Current concepts on monoclonal gammopathies

Monoclonal gammopathy in prostate carcinoma: a case report and review of literature

Background

Monoclonal gammopathy is commonly associated with plasma cell dyscrasia. However, monoclonal gammopathy without bone marrow plasmacytosis in prostate carcinoma has rarely been reported. The association between the two conditions is not clearly established.

Case presentation

We report a case of metastatic prostate carcinoma in a 65-year-old Indian man with the unusual phenomenon of monoclonal band in gamma globulin region without evidence of bone marrow plasmacytosis.

Conclusions

Monoclonal gammopathy in solid tumor has seldom been reported. This case report highlights the rare association of monoclonal gammopathy with malignant prostatic carcinoma. Therefore, while investigating a case such as this, in an elderly male patient, we should always keep a lookout for any solid tumor foci after excluding multiple myeloma.

Immunophenotyping in multiple myeloma and related plasma cell disorders

Plasma cell disorders form a spectrum ranging from the asymptomatic presence of small monoclonal populations of plasma cells to conditions like plasma cell leukemia and multiple myeloma, in which the bone marrow can be replaced by the accumulation of neoplastic plasma cells. Immunophenotyping has become an invaluable tool in the management of hematological malignancies and is increasingly finding a role in the diagnosis and monitoring of plasma cell disorders. Multiparameter flow cytometry has evolved considerably during the past decade with an increasing ability to screen large numbers of events and to detect multiple antigens at the same time. This, along with a better understanding of the phenotypic heterogeneity of the clonal plasma cells in different disorders, has made immunophenotyping an indispensible tool in the diagnosis, prognostic classification and management of plasma cell disorders. This book chapter addresses the approaches taken to evaluate monoclonal plasma cell disorders, and the different markers and techniques that are important for the study of these diseases.

“Primary” antiphospholipid syndrome evolving into Waldenstrom’s macroglobulinaemia: a case report

A 57-year-old woman with a history of transient ischaemic attacks and six recurrent foetal losses accompanied by elevations of antiphospholipid antibodies was diagnosed as having a "primary" antiphospholipid syndrome. She was followed up for 5 years, and she developed anaemia, leucopenia and splenomegaly. A bone marrow trephine was diagnostic of Waldenstrom's macroglobulinaemia. A false positive serological test for syphilis was demonstrated and apparently had been noted in her second pregnancy more than 20 years prior to her presentation with an antiphospholipid syndrome. There had previously been no indication to perform serum electrophoretic studies. This case illustrates the importance of this investigation in any middle-aged patient presenting with an antiphospholipid syndrome and a monoclonal gammopathy This finding might presage the development of a more serious condition, even years later (as in our patient).

Five unusual serum protein presentations found by capillary electrophoresis in the clinical laboratory

Capillary electrophoresis (CE) has been used in our teaching hospital clinical laboratory to assay approximately 13 000 specimens for serum protein electrophoresis (SPE) in 4 1/2 years. During that period we have found several unusual samples, five of which are discussed here. These samples are from separate patients with IgD myeloma, IgG heavy chain disease, a triple IgG(Kappa) monoclonal band, a rapidly changing abnormal/monoclonal band and a mixed type-11 cryoglobulinaemia. Albumin has been used to calibrate the 50-microm fused silica capillary, the quantity of the monoclonal bands being calculated by the software of either the Applied Biosystems 270A-HT or BioFocus instrument. We have found CE for the initial SPE to be a robust, labour-saving, cost effective technique, which is able to determine less than 1 g/l of monoclonal protein. However, because of the expense and time required for immunosubtraction, we prefer isoelectric focusing (IEF) for typing of paraproteins. The only samples which need care in handling are serum containing large amounts of cryoglobulin protein.

Multiple myeloma-associated amyloidosis and giant cell arteritis

Primary systemic amyloidosis has been associated with the development of symptoms and clinical features characteristic of polymyalgia rheumatica and/or giant cell arteritis (GCA). Case reports of this clinical entity have been published, stating that the amyloid deposition leads to the symptoms of vasculitis. In this report, we present a second case in the English literature of a patient presenting with multiple myeloma-associated amyloidosis and GCA. This is the first case in which the histopathologic findings are described in enough detail to suggest a pathogenic relationship between the two diseases.

Racial differences in the prevalence of monoclonal gammopathy in a community-based sample of the elderly

PURPOSE

To determine if there is an increased prevalence of monoclonal gammopathy in elderly blacks compared with whites, analogous to the difference in incidence of multiple myeloma reported for the two racial groups and to confirm age and gender relationships.

PATIENTS AND METHODS

Subjects were from the Duke Established Populations for the Epidemiologic Study of the Elderly, selected on the basis of stratified random household sampling. Blacks were oversampled to allow for increased statistical precision in racial comparisons. In all, 1,732 subjects (aged > 70 years) consented to blood drawing and constitute the sample for this study. Monoclonal immunoglobulins were determined by agarose gel electrophoresis and immunofixation.

RESULTS

One hundred six subjects (6.1%) had a monoclonal gammopathy. There was a greater than twofold difference in prevalence between blacks (8.4%) and whites (3.8%) (P < 0.001); monoclonal gammopathy prevalence increased with age, and was greater in men than women. Those with monoclonal gammopathy did not differ from those without in socioeconomic status, urban/rural residence, or education. The presence of monoclonal gammopathy was not associated with any specific diseases nor with impaired functional status. There was a slight increase in serum creatinine levels and decrease in hemoglobin and albumin levels in patients with monoclonal gammopathy, but no difference in interleukin-6 (IL-6) levels. Moreover, IL-6 levels were not correlated significantly with the level of monoclonal protein.

CONCLUSION

Prevalence of monoclonal gammopathy is significantly greater among blacks than whites in a community-based sample, in approximately the same ratio that multiple myeloma has been reported in the two groups. Given the absence of correlation with environmental factors, there may be a biological racial difference in susceptibility to an early event in the carcinogenic process leading to multiple myeloma.

Monoclonal gammopathy in a Dutch warmblood mare

A 15-year-old Dutch warmblood mare was presented because of lethargy, which had been present for several weeks, and severe anaemia. Total protein was high and serum electrophoresis revealed a monoclonal peak in the alpha-2 region. Monoclonal immunoglobulin, IgG(T), was detected by immuno-electrophoresis in serum and urine. Postmortem examination revealed a relatively large number of plasmacytoid cells in the bone marrow and a monotonous population of plasmacytoid cells in the spleen. These findings are suggestive of a plasma cell myeloma.

Gammopathy associated with advanced prostate carcinoma

As proteinuria was found to be common in patients with prostate cancer, the possible presence of elevated urinary immunoglobulin (Ig) levels was investigated. First morning urine samples from 30 patients with androgen-dependent (AD) and 43 patients with androgen-independent (AI) prostate cancer were tested. A sensitive, solid-phase radioimmunoassay and polyclonal antibody interacting with IgG, IgA and IgM was used to screen urine samples. Compared with 15 normal, age-matched, healthy subjects, urinary Ig levels were elevated in 10 of 30 (33%) patients with AD prostate cancer and in 24 of 43 (56%) patients with AI prostate cancer. In the latter group, five of seven (71%) patients with prostatic SCC had elevated urinary Igs. Further analysis of ten urine samples containing increased urinary Ig levels, using antibodies specific for each heavy chain (gamma, alpha and mu) as well as each light chain (kappa and lambda), indicated that patients with a high or moderate elevation in Ig levels had polyclonal gammopathy, whereas those with a low increase in urinary Igs had monoclonal gammopathy of the IgG class. These results indicate, for the first time, a high frequency of an abnormal increase in Ig levels in patients with advanced prostatic carcinoma.

Monitoring of monoclonal gammopathies: rational use of densitometry and rate nephelometry

The follow-up of patients with monoclonal gammopathies at our institution includes serial serum protein electrophoresis (SPE) with densitometry and IgG, IgA, and IgM quantitative immunoglobulin (QIG) determinations by rate nephelometry. This retrospective audit compares monoclonal protein concentration as estimated by SPE versus QIG in 456 serial serum specimens from 105 patients to determine whether any of the tests provide redundant information. A comparison of the methods demonstrated good correlation between SPE (x-axis) and QIG (y-axis) quantitation for each immunoglobulin class: IgG had a slope of 1.45 and an intercept of 1.60 (Sy/x = 7.46, r = 0.96, n = 250); IgA had a slope of 1.30 and an intercept of -1.37 (Sy/x = 6.85, r = 0.96, n = 78); and IgM had a slope of 1.95 and an intercept of 2.06 (Sy/x = 5.16, r = 0.98, n = 128). The data for individual patients showed similar good correlations. Exceptions included IgA peaks "buried" in the beta region of the SPE (resulting in invalid SPE estimates of monoclonal protein concentration), and IgG peaks of less than 10 g/L (when background polyclonal IgG immunoglobulin skews the QIG estimate of monoclonal protein concentration). An algorithm is proposed whereby monoclonal protein concentration is measured by the specific QIG (i.e., IgG, IgA, or IgM) determination for the routine monitoring of patients, except for those with IgG peaks of less than 10 g/L that are followed by SPE.

Multiple myeloma in the elderly

While multiple myeloma is an incurable disease for nearly all patients, current chemotherapy and supportive care can result in significant disease control and improved duration of survival and quality of life. With the average age of patients about 70, most of the high-dose curative strategies exclude the bulk of patients affected by the disease. Recent advances in understanding the biology and pathophysiology of myeloma have led to novel therapies aimed at altering drug resistance, improving duration of the plateau phase, interrupting the cytokine growth stimulation, and improving management of common complications including infections, anemia, and bone lesions. These latter approaches are not restricted to younger patients, and early evidence indicates that elderly patients are also likely to benefit.