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Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
Serum Free Light Chains
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Serum Free Light Chains

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Presentation webinar March 3, 2010

Presentation webinar March 3, 2010

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  • Protein electrophoresis strip showing (1) normal plasma, (2) polyclonal hypergammaglobulinaemia, (3) serum M protein, and (4) urine M protein (Bence Jones proteinuria) and albuminuria.
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    • 1. PLASMA CELL DISORDERS:NEW STRATEGIES FOR SCREENING , DIAGNOSIS, PROGNOSIS AND MONITORING<br />ParameswaranHari, M.D. <br />Howard S. Robin, M.D.<br />March 3, 2010<br />
    • 2. IMPACT OF LABORATORY TESTING<br />Diagnostic thinking<br />Therapeutic choice<br />Patient outcome<br />Prevention<br />
    • 3. BENCE JONES PROTEINThe First Tumor Marker<br />OSSEOUS MALADIES<br />Multiple Myeloma<br />Bence-Jones, Henry (1813-1873), British nephrologist and clinical pathologist. <br />In 1848 Bence-Jones published an article announcing his discovery of a special protein in the urine of patients suffering from softening of the bones. <br />The first physician to note the occurrence of xanthine in urine, Bence-Jones was also a recognized authority on diseases of the stomach and kidneys.<br />
    • 4. MONOCLONAL GAMMOPATHIES<br />.<br />Disorders<br />Signs and symptoms<br />Bone pain or fractures<br />Elevated serum and/or urine proteins<br />Anemia and fatigue<br />Renal dysfunction<br />1026 patients Mayo 1992<br />
    • 5. OBJECTIVES<br />1. Develop new strategies to screen for and diagnose monoclonal plasma cell gammopathies.<br />2. Evalulate new effective strategies for monitoring relapse and response to therapy of patients with plasma cell disorders.<br />3. Acquire knowledge regarding the prognostic value of current tests for monoclonal gammopathies. <br />
    • 6. CASE 1<br />Previously healthy 75 yr old man<br />Physically active – runs 3 miles /day<br />Exertional dyspnea while running<br />Gave up running after a month<br />Chest discomfort &amp; increasing SOB<br />Cardiopulmonary Tests:<br />Stress test – No inducible ischemia<br />Catheterization – 40% LAD stenosis<br />CT chest – No Pulmonary embolism<br />Echocardiogram – Left Ventricular Hypertrophy<br />
    • 7. DYSPNEA OF UNKNOWN ORIGIN<br />Clinical picture of increasing right heart failure<br />Elevated NT Pro BNP of 1500<br />Repeat echocardiogram<br />Diastolic dysfunction and worsening septal hypertrophy<br />Differential diagnosis <br />Restrictive cardiomyopathy<br />Cardiac amyloidosis<br />Referral to hematology clinic<br />Serum Protein Electrophoresis (SPEP)<br />Immunofixation (IFE)<br />Urine Protein Electrophoresis (UPEP) – 24 hr urine <br />All Negative for Monoclonal Spike<br />
    • 8. SERUM PROTEIN ELECTROPHORESIS<br />
    • 9. SERUM IMMUNOFIXATIONELECTROPHORESIS<br />
    • 10. PHYSIOLOGY OF LIGHT CHAINS <br />≤ 1 g/d<br />500mg/d from normal B and plasma cells<br />k:l production 2:1<br />Lambda is dimeric and has longer T1/2<br />T1/2 varies from hrs to 1-2 d (renal function)<br />Filtered freely by glomeruli then reabsorbed and metabolised by prox. tubules <br />Tubules can absorb upto 10-30 gms per day.<br />
    • 11. IMMUNOELECTROPHORESIS<br />Urine IEP<br />Urine IFE<br />
    • 12. TOOLS FOR EVALUATION OF MONOCLONAL GAMMOPATHIES<br />SPEP<br />Immunofixation<br />UPEP on 24-hour urine<br />Serum free light chain assay<br />
    • 13. PLASMA CELLS PRODUCE WHOLE IMMUNOGLOBULIN AND FREE LIGHT CHAINS<br />Kappa<br />Lambda<br />
    • 14. Free Light Chain<br />Kappa<br />Exposed surface<br />Hidden surface<br />Previously<br />hidden <br />surface<br />SERUM FREE LIGHT CHAIN ASSAY<br />Intact Immunoglobulin<br />
    • 15. SERUM FREE LIGHT CHAINS<br />FLC reference range:<br />k 3.3 – 19.4 mg/L <br />l 5.7 – 26.3 mg/L <br />k/l ratio 0.26 - 1.65<br />
    • 16. SCREENING FOR CARDIAC AMYLOIDOSIS<br />Serum Free Light Chains<br />Free kappa – 530 mg/L<br />Free lambda – 16<br />Increased k:l ratio (33.13)<br />Urine – 950mg/24h of albumin <br />Cardiac MRI scan with Gadolinum<br />
    • 17. MRI Heart<br />septum<br />
    • 18. ELECTRON MICROSCOPY OF FAT PAD ASPIRATE<br />TISSUE CONFIRMATION OF AMYLOID:<br />Marrow Biopsy – 10% Plasma Cells <br /> Kappa Light Chains restricted<br />Fat Pad Aspirate - Positive<br />AL AMYLOIDOSIS:<br />SUSPECT<br />Presence of Amyloid Related Syndrome <br />SCREEN<br />Monoclonal plasma cell disorder <br />PROVE<br />Positive Tissue Biopsy (Fat pad, Marrow, Organ) <br />AL by typing – IHC, sequencing etc <br />
    • 19. SCREENING &amp; DIAGNOSIS OF PLASMA CELL DISORDERS<br />Plasma Cell Disorders are a spectrum of illnesses:<br />Myeloma (MM) <br />AL Amyloidosis<br />Light Chain Deposition<br />MGUS (Monoclonal Gammopathy of Unknown Significance)<br />Smoldering MM<br />Plasmacytoma<br />Plasma Cell Leukemia<br />
    • 20. IDEAL SCREENING PANEL FOR MONOCLONAL GAMMOPATHY<br />Serum Protein Electrophoresis ( SPEP) <br />SPEP + Serum Immunofixation (SIFE)<br />SPEP + SIFE + sFLC<br />SPEP + sFLC<br />SPEP + SIFE + sFLC+ UPEP <br />Most comprehensive<br />
    • 21. INCIDENCE OF ABNORMAL sFLC RATIO IN PLASMA CELL GAMMOPATHIES<br />Mead et al BJH 2004 Aug Draysonet al Blood 2001 Bradwellet al Lancet 2003<br />
    • 22. SCREENING FOR PLASMA CELL DISORDERS<br />Screening panels for detection of monoclonal gammopathies.<br />Katzmann JA et al Clin Chem. 2009 Aug;55(8):1517-22.<br />
    • 23. 100<br />80.8<br />85.7<br />93.5<br />99.5<br />100<br />80<br />60<br />Rate of Positive Patients, %<br />40<br />20<br />0<br />Urine IFE<br />Serum PEP<br />Serum FLC<br />Serum PEP+IFE<br />Serum PEP+IFE+FLC<br />RELATIVE SENSITIVITY OF ASSAYS <br />428 Patients with Monoclonal Urinary Protein<br />Serum PEP/IFE false negative 28 (6.5%):<br />Primary Amyloid, n = 19<br /> Plasmacytoma, n = 3<br /> MGUS, n = 3<br /> Multiple Myeloma, n = 2<br /><ul><li>SmolderingMM, n = 1</li></ul>Serum PEP/IFE or FLC ratio 426 (99.5%)<br /> 1 Idiopathic BJ protein<br /> MGUS (?contamination)<br />
    • 24. SERUM FREE LIGHT CHAIN ASSAY<br />Serum assay<br />Eliminates need to collect urine specimen<br />More sensitive than SPEP or SIFE<br />Indications:<br />Diagnosis of Plasma Cell Disorders<br />Prognosis &amp; Risk Stratification<br />Response Assessment on therapy<br />Disease Monitoring on follow up<br />
    • 25. CASE 2<br />A 74 year old woman presented with elevated total protein August 2003<br />Routine Labs revealed high total protein 9.8 g/dL<br />Normal : CBC, Ca++, Bone X ray screen, Creatinine<br />SPEP &amp; SIFE – IgG Kappa 3.2 g/dl<br />Marrow 23% Plasma cells kappa light chain clone<br />Diagnosis – Smoldering MM (SMM)<br />Risk of Progression to MM?<br />
    • 26. RISK OF PROGRESSION TO MYELOMA OR RELATED DISORDER IN <br />273 PATIENTS WITH SMOLDERING MYELOMA<br />Dispenzieri, A. et al. Blood 2008;111:785-789<br />Copyright ©2008 American Society of Hematology. Copyright restrictions may apply.<br />
    • 27. FOLLOW UP OF PATIENT WITH SMM<br />X 100 mg/L<br />Symptomatic <br />Myeloma<br />FLC Ratio = 28.7<br />Kappa FLC<br />FLC Ratio = 27.8<br />Hb = 13.5<br />Hb = 13.0<br />Hb = 9.8<br />
    • 28. TT3: iFLC Baseline Tertiles<br />100<br />80<br />1 or 2 vs 3, p&lt;0.001<br />1 vs 2, p=0.08<br />60<br />Event free survival, %<br />40<br />24-moTertile (mg/L) N estimate<br />1 (0.6-107) 99 85% <br />2 (108-746) 102 94%<br />3 (762-71210) 100 73%<br />20<br />0<br />0<br />1<br />2<br />3<br />Years<br />SERUM FLC AT DIAGNOSIS IS PROGNOSTIC IN MULTIPLE MYELOMA<br />Data from Arkansas group using involved FLC and EFS after therapy <br />
    • 29. TT3: INFERIOR SURVIVAL WITH TOP-TERTILE SFLC LEVEL AT BASELINE<br />100%<br />80%<br />60%<br />24-Month<br />40%<br />Deaths / N<br />Estimate<br />Tertile 1 (0.06-10.7 mg/dL)<br />9 / 99<br />89% (81,96)<br />Tertile 2 (10.8-74.6 mg/dL)<br />4 / 102<br />94% (88,100)<br />20%<br />Tertile 3 (76.2-7120 mg/dL)<br />22 / 100<br />76% (67,86)<br />p-value Tertiles 1 and 2 vs. 3: &lt;0.001, 1 vs. 2=0.14<br />0%<br />0<br />12<br />24<br />36<br />Months from Enrollment<br />Impact of Serum Free Light Chain (SFLC) on Survival<br />
    • 30. ISS &amp; rFLC<br />100<br />Risk OS,score N mo<br /> 0 73 51<br /> 1 169 39<br /> 2 199 30<br /> 3 135 22<br />80<br />0<br />1<br />2<br />3<br />4<br />5<br />6<br />7<br />8<br />9<br />60<br />Overall survival,%<br />40<br />20<br />0<br />0<br />2<br />4<br />6<br />8<br />10<br />12<br />14<br />Years<br />&gt;32 (k) or &lt;0.03 (l) <br />Snozek CL, et al. Leukemia<br />SERUM FLC RATIO AT DIAGNOSIS IS PROGNOSTIC IN MM<br />Data using FLC ratio<br />rFLC<br />100<br />80<br />60<br />Overall survival,%<br />P=0.0001<br />40<br />rFLC N 5-yr survival (%)<br />“Low” 46 82±9 <br />“High” 47 30±11 <br />20<br />0<br />Years<br />‘High rFLC’ &gt;3.6 (k) or &lt; 0.02 (l)<br />Kyrtsonis MC, et al. Br J Haeml. 2007;137:240-243<br />
    • 31. KEY PROGNOSTIC FACTORS FOR PROGRESSION OF MGUS <br />
    • 32. 20 yr. risk of progression after other causes of death<br />2%<br />10%<br />18%<br />27%<br />MGUS: RISK STRATIFICATION MODEL<br />Absolute risk of progression at 20 yrs.<br />Risk Group<br />5%<br />1. Low-risk<br />Serum M protein &lt;1.5 gm/dL, IgG subtype, <br />normal FLC ratio <br />2. Low/Intermediate-risk <br />Any 1 factor abnormal<br />21%<br />3. Hi/Intermediate-risk<br />Any 2 factors abnormal<br />37%<br />4. High-risk<br />All 3 factors abnormal<br />58%<br />
    • 33. SOLITARY BONE PLASMACYTOMA<br />FLC ratio is prognostic in solitary bone plasmacytoma<br />Time to Progression<br />Overall Survival<br />Normal FLC ratio<br />Abnormal FLC ratio<br />Normal FLC ratio<br />Abnormal FLC ratio<br />Dingli, D. et al. Blood 2006;108:1979-1983<br />Copyright ©2006 American Society of Hematology. Copyright restrictions may apply.<br />
    • 34. WALDENSTROM MACROGLOBULINEMIA:<br />HIGHER DISEASE BURDEN CORRELATES WITH SFLC<br />In WM patients<br />Median sFLC &gt; 60 mg/L was associated with lower hemoglobin and higher B2M<br />sFLC<br />Lower involved FLC 20 mg/L vs. 36 mg/L (p=0.0003) in IgM-MGUS than WM patients <br />Abnormal ratio in 23% vs. 76% (p&lt;0.001) <br />Leleuet al LeukLymph 2008<br />
    • 35. PROGNOSTIC USES IN OTHER SITUATIONS<br />Recovery of renal function in MM<br />Where monitoring for Light Chain elevation is crucial<br />After renal transplant for Light chain deposition disease in remission <br />Sensitive marker for NHL risk in HIV infection 2 -5 years prior to actual<br />Landgren et al J Clin Oncol. 2010 Feb 10;28(5):773-9<br />
    • 36. SERUM FREE LIGHT CHAIN ASSAY:IMPORTANT PROGNOSTIC MARKER<br />Myeloma <br />Smoldering MM<br />MGUS<br />Amyloidosis<br />Plasmacytoma<br />WaldenstromMacroglobulinemia<br />
    • 37. CASE 3<br />65 yr old man with symptomatic anemia<br />Urine light chains - &gt;5gms in 24hrs of lambda light chains<br />SPEP &amp; IFE – IgG lambda 2.2g/dl<br />Marrow – 62% Plasma Cells<br />SYMPOMATIC MYELOMA<br />Treated with VAD chemotherapy with good response<br />Creatinine normalised<br />Complete Remission IFE negative<br /><ul><li>Autologous Transplant - 10/2002
    • 38. Continued in CR till 11/2003</li></li></ul><li>PATIENT WITH MYELOMA NOW IN CR<br />Patient presented to clinic with increasing fatigue<br />CBC:<br />Hb 11.3, WBC 5.4, Plts 132<br />Creatinine 1.4 (baseline)<br />UPEP – no monoclonal bands<br />SPEP – no monoclonal protein<br />Metastatic Bone Survey – NO new lesions<br />Serum free light chains: March 10 2006 April 3 2006<br />FREE KAPPA CHAINS 12.7 mg/L 1.5<br />FREE LAMBDA CHAINS 451.0 (H) mg/L 4430<br />FREE KAPPA/LAMBDA RATIO 0.03 (L) 0.001<br />Rising Free Light Chains – No Clinical Relapse (yet)!<br />No evidence of relapse by M spike <br />or clinical criteria<br />
    • 39. CT Scan of Abdomen and Pelvis<br />CT SCAN OF CHEST/ ABDOMEN/PELVIS<br />Soft tissue plasmacytomas with light chain escape<br />
    • 40. TREATMENT OF LIGHT CHAIN SECRETING PLASMACYTOMAS<br />Patient received D-PACE (Dexamethasone,Cisplatin, Adriamycin,Cytoxan, Etoposide) chemotherapy<br />2 cycles <br />After cycle 1 ----------------- After cycle 2 <br />FREE KAPPA CHAINS &lt;0.1 (L) mg/L too low<br />FREE LAMBDA CHAINS 741.0 (H) mg/L 2.7mg/L<br />FREE KAPPA/LAMBDA RATIO 0.01 (L) ---<br />CT Scan – complete resolution of masses<br />FLC – resolution of involved LC elevation<br />ProteinHalf Life<br />IgG 20–25 days<br />IgA 6 days<br />IgM 6–8 days<br />Free Kappa 2–4 hours<br />Free Lambda 3–6 hours<br />Rapid clinical confirmation of effective therapy<br />
    • 41. FREE LIGHT CHAIN AS A MARKER OF RESPONSE IN MM<br />Stored samples from a mature ECOG clinical trial (E9486) data<br />Assess serum FLC at baseline and after 2 months of alkylator based therapy in 399 patients <br />FLC response after 2 months of therapy <br />Superior to early M-protein measurement to predict overall response, but did not predict for survival endpoints<br />Dispenzieri A et al.Blood. 2008;111:4908-4915.<br />
    • 42. ROC OF FLC REDUCTION VS. M SPIKE RESPONSE<br />Early drop in FLC after 2 cycles<br />Absolute FLC value or<br />Delta FLC <br />40% decline in D FLC has : <br /> 77% sensitivity and 68% specificity for ultimate M spike reponse<br />Why use D FLC ?<br />
    • 43. SERUM FLC VS. UPEP 24 H FOR FOLLOW UP<br />Low correlation between change in M spike by UPEP and FLC change<br />FOR FOLLOW UP – still need 24 hr UPEP <br />Dispenzieri A et al.Blood. 2008;111:4908-4915.<br />
    • 44. 1 Measurable includes serum M-protein ≥ 10 g/L or a urine M-protein ≥ 200 mg/day<br /> for myeloma patients (100 mg/day for AL patients). <br />Gertz MA et al. Am J Hematol. 2005;79:319-328.<br />Durie BG et al. Leukemia. 2006;20:1467-1473.<br />RESPONSE CRITERIA IN MM AND AL INCORPORATE FLC<br />
    • 45. CAVEATS<br />Stringent CR – not well validated for minimal residual disease and long term outcomes<br />SFLC Ratio abnormal despite good remission<br />Oligoclonal reconstitution<br />de Larrea et al Blood. 2009 Dec 3;114(24):4954-6<br />Temporal discordance when measured as rate of drop or rise of FLC is not concurrent with M spike<br />Can lead to erroneous conclusions<br />
    • 46. CONCORDANCE WITH IFE – DEPENDS ON WHEN MEASURED<br />Singhal et al. Blood July 2009; 114 , 38<br />2648 serial samples from 122 patients in varying stages of therapy.<br />Serum IFE positive in 88% samples<br />FLC Ratio abnormal in 62% samples<br />FLC Ratio discordant with FLC in 874 samples<br />Serial Measurements of FLC in MM can be discordant with immunofixation results.<br />For e.g – patients undergoing therapy when the FLC normalizes before IFE<br />Relapse when FLC becomes abnormal prior to IFE change<br />
    • 47. Abnormal FLC ratio <br />Lower Limit for FLC Ratio<br />Urine Electrophoresis<br />Neg --------------------------------------------- Positive<br />SFLC ESCAPE FROM PLATEAU<br />Lambda LC elevation<br />FLC escape precedes clinical relapse<br />FLC Ratio abnormal 16 mo prior to UPEP turning positive<br />Clinical Relapse vs. Biochemical progression<br />Time UPEP of positivity<br />
    • 48. ON AVERAGE : 6 MOS. EARLIER INDICATION OF RELAPSE THAN SIFE<br />, ( mg/L)<br />6-mo Earlier Indication of Relapse<br />Mosbauer et al. Haematologica 2007:92:275-276<br />
    • 49. Overall survival (%)<br />FLC CR? No. Deaths<br /> Yes Yes 28 0<br /> Yes No 13 1<br /> No Yes 14 2<br /> No No 32 4<br />Months<br />CP1312670-3<br />FLC RESPONSE IS BETTER PREDICTOR OF OS THAN IS IFE RESPONSE IN AL<br />Dispenzieri A, et al. Blood. 2006;107:3378-3383<br />
    • 50. SERUM SFLC ASSAY<br />SCREENING for PLASMA CELL DISORDERS<br />DIAGNOSIS of PLASMA CELL DISORDERS<br /> <br />PROGNOSTIC VALUE<br />Monoclonal gammopathy of undermined significance<br />Smoldering myeloma<br />Symptomatic myeloma<br />Plasmacytoma<br />AL amyloidosis<br /> <br />HEMATOLOGIC RESPONSE<br />AL amyloidosis<br />“Non-secretory” myeloma<br />Stringent complete response in multiple myeloma ( not fully validated)<br />Light chain deposition disease<br />EARLY RESPONSE TO THERAPY<br />RARE SITUATIONS <br />Free Light Chain escape <br />HIV and NHL<br />Waldenstrom<br />
    • 51. SERUM FLC ASSAY RATIONALE<br />Simple test<br />Predicts outcome<br />Predicts response to therapy<br />Correlates with current prognostic markers<br />Compatible with practice<br />
    • 52. CLINICIAN’S PERSPECTIVE ON LABORATORY TESTING<br />Screening<br />Diagnosis<br />Prognosis<br />Predictive<br />Monitoring<br />
    • 53. GOALS OF PLASMA CELL DYSCRASIA TESTING <br />Improve predictive value of screening<br />Identify candidates for biopsy<br />Identify candidates to treat<br />Determine optimal therapy<br />Predict response to therapy<br />

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