Multiple myeloma presenting with amyloid arthropathy as the first manifestation: Two case reports

BACKGROUND

Multiple myeloma (MM) can be accompanied by amyloidosis, which occurs in a small number of patients and is characterized by deposition of light chains in the joints, leading to multiple myeloma-associated amyloid arthropathy (MAA). As a rare complication of MM, clinical manifestations of MAA are often similar to those of rheumatoid arthritis, and the two are easily confused.

CASE SUMMARY

In recent years, our center treated two patients of MM with amyloid arthropathy as the first manifestation, both of whom presented with polyarthritis. After treatment for MM, both patients achieved complete remission. However, subsequently, the two patients underwent hip arthroplasty for femoral neck fractures. Congo red staining and immunofluorescence of the joint tissues confirmed MAA after surgery. Eventually, one of the patients died of MM recurrence, while the other survived.

CONCLUSION

MAA should be regarded as an initial symptom of MM and should be taken seriously.

To skim or splice? Comparing the quantification of M-proteins using two peak-integration protocols across multiple electrophoresis platforms

OBJECTIVES

M-protein quantification by peak integration in serum protein electrophoresis (SPE) plays a central role in diagnosing, prognosing and monitoring monoclonal gammopathies. The conventional perpendicular drop (PD) integration approach integrates M-spikes from the baseline, which performs acceptably when the M-protein concentration is relatively high compared to the amount of background proteins present. The alternative peak-integration protocol by tangential skim (TS), however, allows for more accurate M-protein estimations by excluding background proteins. Despite some guideline recommendations, TS has been poorly adopted, making an understanding of the differences between the two protocols and their potential impacts paramount when considering a change from PD to TS.

DESIGN & METHODS

We conducted retrospective investigations of the differences in M-protein quantification over large concentration ranges between PD and TS on 3 of the most popular electrophoresis platforms.

RESULTS

Compared to PD, TS gave consistently lower results; the differences between the two methods increased tremendously and became more sporadic as M-protein concentrations dropped below 15 g/L in all 3 platforms. At < 15 g/L, the average % difference ranged from -81 % to -95 %, while above 15 g/L, the average % difference was only -13 to -31 %. Medical decision point analyses using linear regression predicted statistically significant and platform-dependent differences, which could impact clinical interpretation.

CONCLUSIONS

Careful consideration of the magnitude of concentration changes and the potential impacts on patient classification and management should be made when switching to TS for M-protein quantification.

The Spectrum of Monoclonal Immunoglobulin-Associated Diseases

The spectrum of immunoglobulin paraprotein-associated diseases requiring therapy extends beyond multiple myeloma and AL amyloidosis. Awareness of these is essential in ensuring timely accurate diagnosis and appropriate treatment. As most paraprotein-associated diseases are fairly uncommon, therapeutic decisions must often be made in the absence of data from randomized controlled trials. Treatment is generally directed at the underlying clonal cell population. This review focuses on the spectrum of the less common paraprotein-associated disorders. In most instances, the monoclonal immunoglobulin plays a direct role in the pathophysiology of the disease course; in a select few, the paraprotein may be a disease marker.

Modern Treatments and Future Directions for Relapsed/Refractory Multiple Myeloma Patients

Since the introduction of proteasome inhibitors, immunomodulators, and monoclonal antibodies, the longevity of a patient with multiple myeloma has greatly improved. Although prognosis is improving, multiple myeloma remains an incurable disease and most patients will inevitably relapse. With new studies and prospective trials being published every few months, the landscape of multiple myeloma treatment is changing and sequencing treatments remains complex. In this review, we discuss the current data and approaches to treating a patient with relapsed/refractory multiple myeloma.

[Monoclonal gammopathy related disorders]

Monoclonal gammopathy related disorders. The presence of a monoclonal immunoglobulin in serum or urine reflects the existence of an abnormal clone of B cells. In case of large tumor mass, patient need treatment. Sometimes, the clone is nearly undetectable, but gammopathy is associated with complications not directly related to tumor cells but to the presence of the monoclonal immunoglobulin. Most often, lesions result from the deposit of monoclonal immunoglobulin, organized or not. Other mechanisms include autoantibody activity, immune complex formation or deregulation of the complement system. Finally, in some cases, the physiopathology remains to be determined. The downstream complications of gammopathies are protean and can affect various organs, mainly the kidney, the skin and the peripheral nervous system. A delayed diagnosis may be life-threatening or functional. A rigorous clinical examination, and appropriate explorations are therefore necessary in order to put in place a suitable therapy, targeting most often the underlying clone.

[Conduct in case of monoclonal gammapathy ?]

Conduct in case of monoclonal gammapathy ? Monoclonal gammopathies are frequent in general population (about 3 % beyond 50 years) and their prevalence increases with age. They may be associated with malignant haemopathy (multiple myeloma for IgG and IgA, Waldenström disease for IgM). In absence of malignant haemopathy, the diagnosis is that of monoclonal gammopathy of indeterminate significance (MGUS). MGUS accounts for the majority (over 60 %) cases of monoclonal gammopathy. Only patients with multiple myeloma or Waldenström disease require treatment. For MGUS, smoldering myeloma and smoldering Waldenström disease, therapeutic abstention is recommended but regular and prolonged monitoring is necessary given the risk of progression to malignant hemopathy. Given the prevalence of monoclonal gammopathies in general population and the frequency of MGUS, it is rational to limit initial explorations in asymptomatic patients.

Prospective Identification of Oligoclonal/Abnormal Band of the Same Immunoglobulin Type as the Malignant Clone by Differential Location of M-Spike and Oligoclonal Band

Background

Serum and urine protein electrophoreses and immunofixation electrophoreses are the gold standards in diagnosing monoclonal gammopathy. Identification of oligoclonal bands in post-treatment patients has emerged as an important issue and recording the location of the malignant monoclonal peak may facilitate prospective identification of a new “monoclonal” spike as being distinct from the malignant peak.

Methods

We recorded the locations of monoclonal spikes in descriptive terms, such as being in the cathodal region, mid-gamma region, anodal region, and beta region. The location of monoclonal or restricted heterogeneity bands in subsequent protein electrophoreses was compared to the location of the original malignant spike.

Results

In a patient with plasma cell myeloma, the original monoclonal IgG kappa band was located at the anodal end of gamma region. Post-treatment, an IgG kappa band was noted in mid-gamma region and the primary malignant clone was not detectable by serum protein immunofixation electrophoresis (SIFE) in post-treatment sample. Even though the κ/λ ratio remained abnormal, we were able to recognize stringent complete response by noting the different location of the new IgG kappa band as a benign regenerative process.

Conclusions

Recording the location of the malignant monoclonal spike facilitates the identification of post-treatment oligoclonal bands, prospectively. Recognizing the regenerative, benign, bands in post-transplant patients facilitates the determination of stringent complete response despite an abnormal κ/λ ratio.

Iodine-based contrast media, multiple myeloma and monoclonal gammopathies: literature review and ESUR Contrast Media Safety Committee guidelines

Objectives

Many radiologists and clinicians still consider multiple myeloma (MM) and monoclonal gammopathies (MG) a contraindication for using iodine-based contrast media. The ESUR Contrast Media Safety Committee performed a systematic review of the incidence of post-contrast acute kidney injury (PC-AKI) in these patients.

Methods

A systematic search in Medline and Scopus databases was performed for renal function deterioration studies in patients with MM or MG following administration of iodine-based contrast media. Data collection and analysis were performed according to the PRISMA statement 2009. Eligibility criteria and methods of analysis were specified in advance. Cohort and case-control studies reporting changes in renal function were included.

Results

Thirteen studies were selected that reported 824 iodine-based contrast medium administrations in 642 patients with MM or MG, in which 12 unconfounded cases of PC-AKI were found (1.6 %). The majority of patients had intravenous urography with high osmolality ionic contrast media after preparatory dehydration and purgation.

Conclusions

MM and MG alone are not risk factors for PC-AKI. However, the risk of PC-AKI may become significant in dehydrated patients with impaired renal function. Hypercalcaemia may increase the risk of kidney damage, and should be corrected before contrast medium administration. Assessment for Bence-Jones proteinuria is not necessary.

Key Points

• Monoclonal gammopathies including multiple myeloma are a large spectrum of disorders.

• In monoclonal gammopathy with normal renal function, PC-AKI risk is not increased.

• Renal function is often reduced in myeloma, increasing the risk of PC-AKI.

• Correction of hypercalcaemia is necessary in myeloma before iodine-based contrast medium administration.

• Bence-Jones proteinuria assessment in myeloma is unnecessary before iodine-based contrast medium administration.

Location of monoclonal peak as a tool in checking specimen integrity

OBJECTIVES

Serum protein electrophoresis is a commonly used test in the diagnosis and follow-up of patients with monoclonal gammopathies. The practice of documenting the location of the peak may serve as delta check flags in SPEP samples.

METHODS

We report on the inconsistent finding on two tests performed about three months apart. The inconsistency was discovered due to recognition of the change in the location of the monoclonal immunoglobulin on protein electrophoresis.

RESULTS

Repeat testing with a third specimen revealed that the first test was run on a wrong specimen.

CONCLUSION

Recording the location of the monoclonal spike is recommended to serve as an additional "delta" check.

Dramatic resolution of disseminated pyoderma gangrenosum associated with monoclonal gammopathy after therapy with bortezomib and dexamethasone

Pyoderma gangrenosum (PG) is an uncommon inflammatory and ulcerative skin disorder, which is commonly associated with systemic conditions such as inflammatory bowel disease, arthritis and haematological malignancies. It is widely stated that control of the underlying diseases may lead to resolution of PG. However, standard of care dictates that patients suffering with monoclonal gammopathy of undetermined significance or smouldering multiple myeloma (MM) should not receive therapy unless they progress to symptomatic MM. Here, we report a woman in her 40s with a disseminated corticodependent PG, resistant to any treatment attempted, including anti-tumoral necrosis factor (TNF) therapy in which bortezomib-dexamethasone regimen results in dramatic healing of all lesions in only a month. This case supports the belief that treatment of the underlying monoclonal gammopathy could be necessary when PG presents as an aggressive, non-responding skin disease.

Aberrant p15, p16, p53, and DAPK Gene Methylation in Myelomagenesis: Clinical and Prognostic Implications

BACKGROUND

Aberrant DNA methylation is considered a crucial mechanism in the pathogenesis of monoclonal gammopathies. We aimed to investigate the contribution of hypermethylation of 4 tumor suppressor genes to the multistep process of myelomagenesis.

METHODS

The methylation status of p15, p16, p53, and DAPK genes was evaluated in bone marrow samples from 94 patients at diagnosis: monoclonal gammopathy of uncertain significance (MGUS) (n = 48), smoldering multiple myeloma (SMM) (n = 8) and symptomatic multiple myeloma (MM) (n = 38), and from 8 healthy controls by methylation-specific polymerase chain reaction analysis.

RESULTS

Overall, 63% of patients with MM and 39% of patients with MGUS presented at least 1 hypermethylated gene (P < .05). No aberrant methylation was detected in normal bone marrow. The frequency of methylation for individual genes in patients with MGUS, SMM, and MM was p15, 15%, 50%, 21%; p16, 15%, 13%, 32%; p53, 2%, 12,5%, 5%, and DAPK, 19%, 25%, 39%, respectively (P < .05). No correlation was found between aberrant methylation and immunophenotypic markers, cytogenetic features, progression-free survival, and overall survival in patients with MM.

CONCLUSIONS

The current study supports a relevant role for p15, p16, and DAPK hypermethylation in the genesis of the plasma cell neoplasm. DAPK hypermethylation also might be an important step in the progression from MGUS to MM.

Optimization of utilization of serum protein analysis: role of the electronic medical record in promoting consultation by pathology

Screening for monoclonal gammopathies is usually done by serum protein electrophoresis (SPEP) and serum free light chain tests. SPEP may be followed by immunofixation electrophoresis (IFE). IFE may be ordered by the treating physician or be at the discretion of the pathologist. We examined the appropriateness of IFE ordering by treating physicians and report on our findings, follow-up changes to the ordering process, and results of the change. We retrospectively analyzed the data from our laboratory from April 2009 through July 2012. In April 2009, 3 options for test ordering were available for the clinicians: SPEP with reflex IFE, SPEP only, and SPEP with IFE. This test ordering option was limited to SPEP with reflex IFE only in April 2010. We compared the rates of SPEP and IFE performed in the 2 periods (ie, April 2009 through April 2010 and May 2010 through July 2012). There was a substantial drop in the IFE/SPEP ratio from 0.47 to 0.21. Review of electronic medical records by the consultant pathologist was instrumental in improving the utilization and enhancing the value of pathology consultation. Possible impacts on laboratory costs, revenue, and overall health care are also presented.