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.

Serum Free Light Chains Serum Free Light Chains Presentation Transcript

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