Method comparison with Freelite showed the following correlations: κFLC R=0.94, λFLC R=0.92 and κ/λFLC-ratio R=0.96. The clinical concordance of the κ/λFLC-ratio of both methods was 94%. Significant quantitative differences were observed between both methods, mainly in sera with high FLC concentrations. The Sebia monoclonal FLC concentrations were coherent with those obtained by serum protein electrophoresis (SPE). Freelite monoclonal FLC concentrations were consistently higher, with a mean 12-fold overestimation compared to SPE.
Conclusions:
The Sebia FLC assay provides a novel platform for sensitive and accurate sFLC measurements. The Sebia FLC showed good clinical concordance with Freelite. Further studies are warranted to confirm the clinical value of this assay.
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208
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Milani P, Murray DL, Barnidge DR, Kohlhagen MC, Mills JR, Merlini G, Dasari S, Dispenzieri A. The utility of MASS-FIX to detect and monitor monoclonal proteins in the clinic. Am J Hematol 2017; 92:772-779. [PMID: 28439985 DOI: 10.1002/ajh.24772] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 04/12/2017] [Accepted: 04/18/2017] [Indexed: 01/23/2023]
Abstract
The detection and quantification of monoclonal-proteins (M-proteins) are necessary for the diagnosis and evaluation of response in plasma cell dyscrasias. Immunoglobulin enrichment-coupled with matrix-assisted laser desorption ionization time-of-flight mass-spectrometry (MASS-FIX) is a simple and inexpensive method to identify M-proteins, but its clinical generalizability has not yet been elucidated. We compared MASS-FIX to protein electrophoresis (PEL), serum/urine immunofixation-electrophoresis (IFE), and quantitative serum free-light chain (FLC) for the identification of M-proteins in different clinical diagnoses. Paired serum and urine samples from 257 patients were tested. There were six patients for whom s-IFE and FLC ratio were positive and serum MASS-FIX was negative, but when serum and urine MASS-FIX results were combined, only one patient with light chain-MGUS was missed. Serum/urine-MASS-FIX detected M-proteins in 18 patients with negative serum/urine-PEL/IFE and serum-FLC, 10 of whom had multiple myeloma or AL amyloidosis, who were mistakenly thought to have complete hematologic response by serum/urine-PEL/IFE and serum-FLC. Nearly half of the AL amyloidosis patients had atypical spectra, which may prove to be a clue to the diagnosis and pathogenesis of the disease. In conclusion, MASS-FIX has a comparable sensitivity with PEL/IFE/FLC methods and can help inform the clinical diagnosis.
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Affiliation(s)
- Paolo Milani
- Division of Hematology; Mayo Clinic; Rochester Minnesota
- Amyloidosis Research and Treatment Center; Department of Molecular Medicine, University of Pavia; Pavia Italy
- PhD Program in Experimental Medicine, University of Pavia; Pavia Italy
| | - David L. Murray
- Department of Laboratory Medicine; Mayo Clinic; Rochester Minnesota
| | | | | | - John R. Mills
- Department of Laboratory Medicine; Mayo Clinic; Rochester Minnesota
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center; Department of Molecular Medicine, University of Pavia; Pavia Italy
| | - Surendra Dasari
- Department of Health Sciences Research; Mayo Clinic; Rochester Minnesota
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209
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Jenner EL, Evans JAR, Harding SJ. Serum Free Light Chain (FLC) Analysis: A Guiding Light in Monoclonal Gammopathy Management. J Appl Lab Med 2017; 2:98-106. [PMID: 33636952 DOI: 10.1373/jalm.2016.021352] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 03/31/2017] [Indexed: 11/06/2022]
Abstract
BACKGROUND Monoclonal free light chains (FLCs) were first reported by Dr. Henry Bence Jones over 150 years ago in the urine of patients with multiple myeloma. Now established as important tumor markers, they aid not only in the diagnosis of monoclonal gammopathies but also in their clinical management by indicating the response to treatment and persistence of residual disease. CONTENT A particular focus over the past 15 years has been on the replacement of urine with serum analysis for monoclonal FLC measurement. Because of the limited sensitivity and practical constraints of urine assessment, a combination of serum electrophoresis and serum FLC analysis has been adopted by many laboratories as a first-line screen for patients with a suspected monoclonal gammopathy. Early myeloma diagnosis may translate into improved clinical outcomes, and a new study, iStopMM, is underway to ascertain the benefit of population-wide screening protocols for early detection of the disease in its asymptomatic phase. Laboratory algorithms that include measurement of both monoclonal intact immunoglobulins and FLCs are important for assessing possible changes in myelomic clones in response to treatment, and recent data from Intergroupe Francophone du Myelome trials validate serum FLC as a clinically relevant disease biomarker. Whether sensitive serum techniques such as FLC analysis can be used to guide the use of more invasive procedures for detection of minimal residual disease is the subject of emerging studies. SUMMARY Here we review the current and evolving utility of serum FLC measurements for the management of patients with monoclonal gammopathies.
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210
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Response Assessment in Myeloma: Practical Manual on Consistent Reporting in an Era of Dramatic Therapeutic Advances. Biol Blood Marrow Transplant 2017; 23:1193-1202. [DOI: 10.1016/j.bbmt.2017.03.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Accepted: 03/06/2017] [Indexed: 11/23/2022]
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211
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Kennard A, Hawley C, Tate J, Klingberg S, Pretorius C, Hutchison C, Mollee P. Comparison of Freelite™ and N Latex serum free light chain assays in subjects with end stage kidney disease on haemodialysis. Clin Chem Lab Med 2017; 54:1045-52. [PMID: 26684350 DOI: 10.1515/cclm-2015-0799] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 11/09/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND Quantification of serum free light chains (FLC) is important in the diagnosis of plasma cell diseases where an abnormal kappa:lambda ratio infers a population of monoclonal plasma cells. The Freelite™ and N Latex assays have been validated in populations without kidney disease but there is a paucity of data relating to the use of these assays in end stage kidney disease (ESKD). The aim of the study was to compare FLC assay performance in ESKD patients on haemodialysis. METHODS Cross-sectional multi-centre study comparing the performance of the two assays on 112 haemodialysis patients without known paraproteinaemia. We quantified FLC pre- and post-dialysis using both the N Latex and the Freelite assays. RESULTS FLC levels were elevated by both assays. Lambda FLC levels were considerably higher by the N Latex assay. Using the proposed renal reference range for Freelite (0.37-3.1) all but one patient had normal kappa:lambda FLC ratios. In contrast, there were no abnormal FLC ratios pre-dialysis using the N Latex assay. This was due to lambda FLC reading significantly higher by the N Latex assay. Kappa and lambda FLC levels decreased with dialysis but remained elevated above the normal range. The excess of lambda FLC by N Latex persisted post-dialysis but was somewhat attenuated. Dialysis adequacy and dialysis modality predicted clearance of kappa and lambda FLC by both assays. CONCLUSIONS The N Latex assay reported significantly higher pre-dialysis lambda FLC concentrations compared with the Freelite assays. Clinicians should be aware of the need for a separate renal reference range for interpreting FLC ratio using the Freelite assay but not for the N Latex assay in ESKD patients.
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212
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Leung N, Barnidge DR, Hutchison CA. Laboratory testing in monoclonal gammopathy of renal significance (MGRS). Clin Chem Lab Med 2017; 54:929-37. [PMID: 27107835 DOI: 10.1515/cclm-2015-0994] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Accepted: 02/22/2016] [Indexed: 02/06/2023]
Abstract
Recently, monoclonal gammopathy of renal significance (MGRS) reclassified all monoclonal (M) gammopathies that are associated with the development of a kidney disease but do not meet the definition of symptomatic multiple myeloma (MM) or malignant lymphoma. The purpose was to distinguish the M gammopathy as the nephrotoxic agent independent from the clonal mass. The diagnosis of MGRS obviously depends on the detection of the M-protein. More importantly, the success of treatment is correlated with the reduction of the M-protein. Therefore, familiarity with the M-protein tests is a must. Protein electrophoresis performed in serum or urine is inexpensive and rapid due to automation. However, poor sensitivity especially with the urine is an issue particularly with the low-level M gammopathy often encountered with MGRS. Immunofixation adds to the sensitivity and specificity but also the cost. Serum free light chain (sFLC) assays have significantly increased the sensitivity of M-protein detection and is relatively inexpensive. It is important to recognize that there is more than one assay on the market and their results are not interchangeable. In addition, in certain diseases, immunofixation is more sensitive than sFLC. Finally, novel techniques with promising results are adding to the ability to identify M-proteins. Using the time of flight method, the use of mass spectrometry of serum samples has been shown to dramatically increase the sensitivity of M-protein detection. In another technique, oligomeric LCs are identified on urinary exosomes amplifying the specificity for the nephrotoxic M-protein.
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213
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Altinier S, Proko K, Zaninotto M, Ciubotaru D, Seguso M, Varagnolo M, Lessi F, Briani C, Adami F, Plebani M. Free light chains and heavy/light chains in monitoring POEMS patients. Clin Chem Lab Med 2017; 54:1065-71. [PMID: 27071150 DOI: 10.1515/cclm-2015-0910] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 03/02/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND POEMS syndrome is defined by Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal gammopathy and Skin changes. The vascular endothelial growth factor (VEGF) appears to play a key role in the pathogenesis of the syndrome, and its concentrations are deemed to correlate to disease activity. The aim of the present study was to verify whether other biochemical markers including serum free light chains (FLC) and heavy/light chains (HLC) would be of value in monitoring POEMS patients. METHODS Fifty-three serum samples were collected from seven POEMS patients at diagnosis and during a follow-up period (range 14-56 months). VEGF was measured using an ELISA method, while FLC and HLC concentrations were measured using Binding Site reagents on a BNII (Siemens) nephelometer. RESULTS At diagnosis all patients presented high VEGF concentrations, while the κ/λFLC ratio (FLCr) was within the reference range. Four patients had abnormal HLC, HLCκ/HLCλ (HLCr) and FLC values. The relationship between the trend of VEGF and both HLC and FLC during the follow-up was analysed by means of Cohen's κ coefficient. VEGF and HLC values displayed a significant κ-Cohen (0.537, p=0.002) in all chemotherapy-responder patients while in non-responders it did not. Conversely, in both responders and non-responders, VEGF and FLC values did not attain a significance on κ-Cohen analysis. In three out of four responders HLCr values increased, thus reflecting an improved clinical condition. CONCLUSIONS The findings made in the present study indicate that HLC, either as intact immunoglobulin or as HLCr, may provide useful information, particularly in identifying responders and confirm that the role of FLC is unreliable in monitoring patients with POEMS syndrome.
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214
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Levinson SS. Strengths and weaknesses of methods for identifying monoclonal free light chains of Ig: examples from two cases with renal disease. Clin Chem Lab Med 2017; 54:1039-43. [PMID: 26368046 DOI: 10.1515/cclm-2015-0482] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 07/12/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND Serum free light chain (FLC) analysis with ratio and urine immunofixation electrophoresis (IFE) are both available for routine use in helping to detect plasma cell dyscrasia and related diseases. CASES Case reports showing one serum positive for serum FLC but that showed a hook effect and overestimated the amount of monoclonal FLC while urine IFE was negative for Bence Jones protein, and a second serum that showed elevated FLC κ and λ but a normal κ/λ ratio, while urine IFE was positive for Bence Jones protein. CONCLUSIONS These two techniques complement one another. Neither of the techniques is truly quantitative, and both exhibit methodological defects.
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215
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Jacobs JFM, Tate JR, Merlini G. Is accuracy of serum free light chain measurement achievable? Clin Chem Lab Med 2017; 54:1021-30. [PMID: 26641970 DOI: 10.1515/cclm-2015-0879] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 11/06/2015] [Indexed: 11/15/2022]
Abstract
The serum free light chain (FLC) assay has proven to be an important complementary test in the management of patients with monoclonal gammopathies. The serum FLC assay has value for patients with plasma cell disorders in the context of screening and diagnosis, prognostic stratification, and quantitative monitoring. Nonetheless, serum FLC measurements have analytical limitations which give rise to differences in FLC reporting depending on which FLC assay and analytical platform is used. As the FLC measurements are incorporated in the International Myeloma Working Group guidelines for the evaluation and management of plasma cell dyscrasias, this may directly affect clinical decisions. As new certified methods for serum FLC assays emerge, the need to harmonise patient FLC results becomes increasingly important. In this opinion paper we provide an overview of the current lack of accuracy and harmonisation in serum FLC measurements. The clinical consequence of non-harmonized FLC measurements is that an individual patient may or may not meet certain diagnostic, prognostic, or response criteria, depending on which FLC assay and platform is used. We further discuss whether standardisation of serum FLC measurements is feasible and provide an overview of the steps needed to be taken towards harmonisation of FLC measurements.
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216
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Ting KR, Henry M, Meiller J, Larkin A, Clynes M, Meleady P, Bazou D, Dowling P, O'Gorman P. Novel panel of protein biomarkers to predict response to bortezomib-containing induction regimens in multiple myeloma patients. BBA CLINICAL 2017; 8:28-34. [PMID: 28725572 PMCID: PMC5502697 DOI: 10.1016/j.bbacli.2017.05.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 05/19/2017] [Accepted: 05/19/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND Multiple myeloma (MM) is a complex heterogeneous disease. Various risk stratification models have been recommended including cytogenetic and FISH analysis to identify high-risk patients who may benefit from novel treatments, but such facilities are not widely available. The International Scoring System (ISS) using beta-2-microglobulin and albumin remains a widely used prognostic scoring system in many clinical practices; however it is not useful in predicting response to treatment in MM. The aim of this study is to identify clinically useful biomarkers to predict response to treatment containing bortezomib. METHODS 17 MM patient serum samples (9 responders/8 non-responders) were used for the discovery phase (label-free mass spectrometry) and an additional 20 MM patient serum samples were used for the ELISA-based validation phase (14 responders/6 non-responders). RESULTS CLU and ANG mean levels were higher in the responders group, while Complement C1q had lower concentrations. The combination of all standard biomarkers (albumin, beta-2-microglobulin (ß2M), paraprotein and kappa/lambda (K/L) ratio) had an AUC value of 0.71 with 65% correct classification, while an overall combination of new candidate protein biomarkers with standard biomarkers had an AUC value of 0.89 with 85.3% correct classification. CONCLUSIONS A combination of new and standard biomarkers consisting of CLU, ANG, C1Q, albumin, ß2M, paraprotein and K/L ratio may have potential as a novel panel of biomarkers to predict MM response to treatment containing bortezomib. GENERAL SIGNIFICANCE Use of this biomarker panel could facilitate a more personalized therapy approach and to minimize unnecessary side effects from ineffective drugs.
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Affiliation(s)
- Kay Reen Ting
- Mater Misericordiae University Hospital, Dublin 7, Ireland.,National Institute for Cellular Biotechnology, Dublin City University, Glasnevin, Dublin 9, Ireland
| | - Michael Henry
- National Institute for Cellular Biotechnology, Dublin City University, Glasnevin, Dublin 9, Ireland
| | - Justine Meiller
- National Institute for Cellular Biotechnology, Dublin City University, Glasnevin, Dublin 9, Ireland
| | - Annemarie Larkin
- National Institute for Cellular Biotechnology, Dublin City University, Glasnevin, Dublin 9, Ireland
| | - Martin Clynes
- National Institute for Cellular Biotechnology, Dublin City University, Glasnevin, Dublin 9, Ireland
| | - Paula Meleady
- National Institute for Cellular Biotechnology, Dublin City University, Glasnevin, Dublin 9, Ireland
| | - Despina Bazou
- Mater Misericordiae University Hospital, Dublin 7, Ireland
| | - Paul Dowling
- National Institute for Cellular Biotechnology, Dublin City University, Glasnevin, Dublin 9, Ireland.,Department of Biology, Maynooth University, Maynooth, Co. Kildare, Ireland
| | - Peter O'Gorman
- Mater Misericordiae University Hospital, Dublin 7, Ireland.,National Institute for Cellular Biotechnology, Dublin City University, Glasnevin, Dublin 9, Ireland.,School of Medicine & Medical Science, University College Dublin, Dublin 4, Ireland
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Kumar S, Paiva B, Anderson KC, Durie B, Landgren O, Moreau P, Munshi N, Lonial S, Bladé J, Mateos MV, Dimopoulos M, Kastritis E, Boccadoro M, Orlowski R, Goldschmidt H, Spencer A, Hou J, Chng WJ, Usmani SZ, Zamagni E, Shimizu K, Jagannath S, Johnsen HE, Terpos E, Reiman A, Kyle RA, Sonneveld P, Richardson PG, McCarthy P, Ludwig H, Chen W, Cavo M, Harousseau JL, Lentzsch S, Hillengass J, Palumbo A, Orfao A, Rajkumar SV, Miguel JS, Avet-Loiseau H. International Myeloma Working Group consensus criteria for response and minimal residual disease assessment in multiple myeloma. Lancet Oncol 2017; 17:e328-e346. [PMID: 27511158 DOI: 10.1016/s1470-2045(16)30206-6] [Citation(s) in RCA: 1761] [Impact Index Per Article: 251.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 05/21/2016] [Accepted: 05/24/2016] [Indexed: 12/16/2022]
Abstract
Treatment of multiple myeloma has substantially changed over the past decade with the introduction of several classes of new effective drugs that have greatly improved the rates and depth of response. Response criteria in multiple myeloma were developed to use serum and urine assessment of monoclonal proteins and bone marrow assessment (which is relatively insensitive). Given the high rates of complete response seen in patients with multiple myeloma with new treatment approaches, new response categories need to be defined that can identify responses that are deeper than those conventionally defined as complete response. Recent attempts have focused on the identification of residual tumour cells in the bone marrow using flow cytometry or gene sequencing. Furthermore, sensitive imaging techniques can be used to detect the presence of residual disease outside of the bone marrow. Combining these new methods, the International Myeloma Working Group has defined new response categories of minimal residual disease negativity, with or without imaging-based absence of extramedullary disease, to allow uniform reporting within and outside clinical trials. In this Review, we clarify several aspects of disease response assessment, along with endpoints for clinical trials, and highlight future directions for disease response assessments.
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Affiliation(s)
- Shaji Kumar
- Division of Hematology, Mayo Clinic, Rochester, MN, USA.
| | - Bruno Paiva
- Clinica Universidad de Navarra, Centro de Investigacion Medica Aplicada (CIMA), Pamplona, Spain
| | | | - Brian Durie
- Cedars-Sinai Comprehensive Cancer Center, Los Angeles, CA, USA
| | - Ola Landgren
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | | | - Sagar Lonial
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA
| | | | | | - Meletios Dimopoulos
- Department of Clinical Therapeutics, University of Athens, School of Medicine, Athens, Greece
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, University of Athens, School of Medicine, Athens, Greece
| | - Mario Boccadoro
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Citta della Salute e della Scienza di Torino, Torino, Italy; Mount Sinai Cancer Institute, New York, NY, USA
| | | | - Hartmut Goldschmidt
- Department of Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | | | - Jian Hou
- Chang Zheng Hospital, Shanghai, China
| | | | - Saad Z Usmani
- Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC, USA
| | - Elena Zamagni
- Seragnoli Institute of Hematology, Bologna University School of Medicine, Bologna, Italy
| | | | | | - Hans E Johnsen
- Department of Hematology, Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
| | - Evangelos Terpos
- Department of Clinical Therapeutics, University of Athens, School of Medicine, Athens, Greece
| | - Anthony Reiman
- Dalhousie University Medical School, Dalhousie, Nova Scotia, Canada
| | - Robert A Kyle
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Heinz Ludwig
- Wilhelminenspital Der Stat Wien, Vienna, Austria
| | | | - Michele Cavo
- Seragnoli Institute of Hematology, Bologna University School of Medicine, Bologna, Italy
| | | | | | - Jens Hillengass
- Department of Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | - Antonio Palumbo
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Citta della Salute e della Scienza di Torino, Torino, Italy
| | - Alberto Orfao
- University Hospital of Salamanca/IBSAL, Salamanca, Spain
| | | | - Jesus San Miguel
- Clinica Universidad de Navarra, Centro de Investigacion Medica Aplicada (CIMA), Pamplona, Spain
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Heaney JLJ, Campbell JP, Griffin AE, Birtwistle J, Shemar M, Child JA, Gregory WM, Cairns DA, Morgan G, Jackson G, Drayson MT. Diagnosis and monitoring for light chain only and oligosecretory myeloma using serum free light chain tests. Br J Haematol 2017; 178:220-230. [PMID: 28573706 DOI: 10.1111/bjh.14753] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 03/06/2017] [Indexed: 11/29/2022]
Abstract
This study aims to guide the integration of serum free light chain (sFLC) tests into clinical practice, including a new rapid test (Seralite® ). Blood and urine analysis from 5573 newly diagnosed myeloma patients identified 576 light chain only (LCO) and 60 non-secretory (NS) cases. Serum was tested by Freelite® and Seralite® at diagnosis, maximum response and relapse. 20% of LCO patients had urine FLC levels below that recommended for measuring response but >97% of these had adequate sFLC levels (oligosecretory). The recommended Freelite® sFLC ≥100 mg/l for measuring response was confirmed and the equivalent Seralite® FLC difference (dFLC) >20 mg/l identified. By both methods, ≥38% of NS patients had measurable disease (oligosecretory). Higher sFLC levels were observed on Freelite® at all time points. However, good clinical concordance was observed at diagnosis and in response to therapy. Achieving at least a very good partial response according to either sFLC method was associated with better patient survival. Relapse was identified using a Freelite® sFLC increase >200 mg/l and found 100% concordance with a corresponding Seralite® dFLC increase >30 mg/l. Both Freelite® and Seralite® sensitively diagnose and monitor LCO/oligosecretory myeloma. Rapid testing by Seralite® could fast-track FLC screening and monitoring. Response by sFLC assessment was prognostic for survival and demonstrates the clinical value of routine sFLC testing.
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Affiliation(s)
- Jennifer L J Heaney
- Clinical Immunology Service, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - John P Campbell
- Clinical Immunology Service, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Anne E Griffin
- Clinical Immunology Service, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Jane Birtwistle
- Clinical Immunology Service, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | | | - J Anthony Child
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | | | - David A Cairns
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Gareth Morgan
- The Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | | | - Mark T Drayson
- Clinical Immunology Service, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
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Messiaen AS, De Sloovere MMW, Claus PE, Vercammen M, Van Hoovels L, Heylen O, Debrabandere J, Vanpoucke H, De Smet D. Performance Evaluation of Serum Free Light Chain Analysis: Nephelometry vs Turbidimetry, Monoclonal vs Polyclonal Reagents. Am J Clin Pathol 2017; 147:611-622. [PMID: 28575180 DOI: 10.1093/ajcp/aqx037] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Free light chain (FLC) measurement gained a lot of interest for diagnostic workup of monoclonal gammopathy. METHODS We evaluated the performance of turbidimetric polyclonal Freelite (The Binding Site, Birmingham, UK) assays on Cobas 6000 (Roche Diagnostics, Rotkreuz, Switzerland) and nephelometric monoclonal N Latex (Siemens Healthcare Diagnostics, Marburg, Germany) assays on BN ProSpec (Dade Behring, Deerfield, IL) vs established nephelometric Freelite assays on BN ProSpec. RESULTS Analytical performance was acceptable. Method comparison (n = 118) showed significant proportional FLC differences for N Latex assays. However, good correlation and clinical concordance were shown. Recovery study in the low concentration range demonstrated consistent over- and underrecovery for Freelite reagents, hampering future research on prognostic value of suppressed noninvolved FLC. Antigen excess detection was successful for κ FLC in three-fourths of cases with Freelite reagents and in all cases with N Latex reagents. However, the latter resulted in underestimated κ FLC concentrations. CONCLUSIONS FLC analysis requires continuous awareness of analytical limitations. Monitoring of disease response requires FLC analysis on the same platform using the same reagents.
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Affiliation(s)
- Anne-Sophie Messiaen
- From the Department of Laboratory Medicine, AZ Delta Roeselare-Menen, Roeselare, Belgium
| | - Maxime M W De Sloovere
- From the Department of Laboratory Medicine, AZ Delta Roeselare-Menen, Roeselare, Belgium
| | - Paul-Emile Claus
- From the Department of Laboratory Medicine, AZ Delta Roeselare-Menen, Roeselare, Belgium
| | - Martine Vercammen
- Department of Laboratory Medicine, AZ Sint-Jan Brugge-Oostende, Brugge, Belgium
| | - Lieve Van Hoovels
- Department of Laboratory Medicine, OLV Aalst-Asse, Aalst, Belgium; and
| | - Olivier Heylen
- Department of Laboratory Medicine, AZ Groeninge, Kortrijk, Belgium
| | - Johan Debrabandere
- From the Department of Laboratory Medicine, AZ Delta Roeselare-Menen, Roeselare, Belgium
| | - Hilde Vanpoucke
- From the Department of Laboratory Medicine, AZ Delta Roeselare-Menen, Roeselare, Belgium
| | - Dieter De Smet
- From the Department of Laboratory Medicine, AZ Delta Roeselare-Menen, Roeselare, Belgium
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Moghimi M, Kashkooli Behroozi M, Maghbooli M, Jafari S, Mazloomzadeh S, Pezeshgi A. Association between abnormal serum free light chains ratio and known prognostic factors in lymphoma; a nephrology viewpoint. J Renal Inj Prev 2017; 6:148-152. [PMID: 28497093 PMCID: PMC5423284 DOI: 10.15171/jrip.2017.29] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 12/04/2016] [Indexed: 12/02/2022] Open
Abstract
Introduction: The serum immunoglobulin free light chain (FLC) assay quantities of free kappa (κ) and lambda (λ) light chains. This assay has prognostic value in plasma cell proliferative disorders. There are limited data on serum FLC in B-cell malignancies.
Objectives: The aim of this study was to compare the known prognostic factors in non-Hodgkin’s lymphoma of the type B-cell and Hodgkin disease with an abnormal secretion amount of light chains in these lymphomas.
Patients and Methods: The association of pretreatment FLC and FLC ratio (κ:λ) with previously known prognostic factors for lymphoma such as the international prognostic index (IPI) and B symptoms were evaluated in 50 patients with Hodgkin’s and non-Hodgkin’s lymphoma. IPI is a prognostic score given based on the clinical variables including age, disease stage, serum LDH and extra-nodal involvement. Elevated FLC and an abnormal κ:λ ratio was defined based on the previous publications.
Results: The prevalence of abnormal FLC ratio was 38% in all patients and 40.9% in patients with diffuse large B-cell lymphoma. Abnormal FLC ratio was significantly associated with IPI (P=0.04) and B symptoms (P=0.02) in both groups of the patients with Hodgkin’s and non-Hodgkin’s lymphoma. The stage of the disease in Hodgkin’s lymphoma patients showed a significant relationship with the abnormal FLC ratio (P=0.04). Presence of the B symptoms in patients with Hodgkin’s lymphoma had a modest but not statistically significant association with the abnormal FLC ratio (P=0.07).
Conclusion: Abnormal FLC ratio as a new potent prognostic biomarker has a significant association with IPI which is the most common clinical tool used to predict outcome in lymphoma patients. Since there is a need for developing a reliable and quantitative prognostic biomarker for lymphoma, evaluation of the independent effect of the abnormal serum FLC ratio is suggested to be considered in future prospective studies. The result of these studies will also be useful for nephrologists, while serum immunoglobulin FLC is capable to damage kidney.
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Affiliation(s)
- Minoosh Moghimi
- Department of Hematology-Oncology, Faculty of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran.,Metabolic Diseases Research Center, Zanjan University of Medical Sciences, Zanjan, Iran
| | | | - Mehdi Maghbooli
- Department of Neurology, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Sattar Jafari
- Department of Hematology-Oncology, Faculty of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran.,Metabolic Diseases Research Center, Zanjan University of Medical Sciences, Zanjan, Iran
| | | | - Aiyoub Pezeshgi
- Department of Hematology-Oncology, Faculty of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
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221
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Yi JE, Lee SE, Jung HO, Min CK, Youn HJ. Association between left ventricular function and paraprotein type in patients with multiple myeloma. Korean J Intern Med 2017; 32:459-468. [PMID: 27048256 PMCID: PMC5432795 DOI: 10.3904/kjim.2015.339] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Revised: 11/18/2015] [Accepted: 11/18/2015] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND/AIMS Multiple myeloma (MM)-associated cardiac damage, particularly according to the type of monoclonal (M) protein has not been elucidated. We sought to investigate relationship between elevated serum M protein levels and echocardiographic indices of cardiac structure and function in patients with MM. METHODS We evaluated a total of 184 consecutive MM patients who underwent echocardiography for bone marrow pre-transplant screening. Serum levels of intact immunoglobulin M protein and free light chain kappa/lambda (FLC-κ/-λ) were measured. RESULTS One hundred thirty-nine patients were non-light chain MM (non-LCMM) and 45 patients belonged to LCMM. In patients with non-LCMM, significant correlations were found between serum M protein and left atrial volume index (LAVi; r = 0.720, p < 0.0001), E/e' (r = 0.511, p < 0.0001), and systolic pulmonary arterial pressure (r = 0.485, p < 0.0001). In patients with LCMM, log-transformed FLC-λ (log-λ) was correlated with left ventricular ejection fraction (LVEF, r = -0.536, p = 0.010), left ventricular (LV) end-systolic dimension (r = 0.500, p = 0.018), and LV end-systolic volume (r = 0.444, p = 0.038). On multivariate analyses, hematocrit and serum M protein were independent predictors of LAVi in patients with non-LCMM. In patient with LCMM, FLC-λ isotype was only found to be an independent determinant of LVEF. CONCLUSIONS An increase in serum M protein was associated with LV diastolic dysfunction, whereas an increase in serum FLC-λ concentration showed a negative correlation with the echocardiographic parameters of LV systolic function. These findings also suggest that serum M protein has different effects on LV function according to the type of paraproteins in patients with MM.
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Affiliation(s)
- Jeong-Eun Yi
- Department of Internal Medicine, Ewha Womans University Mokdong Hospital, Seoul, Korea
- Department of Internal Medicine, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Sung-Eun Lee
- Department of Internal Medicine, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Hae-Ok Jung
- Department of Internal Medicine, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Chang-Ki Min
- Department of Internal Medicine, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Ho-Joong Youn
- Department of Internal Medicine, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
- Correspondence to Ho-Joong Youn, M.D. Division of Cardiology, Department of Internal Medicine, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Korea Tel: +82-2-2258-6029 Fax: +82-2-591-1506 E-mail:
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Cigliana G, Gulli F, Napodano C, Pocino K, De Santis E, Colacicco L, Cordone I, Conti L, Basile U. Serum free light chain quantitative assays: Dilemma of a biomarker. J Clin Lab Anal 2017; 32. [PMID: 28444965 DOI: 10.1002/jcla.22243] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Accepted: 03/26/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Serum free light chains detection assays are consistently meeting greater interest for the diagnosis and monitoring of monoclonal gammopathies and plasma cell dyscrasias. Nowadays, there are neither standardized methods nor reference material for the determination of free light chains; for this reason, it is important to compare two different assays used in clinical laboratory. METHODS We evaluated 300 serum samples from patients with B-cell disorders and compared the analytical performances of both assay. Each test was assayed on both testing platforms (Siemens Dade Behring BN II Nephelometer and SPAPLUS by The Binding Site). κ/λ ratios were determined and compared. Results were analyzed by Passing-Bablok and Bland-Altman plots to evaluate comparability of the two techniques and to determine bias. RESULTS The reproducibility of both assays is acceptable, reaching minimum and desirable analytical goals derived from biological variability. However, values are not interchangeable between systems. This study shows that the two systems do not allow results to be transferred from one method to the other even if they display good agreement. CONCLUSION Our study highlights the importance of elaborating an international standard for free light chains quantification in order to offer homogeneous results as well as guarantee harmonization of values among laboratories. Moreover, the assays should be validated in specific patient groups to determine that they are clinically fit for purpose.
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Affiliation(s)
- Giovanni Cigliana
- Laboratory of Clinical Pathology, National Cancer Institute "Regina Elena", Rome, Italy
| | - Francesca Gulli
- Department of Laboratory Medicine, Catholic University of the Sacred Heart, Rome, Italy
| | - Cecilia Napodano
- Department of Laboratory Medicine, Catholic University of the Sacred Heart, Rome, Italy
| | - Krizia Pocino
- Department of Laboratory Medicine, Catholic University of the Sacred Heart, Rome, Italy
| | - Elena De Santis
- Laboratory of Clinical Pathology, National Cancer Institute "Regina Elena", Rome, Italy
| | - Luigi Colacicco
- Department of Laboratory Medicine, Institute of Biochemistry, Catholic University of the Sacred Heart, Rome, Italy
| | - Iole Cordone
- Oncoematology, Clinical Pathology, National Cancer Institute "Regina Elena", Rome, Italy
| | - Laura Conti
- Laboratory of Clinical Pathology, National Cancer Institute "Regina Elena", Rome, Italy
| | - Umberto Basile
- Department of Laboratory Medicine, Catholic University of the Sacred Heart, Rome, Italy
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Analytical Criticalities Associated to Different Immunological Methods for Serum Free Light Chain Detection in Plasma Cell Dyscrasias: A Description of Particular Clinical Cases. Int J Mol Sci 2017; 18:ijms18040804. [PMID: 28417905 PMCID: PMC5412388 DOI: 10.3390/ijms18040804] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 04/03/2017] [Accepted: 04/05/2017] [Indexed: 11/17/2022] Open
Abstract
Current criteria for differential diagnosis of multiple myeloma (MM), Monoclonal gammopathy of undetermined significance (MGUS), and smoldering multiple myeloma (SMM) are included in the 2003 guidelines by the International Myeloma Working Group (IMWG). An updated version was then published in 2014, highlighting the importance of serum free light chain (sFLC) detection, as well as the κ/λ ratio as excellent indicators of clonality. At present, two commercial assays for sFLC quantification are available: the Freelite™ assay and the N-Latex assay. The first was developed by The Binding Site based on a mixture of polyclonal antibodies directed against a variety of FLC epitopes. It may be run on a wide range of nephelometers, as well as on turbidimeters. The second method was developed by Siemens and runs exclusively on Siemens instruments. It employs a probe mixture of mouse monoclonal antibodies. The aim of our study was to evaluate sFLC measurement and calculated κ/λ ratio in 85 patients with monoclonal gammopathies (MGs) in order to compare methods. We demonstrated that there is only a moderate concordance between the two FLC assays. In particular, in one case, we observed no qualitative alterations of the serum protein pattern, and in the absence of a Freelite™ assay, sFLC measurement would not have been possible to highlight the increase of λ FLC.
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Sečník P, Lavríková P, Hošková L, Malíková P, Jabor A, Franeková J. Free light chain and intact immunoglobulin abnormalities in heart transplant recipients: Two year follow-up timelines and clinical correlations. Transpl Immunol 2017; 41:22-26. [DOI: 10.1016/j.trim.2017.01.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 11/01/2016] [Accepted: 01/06/2017] [Indexed: 12/24/2022]
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225
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Lee AYS, Cassar PM, Johnston AM, Adelstein S. Clinical use and interpretation of serum protein electrophoresis and adjunct assays. Br J Hosp Med (Lond) 2017; 78:C18-C20. [DOI: 10.12968/hmed.2017.78.2.c18] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Adrian YS Lee
- Junior Medical Officer, Royal Hobart Hospital, Hobart 7000, Tasmania, Australia; Clinical Lecturer, School of Medicine, University of Tasmania, Tasmania, Australia and University Associate, Menzies Institute for Medical Research, University of Tasmania, Tasmania, Australia
| | - Paul M Cassar
- Senior Scientific Officer, SEALS Sutherland Centre of Immunology, Sutherland Hospital, New South Wales, Australia
| | - Anna M Johnston
- Haematologist and Pathologist, Royal Hobart Hospital, Tasmania, Australia
| | - Stephen Adelstein
- Clinical Immunologist and Allergist, Royal Prince Alfred Hospital, New South Wales, Australia and Clinical Associate Professor, Sydney Medical School, University of Sydney, New South Wales, Australia
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de Mel S, Chen Y, Gopalakrishnan SK, Ooi M, Teo C, Tan D, Teo MLC, Tso ACY, Lee LK, Nagarajan C, Goh YT, Chng WJ. The Singapore Myeloma Study Group Consensus Guidelines for the management of patients with multiple myeloma. Singapore Med J 2017; 58:55-71. [PMID: 27609508 PMCID: PMC5311886 DOI: 10.11622/smedj.2016150] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Multiple myeloma (MM) is an incurable plasma cell neoplasm with an incidence of 100 patients per year in Singapore. Major advances have been made in the diagnosis, risk stratification and treatment of MM in the recent past. The reclassification of a subset of patients with smouldering MM, based on high-risk biomarkers, and the development of the revised international staging system are among the key new developments in diagnosis and staging. The use of novel agent-based treatment has resulted in significant improvements in the survival and quality of life of many patients with MM. Determining the optimal use of proteasome inhibitors, immunomodulators and, more recently, monoclonal antibodies is an area of ongoing investigation. In this guideline, we aim to provide an overview of the management of MM, incorporating the latest developments in diagnosis and treatment.
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Affiliation(s)
- Sanjay de Mel
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore
| | - Yunxin Chen
- Department of Haematology, Singapore General Hospital, Singapore
| | | | - Melissa Ooi
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore
| | - Constance Teo
- Division of Oncology Pharmacy, National University Cancer Institute, National University Health System, Singapore
| | - Daryl Tan
- Raffles Cancer Centre, Raffles Hospital, Singapore
| | | | - Allison CY Tso
- Department of Haematology, Tan Tock Seng Hospital, Singapore
| | - Lian King Lee
- Department of Haematology, Tan Tock Seng Hospital, Singapore
| | | | - Yeow Tee Goh
- Department of Haematology, Singapore General Hospital, Singapore
| | - Wee Joo Chng
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore
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Andrade-Campos M, Murillo-Flórez I, García-Sanz R, Giraldo P. Immunoparesis in IgM gammopathies as a useful biomarker to predict disease progression. ACTA ACUST UNITED AC 2017; 55:1598-1604. [DOI: 10.1515/cclm-2016-0748] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 01/25/2017] [Indexed: 12/26/2022]
Abstract
AbstractBackground:The management of IgM monoclonal gammopathies undetermined significance (IgM-MGUS) and Waldenstrom’s macroglobulinemia (WM) may be challenging. Modern immunoassays that quantify specific monoclonal heavy and light chain immunoglobulins are promising for their use in these applications.Methods:Ninety consecutive patients (39 IgM-MGUS, 32 indolent WM [iWM], and 19 WM) seen between January 2007 and March 2014 were analyzed. Heavy/light chain (HLC) and serum free light chains assays (FLC) were determined at diagnosis to study their utility as biomarkers in IgM monoclonal gammopathies.Results:The HLC involved to uninvolved IgM ratios (iHLC/uHLC) showed a progressive increase when going from IgM-MGUS, to iWM and to WM (p=0.002). Furthermore, an iHLC/uHLC>62 identified a group of iWM patients with a shorter time-to-progression (TTP) (108 vs. 133 months, p=0.033). Separate analysis of the involved and uninvolved components showed that only the suppression of the uninvolvedimmunoglobulin was predictive of shorter TTP (HR=3.04, p=0.03) suggesting that it could be the majorcontributor to the prognostic value of the Hevylite assay. Additionally, a multivariate analysis showed that immunosuppression (either classical immunoparesis or Hevylite immunosuppression) was an independent prognostic factor (p=0.016) reinforcing its relevance in the disease mechanism. Finally, monoclonal sFLC levels were highest in WM patients, with 83% presenting values>60 mg/L.Conclusions:The results suggest that the levels of immunosuppression and/or the iHLC/uHLC ratio of IgM immunoglobulins measured by Hevylite are associated with greater disease activity which significantly impacts in the outcome of WM patients and may also help in the differentiation of IgMMGUS from iWM.
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Kubicki T, Dytfeld D, Baszczuk A, Wysocka E, Komarnicki M, Lewandowski K. Clinical usefulness of serum free light chains measurement in patients with multiple myeloma: comparative analysis of two different tests. POSTEP HIG MED DOSW 2017. [DOI: 10.5604/01.3001.0010.3788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
<b>Introduction:</b> There are two commercially available tests for measurement of serum free light chains (sFLC) in multiple myeloma (MM) patients – Freelite and N Latex FLC. The aim of this study was to perform an assessment and direct comparison of the usefulness of the methods in routine clinical practice.<br/><b>Methods:</b> 40 refractory/relapsed MM patients underwent routine disease activity assessment studies, along with sFLC analysis using both assays. Correlation and concordance between the tests and sensitivity of studied methods of sFLC assessment were established. Special attention was focused on sFLC results in patients finally evaluated after completing the treatment. <br/><b>Results:</b> A weak correlation for the measurement of both κ [Passing–Bablok slope (PB) = 0.7681] and λ chains [(PB) = 1.542] was found. Using Bland–Altman plots, a bias of 0.0467 (κ) and -0.2133 (λ) between the measurements was documented. The concordance coefficient equaled 0.87 for κ, 0.62 for λ and 0.52 for κ/λ ratio. Ten patients had an abnormal Freelite assay κ/λ ratio and normal N Latex FLC κ/λ ratio. Three of these patients had negative serum protein electrophoresis results and fulfilled diagnostic criteria of stringent complete remission (sCR) according to N Latex FLC (but not according to Freelite). When the κ/λ ratio obtained by both methods was compared to patients’ serum/urine protein electrophoresis and immunofixation results, sensitivity of Freelite and N Latex FLC was established to be 62.5% and 41%, respectively. <br/><b>Conclusions:</b> There was no strong correlation or concordance between the two assays, and the sensitivity in terms of sFLC detection was different. This may cause problems when diagnosis of sCR is considered.
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Affiliation(s)
- Tadeusz Kubicki
- Students’ Scientific Society, University of Medical Sciences, Poznań, Poland
| | - Dominik Dytfeld
- Department of Hematology and Bone Marrow Transplantation, University of Medical Sciences, Poznań, Poland
| | - Aleksandra Baszczuk
- Department of Laboratory Diagnostics, University of Medical Sciences, Poznań, Poland
| | - Ewa Wysocka
- Department of Laboratory Diagnostics, University of Medical Sciences, Poznań, Poland
| | - Mieczysław Komarnicki
- Department of Hematology and Bone Marrow Transplantation, University of Medical Sciences, Poznań, Poland
| | - Krzysztof Lewandowski
- Department of Hematology and Bone Marrow Transplantation, University of Medical Sciences, Poznań, Poland
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Campbell JP, Heaney JL, Shemar M, Baldwin D, Griffin AE, Oldridge E, Goodall M, Afzal Z, Plant T, Cobbold M, Jefferis R, Jacobs JF, Hand C, Drayson MT. Development of a rapid and quantitative lateral flow assay for the simultaneous measurement of serum κ and λ immunoglobulin free light chains (FLC): inception of a new near-patient FLC screening tool. ACTA ACUST UNITED AC 2017; 55:424-434. [DOI: 10.1515/cclm-2016-0194] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 07/07/2016] [Indexed: 12/23/2022]
Abstract
AbstractBackground:Serum free light chains (FLC) are sensitive biomarkers used for the diagnosis and management of plasma cell dyscrasias, such as multiple myeloma (MM), and are central to clinical screening algorithms and therapy response criteria. We have developed a portable, near-patient, lateral-flow test (SeraliteMethods:Assay interference, imprecision, lot-to-lot variability, linearity, and the utility of a competitive-inhibition design for the elimination of antigen-excess (‘hook effect’) were assessed. Reference ranges were calculated from 91 healthy donor sera. Preliminary clinical validation was conducted by retrospective analysis of sera from 329 patients. Quantitative and diagnostic results were compared to FreeliteResults:SeraliteConclusions:Seralite
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230
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Zumbo G, Sadeghi-Alavijeh O, Hawkins PN, Fontana M. New and developing therapies for AL amyloidosis. Expert Opin Pharmacother 2016; 18:139-149. [DOI: 10.1080/14656566.2016.1274971] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Giulia Zumbo
- National Amyloidosis Centre, University College London, London, UK
| | | | | | - Marianna Fontana
- National Amyloidosis Centre, University College London, London, UK
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Dupuis MM, Tuchman SA. Non-secretory multiple myeloma: from biology to clinical management. Onco Targets Ther 2016; 9:7583-7590. [PMID: 28008276 PMCID: PMC5171196 DOI: 10.2147/ott.s122241] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Multiple myeloma (MM) is the second most common hematologic malignancy in the US. It is typically characterized by production of large amounts of defective immunoglobulin (Ig). Diagnosing MM and monitoring treatment response, including eventual relapse, are largely based on sequential measurements of Ig. However, a small subset of MM called non-secretory multiple myeloma (NSMM) produces no detectable Ig. This subset of true NSMM has become even smaller over time, as the advent of the serum free light chain assay has resulted in the majority of NSMM patients being recategorized as light-chain MM – that is, MM cells that produce only the light-chain component of Ig. True forms of NSMM, meaning MM that secretes no monoclonal proteins whatsoever, constitute a distinct entity that is reviewed; definition of NSMM using current detection methods, discuss the biology underpinning NSMM development, and share recommendations for how NSMM should be managed clinically with respect to detection, treatment, and monitoring.
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Affiliation(s)
| | - Sascha A Tuchman
- Division of Hematology/Oncology, Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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233
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Rosner MH, Edeani A, Yanagita M, Glezerman IG, Leung N. Paraprotein-Related Kidney Disease: Diagnosing and Treating Monoclonal Gammopathy of Renal Significance. Clin J Am Soc Nephrol 2016; 11:2280-2287. [PMID: 27526705 PMCID: PMC5142062 DOI: 10.2215/cjn.02920316] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Paraprotein-related kidney disease represents a complex group of diseases caused by an abnormal paraprotein secreted by a clone of B cells. The disease manifestations range from tubulopathies, such as the Fanconi syndrome, to a spectrum of glomerular diseases that can present with varying degrees of proteinuria and renal dysfunction. Diagnosis of these diseases can be challenging because of the wide range of manifestations as well as the relatively common finding of a serum paraprotein, especially in elderly patients. Thus, renal biopsy along with detailed hematologic workup is essential to link the presence of the paraprotein to the associated renal disease. Recent advances in treatment with more effective and targeted chemotherapies, as well as stem cell transplantation, have improved the renal and overall prognosis for many of these disorders.
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Affiliation(s)
- Mitchell H. Rosner
- Division of Nephrology, University of Virginia Health System, Charlottesville, Virginia
| | - Amaka Edeani
- Kidney Diseases Branch, National Institute of Diabetes, Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Motoko Yanagita
- Department of Nephrology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ilya G. Glezerman
- Renal Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Medicine, Weill Cornell Medical College, New York, New York; and
| | - Nelson Leung
- Divisions of Nephrology and Hypertension and
- Hematology, Mayo Clinic, Rochester, Minnesota
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234
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Prokaeva T, Spencer B, Sun F, O'Hara RM, Seldin DC, Connors LH, Sanchorawala V. Immunoglobulin heavy light chain test quantifies clonal disease in patients with AL amyloidosis and normal serum free light chain ratio. Amyloid 2016; 23:214-220. [PMID: 27677679 DOI: 10.1080/13506129.2016.1219715] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Serum and urine immunofixation electrophoreses (SIFE/UIFE) are used for clonal detection in plasma cell dyscrasias, while serum free light chain (sFLC) testing provides quantitation of clonal disease. Up to 20% of patients with light chain (AL) amyloidosis may present with normal FLC ratio (FLCr). METHODS We assessed the diagnostic, quantitative and prognostic potential of serum heavy light chain ratio (HLCr) in 199 untreated patients at initial evaluation. RESULTS An abnormal HLCr was found in 37.2%, abnormal FLCr in 81.9% and positivity by SIFE/UIFE in 94% of patients. HLCr together with SIFE/UIFE identified clonality in 94% patients; the combination with FLCr yielded 100% sensitivity. An HLCr abnormality was significantly over-represented in normal compared to abnormal FLCr group (63.9% versus 31.3%). HLCr did not predict overall survival (OS) (log rank, p = 0.09), while an abnormal FLCr was associated with decreased OS (log rank, p = 0.03). The combined use of both ratios trended toward increased OS in the abnormal HLCr/normal FLCr group (log rank, p = 0.11; Wilcoxon, p = 0.04). On multivariate analysis, HLCr was not predictive of OS, whereas an abnormal FLCr was associated with shorter OS (HR = 1.7, p = 0.04). CONCLUSIONS The HLC assay has potential as a supplemental test to quantify monoclonal protein in patients with normal FLCr results.
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Affiliation(s)
- Tatiana Prokaeva
- a Amyloidosis Center , Boston University School of Medicine , Boston , MA , USA
| | - Brian Spencer
- a Amyloidosis Center , Boston University School of Medicine , Boston , MA , USA
| | - Fangui Sun
- b Boston University School of Public Health , Boston , MA , USA
| | | | - David C Seldin
- a Amyloidosis Center , Boston University School of Medicine , Boston , MA , USA.,d Department of Medicine , Section of Hematology and Oncology, Boston Medical Center , Boston , MA , USA
| | - Lawreen H Connors
- a Amyloidosis Center , Boston University School of Medicine , Boston , MA , USA
| | - Vaishali Sanchorawala
- a Amyloidosis Center , Boston University School of Medicine , Boston , MA , USA.,d Department of Medicine , Section of Hematology and Oncology, Boston Medical Center , Boston , MA , USA
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235
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Tacchetti P, Pezzi A, Zamagni E, Pantani L, Rocchi S, Zannetti BA, Mancuso K, Rizzello I, Cavo M. Role of serum free light chain assay in the detection of early relapse and prediction of prognosis after relapse in multiple myeloma patients treated upfront with novel agents. Haematologica 2016; 102:e104-e107. [PMID: 27909220 DOI: 10.3324/haematol.2016.154070] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Affiliation(s)
- Paola Tacchetti
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine, Bologna University School of Medicine, Italy
| | - Annalisa Pezzi
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine, Bologna University School of Medicine, Italy
| | - Elena Zamagni
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine, Bologna University School of Medicine, Italy
| | - Lucia Pantani
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine, Bologna University School of Medicine, Italy
| | - Serena Rocchi
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine, Bologna University School of Medicine, Italy
| | - Beatrice Anna Zannetti
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine, Bologna University School of Medicine, Italy
| | - Katia Mancuso
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine, Bologna University School of Medicine, Italy
| | - Ilaria Rizzello
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine, Bologna University School of Medicine, Italy
| | - Michele Cavo
- "Seràgnoli" Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine, Bologna University School of Medicine, Italy
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236
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Voortman MM, Stojakovic T, Pirpamer L, Jehna M, Langkammer C, Scharnagl H, Reindl M, Ropele S, Seifert-Held T, Archelos JJ, Fuchs S, Enzinger C, Fazekas F, Khalil M. Prognostic value of free light chains lambda and kappa in early multiple sclerosis. Mult Scler 2016; 23:1496-1505. [DOI: 10.1177/1352458516681503] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Cerebrospinal fluid (CSF) immunoglobulin free light chains (FLC) have been suggested as quantitative alternative to oligoclonal bands (OCB) in the diagnosis of multiple sclerosis (MS). However, little is known on their role in predicting clinical and paraclinical disease progression, particularly in early stages. Objective: To assess the prognostic value of FLC in OCB-positive patients with clinically isolated syndrome (CIS) suggestive of MS and early MS. Methods: We determined FLC kappa (KFLC) and lambda (LFLC) in CSF and serum by nephelometry in 61 patients (CIS ( n = 48), relapsing-remitting multiple sclerosis ( n = 13)) and 60 non-inflammatory neurological controls. Median clinical follow-up time in CIS was 4.8 years (interquartile range (IQR), 1.5–6.5 years). Patients underwent 3T magnetic resonance imaging (MRI) at baseline and follow-up (median time interval, 2.2 years; IQR, 1.0–3.7 years) to determine T2 lesion load (T2LL) and percent brain volume change (PBVC). Results: CSF FLC were significantly increased in CIS/MS compared to controls (all p < 0.001). A lower KFLC/LFLC CSF ratio was associated with CIS-clinically definite multiple sclerosis (CDMS) conversion (hazard ratio (HR) = 2.89; 95% confidence interval (CI) = 1.17–7.14; p < 0.05). No correlations were found for FLC variables with T2LL or PBVC. Conclusion: Our study confirms increased intrathecal synthesis of FLC in CIS/MS which supports their diagnostic contribution. The KFLC/LFLC CSF ratio appears to have a prognostic value in CIS beyond OCB.
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Affiliation(s)
| | - Tatjana Stojakovic
- Clinical Institute of Medical and Chemical
Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Lukas Pirpamer
- Department of Neurology, Medical University of
Graz, Graz, Austria
| | - Margit Jehna
- Division of Neuroradiology, Vascular and
Interventional Radiology, Medical University of Graz, Graz, Austria
| | | | - Hubert Scharnagl
- Clinical Institute of Medical and Chemical
Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Markus Reindl
- Clinical Department of Neurology, Medical
University of Innsbruck, Innsbruck, Austria
| | - Stefan Ropele
- Department of Neurology, Medical University of
Graz, Graz, Austria
| | | | | | - Siegrid Fuchs
- Department of Neurology, Medical University of
Graz, Graz, Austria
| | - Christian Enzinger
- Department of Neurology, Medical University of
Graz, Graz, Austria/Division of Neuroradiology, Vascular and Interventional
Radiology, Medical University of Graz, Graz, Austria
| | - Franz Fazekas
- Department of Neurology, Medical University of
Graz, Graz, Austria
| | - Michael Khalil
- Department of Neurology, Medical University of
Graz, Graz, Austria
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237
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Krishnan SR, Luk F, Brown RD, Suen H, Kwan Y, Bebawy M. Isolation of Human CD138(+) Microparticles from the Plasma of Patients with Multiple Myeloma. Neoplasia 2016; 18:25-32. [PMID: 26806349 PMCID: PMC4735625 DOI: 10.1016/j.neo.2015.11.011] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 11/24/2015] [Accepted: 11/30/2015] [Indexed: 02/06/2023] Open
Abstract
The confinement of multiple myeloma (MM) to the bone marrow microenvironment requires an invasive bone marrow biopsy to monitor the malignant compartment. The existing clinical tools used to determine treatment response and tumor relapse are limited in sensitivity mainly because they indirectly measure tumor burden inside the bone marrow and fail to capture the patchy, multisite tumor infiltrates associated with MM. Microparticles (MPs) are 0.1- to 1.0-μm membrane vesicles, which contain the cellular content of their originating cell. MPs are functional mediators and convey prothrombotic, promalignant, proresistance, and proinflammatory messages, establishing intercellular cross talk and bypassing the need for direct cell-cell contact in many pathologies. In this study, we analyzed plasma cell–derived MPs (CD138+) from deidentified MM patients (n = 64) and normal subjects (n = 18) using flow cytometry. The morphology and size of the MPs were further analyzed using scanning electron microscopy. Our study shows the proof of a systemic signature of MPs in MM patients. We observed that the levels of MPs were significantly elevated in MM corresponding to the tumor burden. We provide the first evidence for the presence of MPs in the peripheral blood of MM patients with potential applications in personalized MM clinical monitoring.
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Affiliation(s)
- Sabna Rajeev Krishnan
- Graduate School of Health, Discipline of Pharmacy, University of Technology Sydney, NSW 2007, Australia
| | - Frederick Luk
- Graduate School of Health, Discipline of Pharmacy, University of Technology Sydney, NSW 2007, Australia
| | - Ross D Brown
- Institute of Haematology, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia
| | - Hayley Suen
- Institute of Haematology, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia
| | - Yiulam Kwan
- Department of Haematology, Concord Repatriation General Hospital, Concord, NSW 2139, Australia
| | - Mary Bebawy
- Graduate School of Health, Discipline of Pharmacy, University of Technology Sydney, NSW 2007, Australia.
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Mills JR, Kohlhagen MC, Dasari S, Vanderboom PM, Kyle RA, Katzmann JA, Willrich MAV, Barnidge DR, Dispenzieri A, Murray DL. Comprehensive Assessment of M-Proteins Using Nanobody Enrichment Coupled to MALDI-TOF Mass Spectrometry. Clin Chem 2016; 62:1334-44. [DOI: 10.1373/clinchem.2015.253740] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 07/18/2016] [Indexed: 01/20/2023]
Abstract
Abstract
BACKGROUND
Electrophoretic separation of serum and urine proteins has played a central role in diagnosing and monitoring plasma cell disorders. Despite limitations in resolution and analytical sensitivity, plus the necessity for adjunct methods, protein gel electrophoresis and immunofixation electrophoresis (IFE) remain front-line tests.
METHODS
We developed a MALDI mass spectrometry–based assay that was simple to perform, automatable, analytically sensitive, and applicable to analyzing the wide variety of monoclonal proteins (M-proteins) encountered clinically. This assay, called MASS-FIX, used the unique molecular mass signatures of the different Ig isotypes in combination with nanobody immunoenrichment to generate information-rich mass spectra from which M-proteins could be identified, isotyped, and quantified. The performance of MASS-FIX was compared to current gel-based electrophoresis assays.
RESULTS
MASS-FIX detected all M-proteins that were detectable by urine or serum protein electrophoresis. In serial dilution studies, MASS-FIX was more analytically sensitive than IFE. For patient samples, MASS-FIX provided the same primary isotype information for 98% of serum M-proteins (n = 152) and 95% of urine M-proteins (n = 55). MASS-FIX accurately quantified M-protein to <1 g/dL, with reduced bias as compared to protein electrophoresis. Intraassay and interassay CVs were <20% across all samples having M-protein concentrations >0.045 g/dL, with the ability to detect M-proteins <0.01 g/dL. In addition, MASS-FIX could simultaneously measure κ:λ light chain ratios for IgG, IgA, and IgM. Retrospective serial monitoring of patients with myeloma posttreatment demonstrated that MASS-FIX provided equivalent quantitative information to either protein electrophoresis or the Hevylite™ assay.
CONCLUSIONS
MASS-FIX can advance how plasma cell disorders are screened, diagnosed, and monitored.
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Affiliation(s)
- John R Mills
- Departments of Laboratory Medicine and Pathology
| | | | | | | | - Robert A Kyle
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
| | | | | | | | - Angela Dispenzieri
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
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239
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Investigation into the interference of the monoclonal antibody daratumumab on the free light chain assay. Clin Biochem 2016; 49:1202-1204. [DOI: 10.1016/j.clinbiochem.2016.07.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 07/25/2016] [Accepted: 07/25/2016] [Indexed: 11/20/2022]
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240
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[The consensus of the diagnosis and treatment of primary light chain amyloidosis in China (2016 version)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2016; 37:742-746. [PMID: 27719714 PMCID: PMC7342122 DOI: 10.3760/cma.j.issn.0253-2727.2016.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Indexed: 12/11/2022]
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241
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Koo EH, Shin JH, Jang HR, Park HD, Kwon GY, Huh W, Kim DJ, Kim YG, Oh HY, Lee JE. Diagnostic performances of M-protein tests according to the clinical presentations of kidney disease. Eur J Intern Med 2016; 33:88-92. [PMID: 27421913 DOI: 10.1016/j.ejim.2016.06.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 05/14/2016] [Accepted: 06/11/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Screening for monoclonal immunoglobulin (MIg) is critical in patients with kidney disease. METHODS We identified 943 subjects who underwent kidney biopsy and at least one of monoclonal (M)-protein tests (serum and urine electrophoresis [EP], serum and urine immunofixation [IF], and serum free light chain [FLC] ratio). The sensitivities of several combinations of the 5 tests were examined by clinical presentations of kidney disease. RESULTS The sensitivities of serum EP, urine EP, and the serum FLC ratio were 65%, 68%, and 71%, respectively, which were lower than those of serum IF (79%) and urine IF (87%) to detect MIg. In the nephrotic syndrome (NS) group, the panel including serum IF, urine IF, and the serum FLC ratio exhibited 100% sensitivity to identify MIg in patients with multiple myeloma (MM) or with monoclonal gammopathy of renal significance (MGRS). In subjects without NS, the panel of serum EP and serum FLC ratio detected MIg in all cases of MM, and the serum IF plus serum FLC ratio detected MIg in all cases of MGRS. CONCLUSION This study demonstrated that the sensitivity of screening panels differed by the presenting features of kidney disease. The M-protein tests had lower sensitivity for detection of MIg in subjects with NS compared to those with other clinical presentation.
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Affiliation(s)
- Eun Hee Koo
- Nephrology Division, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jung-Ho Shin
- Nephrology Division, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hye Ryoun Jang
- Nephrology Division, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyung-Doo Park
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Gee-Young Kwon
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Wooseong Huh
- Nephrology Division, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dae Joong Kim
- Nephrology Division, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yoon-Goo Kim
- Nephrology Division, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ha Young Oh
- Nephrology Division, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jung Eun Lee
- Nephrology Division, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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Gertz MA. Immunoglobulin light chain amyloidosis: 2016 update on diagnosis, prognosis, and treatment. Am J Hematol 2016; 91:947-56. [PMID: 27527836 DOI: 10.1002/ajh.24433] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 05/22/2016] [Indexed: 02/01/2023]
Abstract
DISEASE OVERVIEW Immunoglobulin light chain amyloidosis is a clonal, nonproliferative plasma cell disorder in which fragments of immunoglobulin light chain are deposited in tissues. Clinical features depend on organs involved but can include restrictive cardiomyopathy, nephrotic syndrome, hepatic failure, peripheral/autonomic neuropathy, and atypical multiple myeloma. DIAGNOSIS Tissue biopsy stained with Congo red demonstrating amyloid deposits with applegreen birefringence is required for diagnosis. Invasive organ biopsy is not required because amyloid deposits can be found in bone marrow biopsy or subcutaneous fat aspirate in 85% of patients. Verification that amyloid is composed of immunoglobulin light chains is mandatory. PROGNOSIS N-terminal pro-brain natriuretic peptide (NTproBNP), serum troponin T, and difference between involved and uninvolved immunoglobulin free light chain values are used to classify patients into four groups of similar size; median survivals are 94.1, 40.3, 14.0, and 5.8 months. THERAPY All patients with a systemic amyloid syndrome require therapy to prevent deposition of amyloid in other organs and prevent progressive organ failure of involved sites. Stem cell transplant (SCT) is preferred, but only 20% of patients are eligible. Requirements for safe SCT include systolic blood pressure >90 mmHg, troponin T <0.06 ng mL21, age <70 years, and serum creatinine 1.7 mg dL21. Nontransplant candidates can be offered melphalan-dexamethasone or cyclophosphamide-bortezomib-dexamethasone. Other combinations of chemotherapy with agents such as cyclophosphamide-thalidomide (or lenalidomide)-dexamethasone, bortezomib-dexamethasone, and melphalan-prednisone-lenalidomide have documented activity. Antibodies designed to dissolve existing amyloid deposits are under study for previously treated and untreated patients. Late diagnosis remains a major obstacle to initiating effective therapy. Am. J. Hematol., 2016. © 2016 Wiley Periodicals, Inc. Am. J. Hematol. 91:948-956, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Morie A. Gertz
- Division of Hematology; Mayo Clinic; Rochester Minnesota
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243
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Evaluation of the Impact of Renal Failure on Correlation and Concordance Between 2 Free Light Chain Assays. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2016; 16:693-704. [PMID: 27618362 DOI: 10.1016/j.clml.2016.08.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 07/17/2016] [Accepted: 08/02/2016] [Indexed: 01/11/2023]
Abstract
BACKGROUND Free light chain (FLC) assays are essential for diagnosis and follow-up of plasma cell dyscrasia. Two assays are available: Freelite (Binding Site) and N Latex FLC (Siemens). The aim of our study was to evaluate the impact of renal failure on concordance and correlation between the 2 FLC assays. METHODS FLC measurements using both assays were performed on 1215 fresh serum samples from patients with or without monoclonal gammopathy and renal failure. Concordance and correlation were evaluated using Passing-Bablock regression, Pearson correlation coefficient, and the Cohen kappa coefficient, taking into account the renal failure stage (evaluated with Chronic Kidney Disease-Epidemiology Collaboration formulae) and evaluation of treatment response in patients' follow-up. RESULTS A good correlation was demonstrated between both assays, irrespective of the renal failure stage (Pearson correlation coefficient > 0.90). For FLC ratio interpretation, there remained 7.6% to 20.8% discordances between the 2 methods throughout the whole range of renal impairment. To evaluate FLC evolution in patient follow-up, 41 patients were selected with at least 6 consecutive serum samples being collected during the study period: we observed a concordant evolution of FLC concentrations between both assays. However, few discrepancies were observed with 4 patients. CONCLUSIONS Despite adjusted reference ranges for Freelite FLC ratio, there are approximately 12.5% discrepancies in interpretation of FLC ratio between the 2 available assays. They are not linked to renal failure stage and neither of the assays performed better than the other: results must be interpreted taking into account clinical data and the same assay must be used for patient follow-up.
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Gagliardi A, Carbone C, Russo A, Cuccurullo R, Lucania A, Cioppa PD, Misso G, Caraglia M, Tommasino C, Mastrullo L. Combined use of free light chain and heavy/light chain ratios allow diagnosis and monitoring of patients with monoclonal gammopathies: Experience of a single institute, with three exemplar case reports. Oncol Lett 2016; 12:2363-2370. [PMID: 27698801 PMCID: PMC5038391 DOI: 10.3892/ol.2016.4965] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 06/02/2016] [Indexed: 01/06/2023] Open
Abstract
Monoclonal gammopathies are characterized by serum monoclonal component (MC) plus an intact immunoglobulin and a free light chain (FLC), or a combination of both. The measurement of FLC with Freelite® is the standard practice recommended by International Myeloma Working Group guidelines. Recently, Hevylite® heavy/light chains (HLC) assays were introduced to specifically target junctional epitopes between the heavy and light chains of intact immunoglobulins, allowing the independent quantification of the involved (MC) and uninvolved (polyclonal immunoglobulin background) HLC isotype. Between January 2012 and March 2014, 90 patients were examined: 49 multiple myeloma (MM), 6 smoldering MM (SMM) and 35 monoclonal gammopathy of undetermined significance (MGUS). Of these 90 patients, 300 samples were collected at different times. The diagnostic and monitoring contribution of Hevylite A and G assays was assessed in all 90 patients examined. Additionally, 3 representative cases were selected. The Hevylite absolute values and ratio demonstrated high sensitivity and specificity with respect to serum protein electrophoresis and serum immunofixation. The combined use of Hevylite A and G with Freelite was particularly useful in dubious cases with more than one MC or with co-migrating components, as well as in the course of monitoring to assess the independent change of FLC and HLC, possibly reflecting the presence of clonal heterogeneity in the cohort. From this study, it can be concluded that FLC and HLC are independent, useful markers to monitor the MC and to assess with greater specificity and sensitivity the effect of therapy, thereby providing clinical support. Further studies are required to assess the prognostic potential of Hevylite in MGUS and SMM.
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Affiliation(s)
- Alfredo Gagliardi
- Complex Operative Unit of Hematology, San Gennaro Hospital, Naples 1 Local Health Center, I-80135 Naples, Italy
| | - Claudio Carbone
- Complex Operative Unit of Clinical Pathology, San Gennaro Hospital, Naples 1 Local Health Center, I-80135 Naples, Italy
| | - Angela Russo
- Complex Operative Unit of Clinical Pathology, San Gennaro Hospital, Naples 1 Local Health Center, I-80135 Naples, Italy
| | - Rosanna Cuccurullo
- Complex Operative Unit of Hematology, San Gennaro Hospital, Naples 1 Local Health Center, I-80135 Naples, Italy
| | - Anna Lucania
- Complex Operative Unit of Hematology, San Gennaro Hospital, Naples 1 Local Health Center, I-80135 Naples, Italy
| | - Paola Della Cioppa
- Complex Operative Unit of Hematology, San Gennaro Hospital, Naples 1 Local Health Center, I-80135 Naples, Italy
| | - Gabriella Misso
- Department of Biochemistry, Biophysics and General Pathology, Second University of Naples, I-80138 Naples, Italy
| | - Michele Caraglia
- Department of Biochemistry, Biophysics and General Pathology, Second University of Naples, I-80138 Naples, Italy
| | - Catello Tommasino
- Complex Operative Unit of Clinical Pathology, San Gennaro Hospital, Naples 1 Local Health Center, I-80135 Naples, Italy
| | - Lucia Mastrullo
- Complex Operative Unit of Hematology, San Gennaro Hospital, Naples 1 Local Health Center, I-80135 Naples, Italy
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Autoimmunity and lymphoproliferation markers in naïve HCV-RNA positive patients without clinical evidences of autoimmune/lymphoproliferative disorders. Dig Liver Dis 2016; 48:927-33. [PMID: 27289333 DOI: 10.1016/j.dld.2016.05.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 05/03/2016] [Accepted: 05/17/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND HCV can lead to both chronic liver disease and B-cell lymphoproliferative disorders. A strong association exists between HCV and mixed cryoglobulinaemia (MC). METHODS Anti-nuclear antibodies (ANA), rheumatoid factor Ig-G (RF-IgG), free light chain κ and λ (FLC-κ, FLC-λ) levels and κ/λ ratio were evaluated in 50/420 subjects unexpectedly resulted anti-HCV positive after routine screenings for non-hepathological procedures. RESULTS Three/fifty patients had HCV-RNA undetectable in the serum and were excluded from the analysis. Thirty-nine/fifty patients had laboratory evidence of circulating cryoglobulins without liver disease and MC-related symptoms. Among them, 17 resulted ANA-positive. The mean cryocrit was higher in ANA-positive patients, while no other demographic/clinical differences were observed between the groups. Significantly higher levels of RF-IgG were observed in ANA-positive vs ANA-negative patients. κ and λ FLC were higher in ANA-positive patients. A ROC analysis, based on ANA-positivity vs ANA-negativity, confirmed a high sensitivity and specificity of RF-IgG test. CONCLUSIONS Published data concerning MC come mostly from symptomatic vasculitis. We analyzed HCV-patients without MC symptoms, founding cryoglobulins in the majority of them. The increased levels of FR-IgG and FLC in CGs-ANA-positive patients, suggest these test could be used to identify a state of silent autoimmune and/or lymphoproliferative condition before the transition to a frank disease in naïve HCV-patients without symptoms of extrahepatic manifestations.
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246
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Milani P, Palladini G, Merlini G. Serum-free light-chain analysis in diagnosis and management of multiple myeloma and related conditions. Scand J Clin Lab Invest Suppl 2016; 245:S113-8. [PMID: 27467897 DOI: 10.1080/00365513.2016.1210337] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The introduction of the serum-free light-chain (S-FLC) assay has been a breakthrough in the diagnosis and management of plasma cell dyscrasias, particularly monoclonal light-chain diseases. The first method, proposed in 2001, quantifies serum-free light-chains using polyclonal antibodies. More recently, assays based on monoclonal antibodies have entered into clinical practice. S-FLC measurement plays a central role in the screening for multiple myeloma and related conditions, in association with electrophoretic techniques. Analysis of S-FLC is essential in assessing the risk of progression of precursor diseases to overt plasma cell dyscrasias. It is also useful for risk stratification in solitary plasmacytoma and AL amyloidosis. The S-FLC measurement is part of the new diagnostic criteria for multiple myeloma, and provides a marker to follow changes in clonal substructure over time. Finally, the evaluation of S-FLC is fundamental for assessing the response to treatment in monoclonal light chain diseases.
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Affiliation(s)
- Paolo Milani
- a Amyloidosis Research and Treatment Center, Foundation IRCCS Policlinico San Matteo and Department of Molecular Medicine , University of Pavia , Pavia , Italy
| | - Giovanni Palladini
- a Amyloidosis Research and Treatment Center, Foundation IRCCS Policlinico San Matteo and Department of Molecular Medicine , University of Pavia , Pavia , Italy
| | - Giampaolo Merlini
- a Amyloidosis Research and Treatment Center, Foundation IRCCS Policlinico San Matteo and Department of Molecular Medicine , University of Pavia , Pavia , Italy
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Mahmood S, Wassef NL, Salter SJ, Sachchithanantham S, Lane T, Foard D, Whelan CJ, Lachmann HJ, Gillmore JD, Hawkins PN, Wechalekar AD. Comparison of Free Light Chain Assays: Freelite and N Latex in Diagnosis, Monitoring, and Predicting Survival in Light Chain Amyloidosis. Am J Clin Pathol 2016; 146:78-85. [PMID: 27353767 DOI: 10.1093/ajcp/aqw079] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Measurement of serum free light chains (FLCs) is critical in diagnosis, prognosis, and monitoring treatment responses in light chain (AL) amyloidosis. We compare the Freelite assay (polyclonal antibodies to hidden light chain epitopes), which is the current gold standard, with a new assay: a mixture of monoclonal antibodies to light chain epitopes (N Latex). METHODS We collected 240 serum samples from 94 consecutive patients with newly diagnosed AL amyloidosis (at least three serial serum samples during the first 6 months) analyzed at the National Amyloidosis Centre, London, from January 2011 to April 2012. Concordance in detecting abnormal light chain components and hematologic response was assessed at 2, 4, and 6 months. RESULTS The κ and λ clonal light chain involvement was 21% and 79%, respectively, with an abnormal κ/λ ratio or detectable protein in 78.7%. Median κ, λ, and difference in involved and uninvolved FLCs by Freelite and N Latex assays were 17.3 vs 16 mg/L (R(2 ) = 0.91), 48.8 vs 52.6 mg/L (R(2) = 0.52), and 43.2 vs 39.1 mg/L, respectively. Discordant κ/λ ratios at presentation were as follows: 10 of 90 abnormal by Freelite/normal by N Latex and 11 of 90 abnormal by N Latex/normal by Freelite. CONCLUSIONS Both FLC assays show good correlation in detecting the abnormal light chain subtype with discordance in absolute values and thus are not interchangeable.
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Affiliation(s)
- Shameem Mahmood
- From the National Amyloidosis Centre, University College London Medical School, Royal Free Hospital Campus, London, United Kingdom
| | - Nancy L Wassef
- Clinical Biochemistry Department, Royal Free London Foundation Trust, London, United Kingdom
| | - Simon J Salter
- Clinical Biochemistry Department, Royal Free London Foundation Trust, London, United Kingdom
| | - Sajitha Sachchithanantham
- From the National Amyloidosis Centre, University College London Medical School, Royal Free Hospital Campus, London, United Kingdom
| | - T Lane
- From the National Amyloidosis Centre, University College London Medical School, Royal Free Hospital Campus, London, United Kingdom
| | - D Foard
- From the National Amyloidosis Centre, University College London Medical School, Royal Free Hospital Campus, London, United Kingdom
| | - Carol J Whelan
- From the National Amyloidosis Centre, University College London Medical School, Royal Free Hospital Campus, London, United Kingdom
| | - Helen J Lachmann
- From the National Amyloidosis Centre, University College London Medical School, Royal Free Hospital Campus, London, United Kingdom
| | - Julian D Gillmore
- From the National Amyloidosis Centre, University College London Medical School, Royal Free Hospital Campus, London, United Kingdom
| | - Philip N Hawkins
- From the National Amyloidosis Centre, University College London Medical School, Royal Free Hospital Campus, London, United Kingdom
| | - Ashutosh D Wechalekar
- From the National Amyloidosis Centre, University College London Medical School, Royal Free Hospital Campus, London, United Kingdom
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Rajkumar SV. Multiple myeloma: 2016 update on diagnosis, risk-stratification, and management. Am J Hematol 2016; 91:719-34. [PMID: 27291302 PMCID: PMC5291298 DOI: 10.1002/ajh.24402] [Citation(s) in RCA: 311] [Impact Index Per Article: 38.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 04/25/2016] [Indexed: 02/07/2023]
Abstract
Multiple myeloma accounts for approximately 10% of hematologic malignancies.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) features felt related 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. Patients with del(17p), t(14;16), and t(14;20) have high-risk multiple myeloma. Patients with t(4;14) translocation and gain(1q) have intermediate-risk. All others are considered standard-risk. Initial treatment consists of bortezomib, lenalidomide, dexamethasone (VRD). In high-risk patients, carfilzomib, lenalidomide, dexamethasone (KRD) is an alternative to VRD. In eligible patients, initial therapy is given for approximately 3-4 months followed by autologous stem cell transplantation (ASCT). Standard risk patients can opt for delayed ASCT at first relapse. Patients not candidates for transplant are treated with Rd until progression, or alternatively, a triplet regimen such as VRD for approximately 12-18 months. After ASCT, lenalidomide maintenance is considered for standard risk patients especially in those who are not in very good partial response or better, while maintenance with a bortezomib-based regimen is needed for patients with intermediate or high-risk disease. Patients with indolent relapse can be treated with 2-drug or 3-drug combinations. Patients with more aggressive relapse require a triplet regimen or a combination of multiple active agents. Am. J. Hematol. 91:720-734, 2016. © 2016 Wiley Periodicals, Inc.
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Marron TU, Hanna MG, Ramanathan L, Chari A. Validation and Utility of the Free Light Chain Assay in Pleural Effusions of Patients With Multiple Myeloma. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2016; 16:e113-7. [PMID: 27349767 DOI: 10.1016/j.clml.2016.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 04/06/2016] [Accepted: 04/26/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Thomas U Marron
- Division of Hematology and Oncology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Matthew G Hanna
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Lakshmi Ramanathan
- Department of Laboratory Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Ajai Chari
- Division of Hematology and Oncology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
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Hansen CT. Performance goals for immunoglobulins and serum free light chain measurements in plasma cell dyscrasias can be based on biological variation. Clin Chem Lab Med 2016; 54:1031-3. [PMID: 26824979 DOI: 10.1515/cclm-2015-0792] [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: 08/17/2015] [Accepted: 01/02/2016] [Indexed: 11/15/2022]
Abstract
Measurements of immunoglobulins and serum free light chains (sFLC) are frequently used in patients with monoclonal plasma cell dyscrasia (PCD). For optimum patient care, well-defined performance standards or goals for the measured concentrations of immunoglobulins and sFLC are required. Generally, data based on biological variation is a good and reliable method for setting desirable performance standards; this also applies for the measurements of paraprotein and sFLC. The benefits of this approach are several. Among others, it is independent of the clinician, and it provides us with information about reference change value and index of individuality. Several studies on biological variation of both immunoglobulins and sFLC have been published, and mostly the studies are well performed. The studies normally show small within-subject biological variation resulting in strict analytical goals, which in most cases are difficult to meet. Nevertheless, we still need further information on biological variation of immunoglobulins and sFLC in patients with PCD and in the elderly, which are the main target populations for the two measurands. Furthermore, to improve data on biological variation of immunoglobulins and sFLC, studies accounting for number of individuals, samples, and replicates, as well as time length of the studies are needed.
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