HLC Ratios Research Articles

Laboratory characteristics of IgG4-related disease: A retrospective study from a single tertiary medical center.

Immunoglobulin G4-related disease (IgG4-RD) is an immune-mediated fibroinflammatory condition with unique histopathological features that can affect most organs, making diagnosis challenging. This study characterized detailed laboratory characteristics of IgG4-RD. Baseline clinical and laboratory features of 33 patients with IgG4-RD were reviewed, including serum IgG4 concentrations, serum free light chains (sFLCs), IgGĸ- and IgGλ-heavy/light chains (HLCs), capillary serum protein electrophoresis (SPE), and immunofixation electrophoresis (IFE) of IgG4 subclass. The cohort of 33 patients showed male predominance (94%), with 8 (24%) exhibiting multiple organ involvement. Most patients (88%) had an elevated IgG4 concentration, and 67% had elevated erythrocyte sedimentation rate and IgE levels. Median IgG4 concentration at baseline was significantly higher in patients with >2 organs involved than those with ≤2. Furthermore, erythrocyte sedimentation rate was significantly correlated with serum IgG4 concentrations at baseline. SPE results demonstrated polyclonal gammopathy in most patients. Half of the patients had an increased κ/λ sFLC ratio, 42% had an increased IgGκ/IgGλ HLC ratio. Most patients exhibited hypergammaglobulinemia in the anodal end of the ɤ region on SPE. This study describes detailed laboratory features of IgG4-RD. Although none of these tests are considered diagnostically sufficient by itself, the provided laboratory characteristics can increase awareness of this disorder and help distinguish it from other IgG4-RD mimics.

Direct Assessment of IgA and IgG Paraprotein By Hevylite Assay and Correlation to IMWG Response and Progression-Free Survival in Newly Diagnosed, Transplant-Eligible Multiple Myeloma Patients in the Prospective Phase III GMMG-MM5 Trial

Direct Assessment of IgA and IgG Paraprotein By Hevylite Assay and Correlation to IMWG Response and Progression-Free Survival in Newly Diagnosed, Transplant-Eligible Multiple Myeloma Patients in the Prospective Phase III GMMG-MM5 Trial

Heavy and Light Chain Monitoring in High Risk Smoldering Multiple Myeloma Patients Included in the GEM-CESAR Trial: Comparison with Conventional and Minimal Residual Disease IMWG Response Assessment

Heavy and Light Chain Monitoring in High Risk Smoldering Multiple Myeloma Patients Included in the GEM-CESAR Trial: Comparison with Conventional and Minimal Residual Disease IMWG Response Assessment

Bortezomib-Based Induction, Augmented Conditioning with Busulfan and Melphalan + ASCT and Lenalidomide Maintenance for Newly Diagnosed Multiple Myeloma: Long-Term Results of the National Canadian Mcrn-001 Study

Bortezomib-Based Induction, Augmented Conditioning with Busulfan and Melphalan + ASCT and Lenalidomide Maintenance for Newly Diagnosed Multiple Myeloma: Long-Term Results of the National Canadian Mcrn-001 Study

Heavy/light chain assay in the monitoring of multiple myeloma

Serum protein (SPE) and immunofixation electrophoresis (IFE) have been extensively validated for the routine use of identifying, characterising and quantifying monoclonal proteins. However, accurate quantitation of IgA monoclonal proteins can be difficult when they migrate in to the β fraction, due to co-migration with transferrin and complement components. The heavy/light chain (HLC) immunoassay is an additional tool for measuring intact immunoglobulin monoclonal proteins. Therefore, we aimed to examine the clinical utility of the HLC assay for the disease monitoring of IgG and IgA multiple myeloma (MM) patients. A total of 177 samples from 30 MM patients (21 IgG and 9 IgA) were analysed retrospectively with median number of six follow up samples per patient (range 3-13). Serum free light chains (sFLC) and HLC were quantified using Freelite and Hevylite immunoassays. Details of M-protein concentration, β-globulin levels, total immunoglobulin levels and disease treatment response were obtained from the laboratory and patient information system. Passing-Bablok regression analysis was performed to compare (i) M-protein quantification with involved HLC (iHLC) and (ii) total immunoglobulin with summated HLC pairs for each immunoglobulin type (e.g., IgGκ+IgGλ). For 127 IgG MM samples, IgG iHLC levels showed a good correlation with SPE quantification (iHLC y=0.96x+4.9; r=0.917) and summated HLC showed a good correlation with total IgG concentration (summated HLC y=0.94x+5.74; r=0.91). In total, 95/127 (75%) IgG MM follow-up samples had an abnormal HLC ratio and 122/127 (96%) had a positive SPE, probably due to the lower sensitivity of HLC assay in detecting clonality in patients with IgG MM. Consistent with this, one patient assigned a very good partial response by International Myeloma Working Group criteria would be assigned a complete response based on HLC measurements. For 50 IgA MM samples, 42/50 (84%) had an abnormal HLC ratio. Conversely, 50/50 (100%) of M-proteins showed β fraction migration and were difficult to accurately quantify by SPE. Therefore, M-protein concentration and iHLC did not correlate as well in IgA MM (y=1.9x-8.4; r=0.8) compared to IgG MM. However, there was good correlation between total IgA and summated IgA HLC (IgAκ+IgAλ y=1.35x-0.33; r=0.95). Of the 8/50 (16%) IgA samples with a normal HLC ratio, 6/8 (75%) were consistent with the disease status being in complete remission. Interestingly, in one IgA MM patient, SPE and IFE were negative, but the serum FLC ratio and involved FLC were highly abnormal, consistent with the presence of light chain escape. Our data suggest HLC measurements could add value to the current disease monitoring of MM patients. In IgG MM patients, the M-protein level correlated well with HLC values. The HLC assay complements the serum FLC assay and is especially useful for monitoring of IgA MM patients who display M-proteins migrating in the β region on SPE.

PF609 HEAVY&LIGHT CHAIN MONITORING IN HIGH RISK SMOLDERING MULTIPLE MYELOMA PATIENTS INCLUDED IN THE GEM‐CESAR TRIAL: COMPARISON WITH CONVENTIONAL AND MINIMAL RESIDUAL DISEASE IMWG RESPONSE ASSESSMENT

Background:The GEM‐CESAR trial is a potentially curative strategy for high‐risk smoldering multiple myeloma (HRsMM) patients (pts) in which the primary endpoint is the assessment of bone marrow minimal residual disease (MRD) negativity. However, alternative methods of disease evaluation in serum such as heavy+light chain (HLC), with a potential added value to the IMWG response criteria, have also been tested.Aims:To analyze HLC disease in this group of pts at diagnosis and before maintenance, comparing the results with standard serological methods and with MRD assessed by Next Generation Flow (NGF).Methods:The 90 HRsMM pts included in the GEM‐CESAR trial received six 4‐weeks cycles of carfilzomib, lenalidomide and dexamethasone followed by high dose melphalan and 2 further cycles of consolidation with the same regimen. All pts received maintenance with lenalidomide up to 2 years. SPEP and IFE were performed using standard procedures. Serum IgGk, IgGl, IgAk and IgAl HLC concentrations were measured using Hevylite (The Binding Site Group Ltd, Birmingham, UK) on a SPA PLUS turbidimeter. HLC concentrations and ratios were considered abnormal if they were outside the 95% reference ranges provided by the manufacturer. MRD was analyzed by flow cytometry following EuroFlow recommendations. Standard response assignment was carried out as per the IMWG guidelines. HLC responses and HLC‐pair suppression were calculated as in Michalet et al (Leukemia 2018).Results:We analyzed 75 out of the 90 pts in the trial with intact immunoglobulin and available samples at diagnosis (50 IgG and 25 IgA). HLC ratio was abnormal in 98% (49/50) of the IgG pts and in 100% of IgA pts. A comparison of HLC‐ vs standard IMWG response rates post‐consolidation is detailed in Table 1. In the 60 cases with paired samples for both methods at this moment, there was a moderate agreement between them, with 78.3% of concordant results. The number of cases in the PR and VGPR groups is limited to extract any conclusion but among the 45 in CR as per the IMWG, there were 3 and 8 categorized as in PR and VGPR according to the HLC method, respectively. We then compared these results with those from the analysis of MRD by NGF in 59 out of the 60 cases with paired BM samples available. HLC and NGF reported concordant results in 71.1% of cases (42/59; HLC+/NGF+ in 15 cases and HLC‐/NGF‐ in 27 cases) and discordant in the remaining 28.9% (17/59; HLC‐/NGF+ in 7 cases and HLC+/NGF‐ in 10 cases). The percentage of positive cases post‐consolidation was 25% by SPEP, 37.2% by NGF and 43% by HLC. HLC‐pair suppression was identified in 13/60 pts (21.6%) and 10 of them (16.6%) had severe HLC‐pair suppression at the end of consolidation. After a median follow‐up of 32 months (8–128), 93% of pts remain alive and free of progression. We have analyzed responses post‐consolidation of the 2 cases included in this study that had already progressed. The first pt was in VGPR by the IMWG, in PR by HLC and MRD positive by NGF; the second one in RC by IMWG and by HLC but had severe HLC‐pair immunosuppression and was MRD positive by NGF.Summary/Conclusion:Response monitoring by HLC shows a moderate concordance with the IMWG response criteria as well as with MRD assessment by NGF. Most discordances are due to persistent disease by HLC while negative with the alternative methods, but longer follow‐up is needed to ascertain its clinical value. HLC assessment could have anticipated the progression noted in the 2 cases included in the study.image

PB2100 MULTI‐BIOMARKER NORMALIZATION OF MM SERUM PATIENTS AS POSSIBLE GATEWAY FOR BONE MARROW MRD BY MULTIPARAMETER FLOW CYTOMETRY

Background:With the continuous development of more effective treatments and with new mechanisms of action leading to deeper responses of patients with Multiple Myeloma, the use of more sensitive tools to evaluate the effectiveness of treatments is required. Minimal residual disease by bone marrow multiparametric flow cytometry (BMMFC) has progressively gained wide acceptance and is presently the final goal of treatment. However, the acquisition of bone marrow remains a limitation due to its invasive nature. The incorporation to the laboratory routine of automated more sensitive techniques for the quantification of the monoclonal protein (MP), as serum free light chains (sFLC) and Heavy‐light chains assays (HLC) have increased the sensitivity to detect blood circulating monoclonal proteins.Aims:To investigate if a correlation exists between BMMFC minimal residual disease (MRD) and a panel of serological MP biomarkers. The hypothesis is that a non‐negative panel of biomarkers is a good surrogate for positive BM MRD by MFC.MethodsPaired BM and serum samples were analyzed, respectively by 8‐color MFC and by the serum monoclonal protein biomarker panel. The serum MP biomarker panel was composed by immunofixation (sIFE), serum free light chains (sFLC) and the Hevylite assay that targets heavy + light chain immunoglobulin isotypes. Regarding sIFE, two different approaches have been carried out when interpreting results of the presence of possible oligoclonal bands (OCB): 1 ‐ sIFE with possible OCB were considered positive and by consequence an abnormal marker on the serum panel; 2 ‐ the oligoclonality seen on the sIFE had to be confirmed by the normalization of both the sFLC and HLC assays, i.e., patients with OCB but normal FLC and HLC ratios were considered as normal. Positive (PPV) and negative predictive values (NPV) were calculated by Fisher exact test.Results:43 paired samples were analyzed. Twenty‐one out of 41 (51%) BM samples were MRD negative. Of the 12 possible OCB observed in sIFE, 4 were MRD positive and 4 were negative by FLC and HLC. Of these, only one was positive by BM MRD. Contingency tables were created to compare the serum biomarker panel results vs BM MRD. When the OCB were considered as an abnormal sIFE result, we found a PPV of 0.95 and NPV of 0.24, however, no statistical significance was found (p = 0.1836). When OCB were interpreted on the basis of the sFLC and HLC results, a significant statistically result was achieved (p = 0.0002) with a PPV of 0.95 (CI: 0.7513‐0.9987) and an NPV of 0.62 (CI: 0.3844–0.8189). The specificity found to predict BM positive MRD was 0.93 (CI: 0.6613 ‐0.9982).Summary/Conclusion:Our results suggest that the proposed serum MP biomarker panel composed by sIFE + sFLC + HLC might be sensitive enough to guide clinicians to more selective requests of BM MRD. Also, in cases where probable OCB bands are found on the sIFE, the normalization of the sFLC and HLC ratio can help in the interpretation of a real phenomenon of oligoclonality. Further studies are required to validate these results mainly with a greater number of samples and follow‐up time.

QIP-MS: A specific, sensitive, accurate, and quantitative alternative to electrophoresis that can identify endogenous m-proteins and distinguish them from therapeutic monoclonal antibodies in patients being treated for multiple myeloma

Serum protein (SPE) and immunofixation electrophoresis (IFE) have been extensively validated for the routine use of identifying, characterising and quantifying monoclonal proteins. However, accurate quantitation of IgA monoclonal proteins can be difficult when they migrate in to the β fraction, due to co-migration with transferrin and complement components. The heavy/light chain (HLC) immunoassay is an additional tool for measuring intact immunoglobulin monoclonal proteins. Therefore, we aimed to examine the clinical utility of the HLC assay for the disease monitoring of IgG and IgA multiple myeloma (MM) patients.A total of 177 samples from 30 MM patients (21 IgG and 9 IgA) were analysed retrospectively with median number of six follow up samples per patient (range 3–13). Serum free light chains (sFLC) and HLC were quantified using Freelite and Hevylite immunoassays. Details of M-protein concentration, β-globulin levels, total immunoglobulin levels and disease treatment response were obtained from the laboratory and patient information system. Passing–Bablok regression analysis was performed to compare (i) M-protein quantification with involved HLC (iHLC) and (ii) total immunoglobulin with summated HLC pairs for each immunoglobulin type (e.g., IgGκ+IgGλ).For 127 IgG MM samples, IgG iHLC levels showed a good correlation with SPE quantification (iHLC y=0.96x+4.9; r=0.917) and summated HLC showed a good correlation with total IgG concentration (summated HLC y=0.94x+5.74; r=0.91). In total, 95/127 (75%) IgG MM follow-up samples had an abnormal HLC ratio and 122/127 (96%) had a positive SPE, probably due to the lower sensitivity of HLC assay in detecting clonality in patients with IgG MM. Consistent with this, one patient assigned a very good partial response by International Myeloma Working Group criteria would be assigned a complete response based on HLC measurements. For 50 IgA MM samples, 42/50 (84%) had an abnormal HLC ratio. Conversely, 50/50 (100%) of M-proteins showed β fraction migration and were difficult to accurately quantify by SPE. Therefore, M-protein concentration and iHLC did not correlate as well in IgA MM (y=1.9x–8.4; r=0.8) compared to IgG MM. However, there was good correlation between total IgA and summated IgA HLC (IgAκ+IgAλ y=1.35x–0.33; r=0.95). Of the 8/50 (16%) IgA samples with a normal HLC ratio, 6/8 (75%) were consistent with the disease status being in complete remission. Interestingly, in one IgA MM patient, SPE and IFE were negative, but the serum FLC ratio and involved FLC were highly abnormal, consistent with the presence of light chain escape.Our data suggest HLC measurements could add value to the current disease monitoring of MM patients. In IgG MM patients, the M-protein level correlated well with HLC values. The HLC assay complements the serum FLC assay and is especially useful for monitoring of IgA MM patients who display M-proteins migrating in the β region on SPE.

Prognostic Value of the Hevylite Chain in MGUS Patients in a Population Study

Introduction: Studies have shown that a large monoclonal protein (MP) and immunoparesis in MGUS/SMM have predictive value of progression since they may be indirectly related to the degree of clonal expansion of bone marrow plasma cells (BMPC). A recently available assay, the Hevylite ® (HLC), has allowed a more precise determination of MP and the quantification of isotype-matched immunosuppression (i.e. suppression of the monoclonal isotype but of the alternative light chain) which has shown prognostic value in some studies. In this study, we aim to evaluate the association between the alteration of the HLC parameters in MGUS patients with already known prognostic factors, but also, with less studied biomarkers such as circulating clonal plasma cells (cCPC) by Next Generation Flow (NGF) (Flores-Montero et al., Leukemia, 2017). Methods: A total of 175 MGUS patients diagnosed between October 2008 and September 2015 were included in the study. The median follow-up was 64 months (range: 1-100 months). MGUS and MGUS progression were defined according to the International Myeloma Working Group (IMWG) criteria. Clinical records were retrieved for all patients. HLC determinations were carried on a SPA+ turbidimeter analyzer and using specific reagents (Binding Site®, UK). The 6 HLCs pairs (IgGk, IgGl, IgAk, IgAl, IgMk and IgMl) were analyzed in all samples. HLC normal ranges were defined by the laboratory based on normal sera. Statistical analysis was done using IBM-SPSS-22. Results: HLC ratio was altered in 56.3% of the 111 patients with available sera (47.5% for IgG MGUS and 73.9% and 87.5% for IgA and IgM), respectively (p = 0.026). Patients with altered HLC ratio presented an MP significantly higher (Table 1) than those with normal ratio (0.62 g/dL vs 0.33 g/dL, p 1.5 g/dL (p = 0.044)). Interestingly, it also correlated with a greater frequency and a greater amount of cCPC by NGF (68.29%, p=0.001; 0.2864 /mL vs 0.0139 /mL p=0.0001). Regarding BMPC infiltration, there was a correlation between altered HLC ratios and greater percentages of infiltration of BMPC (3.72% vs. 2.43%, p = 0.001) and higher percentage of BMPC measured by multiparameter flow cytometry (MFC) (54.42% vs 24.42%, p 1.5 mg/dL (100%, p = 0.044), non-IgG (78,12%, p = 0.003) and ratio of altered CLL (77,77%, p = 0.011). Patients with normal HLC ratios correlated with other low risk of progression to MM parameters, such as a MP 25% was observed in 15.2% of the patients. These patients presented significantly higher MP (0.91 g/dL vs 0.42 g/dL, p Conclusions: HLC abnormalities have been associated with negative prognostic factors previously established, reinforcing the idea that the HLC parameters are directly related to a greater propensity of clonal expansion, or a greater tumor load. However, the short follow-up time did not allow the confirmation of the prognostic value of HLC alterations regarding greater risk of progression to MM. A re-evaluation of the results at 10 years is foreseen. We expect to be able to access whether an evolving pattern exists for the HLC parameters mainly to investigate if the immune suppression by HLC progressively intensifies in patients closest to progressing to MM. Disclosures Garcia Mateo: Celgene: Honoraria; Amgen: Honoraria; Binding Site: Research Funding. Mateos: Celgene: Consultancy, Honoraria, Membership on an entity9s Board of Directors or advisory committees; Janssen: Consultancy, Honoraria, Membership on an entity9s Board of Directors or advisory committees; GSK: Consultancy, Membership on an entity9s Board of Directors or advisory committees; Abbvie: Consultancy, Membership on an entity9s Board of Directors or advisory committees; Takeda: Consultancy, Honoraria, Membership on an entity9s Board of Directors or advisory committees; GSK: Consultancy, Membership on an entity9s Board of Directors or advisory committees; Amgen: Consultancy, Honoraria, Membership on an entity9s Board of Directors or advisory committees; Amgen: Consultancy, Honoraria, Membership on an entity9s Board of Directors or advisory committees. Puig: Celgene: Honoraria, Research Funding; Takeda: Consultancy, Honoraria; Janssen: Consultancy, Honoraria, Research Funding. Queizan: Janssen: Consultancy. Olivier: Celgene: Honoraria; Jassen: Honoraria.

A Novel Risk-Model to Predict Time to First Treatment (TTT) in Chronic Lymphocytic Leukemia Based on Heavy+Light Chain Immunoparesis and Serum Free Light Chain Analysis: Results from the Israeli CLL Study Group

Introduction:Chronic Lymphocytic Leukemia (CLL) is frequently accompanied by immune dysregulation. Hypogammaglobulinemia is one of the most important immune defects encountered, and all three classes of immunoglobulins (IgG, A and M) can be involved. Recently, novel heavy+light chain (HLC) immunoassays have become available that quantify the light chain types of each immunoglobulin class (e.g. IgGk and IgGl). These assays are measured in pairs and provide information on the isotype produced by a tumour (the “involved” HLC), the non-clonal (“uninvolved”) HLC, and the ratio (e.g. IgGk/IgGl) - which indicates monoclonality. HLC assays have been shown to improve monitoring of plasma cell dyscrasias, but their role in CLL is yet to be studied.MethodsThis is a multi-center study performed in collaboration with the Israeli CLL Study Group and involved 10 medical centers.The cohort included 122 patients with CLL and 26 healthy controls. Baseline was defined as the time the blood sample was taken. Serum samples were analyzed for levels of IgG subclasses (IgG1, IgG2, IgG3, IgG4), heavy+light chains (HLC) (IgGκ, IgGλ, IgAκ, IgAλ, IgMκ or IgMλ) and free light chains (sFLC).HLC-pair suppression was defined as an abnormal HLC ratio and uninvolved HLC levels below the normal reference range (i.e. in g/L: IgGκ<3.84; IgGλ<1.91; IgAκ<0.57; IgAλ<0.44; IgMκ<0.19; IgMλ<0.12).HLC immunoparesis was defined as HLC isotype levels below the normal reference range, regardless of HLC ratio (i.e. HLC immunoparesis of at least 1 isotype indicates at least one of IgGκ, IgGλ, IgAκ, IgAλ, IgMκ or IgMλ below the normal reference range).Severe HLC-pair suppression or severe HLC immunoparesis was defined as a concentration of the uninvolved HLC or any HLC isotype that is suppressed by >50% below the normal reference range. The association of variables with time to first treatment (TTT) was performed with Cox proportional hazard model.ResultsCurrent analysis was performed on 105 CLL patients who had complete data available; median age was 68 years, 64% were males and Binet stage A, B, C, were 80%, 18.1% and 1.9% respectively. Median time from diagnosis to baseline measurements was 27 months (range 0-328 months).An abnormal sFLC ratio was identified in 70% (73/105) patients and summated k and λ concentrations (SFLC) were ≥70 mg/L in 18% of cases. An abnormal HLC ratio was present in 32% (34/105) patients, and 21% had HLC pair suppression of any 1 HLC isotype. HLC immunoparesis of 1, ≥2 and ≥3 isotypes was observed in 74 (70%), 58 (55%) and 36 (34%) of patients, respectively, with severe HLC immunoparesis identified in 40 patients (38%).Patients with IgG2 suppression were more frequently hospitalized due to infection with an Odds Ratio of 3.826 (p=0.031).In multivariate analysis, SFLC ≥70 mg/L and severe HLC immunoparesis were independently associated with TTT (HR 15.3, p<0.001; HR 80, p<0.001 respectively). Using these 2 variables, a risk-stratification model was constructed that separated CLL patients into 3 risk groups (with 0, 1 or 2 risk factors) with significantly different TTT (p<0.001, Figure 1). Patients with both risk factors (SFLC ≥70 mg/L and severe HLC immunoparesis) had the shortest TTT.ConclusionsThe findings presented here demonstrate that there is considerable potential for the use of HLC and FLC immunoassays to provide prognostic information in CLL. [Display omitted] DisclosuresTadmor:PFIEZER: Consultancy; JNJ: Consultancy; ABBVIE: Consultancy; NOVARTIS: Consultancy; ROCHE: Research Funding. Aviv:ABBVIE: Consultancy; ROCHE: Research Funding. Herishanu:ROCHE: Research Funding; JNJ: Consultancy; ABBVIE: Consultancy. Shvidel:ROCHE: Consultancy, Research Funding; ABBVIE: Consultancy, Research Funding; JNJ: Consultancy. Rahimi-Levene:ABBVIE: Consultancy. Ruchlemer:ABBVIE: Consultancy; JNJ: Consultancy. Fogl:The Binding Site Group Ltd: Employment. Polliack:ROCHE: Research Funding; ABBVIE: Consultancy. Magal:The Binding Site: Employment. Townsend:The Binding Site Group Ltd: Employment.

Prognostic utility of serum free light chain ratios and heavy-light chain ratios in multiple myeloma in three PETHEMA/GEM phase III clinical trials.

We investigated the prognostic impact and clinical utility of serum free light chains (sFLC) and serum heavy-light chains (sHLC) in patients with multiple myeloma treated according to the GEM2005MENOS65, GEM2005MAS65, and GEM2010MAS65 PETHEMA/GEM phase III clinical trials. Serum samples collected at diagnosis were retrospectively analyzed for sFLC (n = 623) and sHLC (n = 183). After induction or autologous transplantation, 309 and 89 samples respectively were available for sFLC and sHLC assays. At diagnosis, a highly abnormal (HA) sFLC ratio (sFLCr) (<0.03 or >32) was not associated with higher risk of progression. After therapy, persistence of involved-sFLC levels >100 mg/L implied worse survival (overall survival [OS], P = 0.03; progression-free survival [PFS], P = 0.007). Among patients that achieved a complete response, sFLCr normalization did not necessarily indicate a higher quality response. We conducted sHLC investigations for IgG and IgA MM. Absolute sHLC values were correlated with monoclonal protein levels measured with serum protein electrophoresis. At diagnosis, HA-sHLCrs (<0.29 or >73) showed a higher risk of progression (P = 0.006). Additionally, involved-sHLC levels >5 g/L after treatment were associated with shorter survival (OS, P = 0.001; PFS, P = 0.018). The HA-sHLCr could have prognostic value at diagnosis; absolute values of involved-sFLC >100 mg/L and involved-sHLC >5 g/L could have prognostic value after treatment.

The value of serum heavy/light chain immunoassay to assess therapeutic response in patients with multiple myeloma

目的评价重轻链（HLC）检测在多发性骨髓瘤（MM）疗效评价中的意义。方法纳入2013至2016年北京协和医院诊治的45例MM患者，连续收集其治疗过程中115份血清。采用常规M蛋白检查及HLC比值（rHLC）法同时评估疗效。结果①45例患者中男30例，女15例，平均年龄59（43~80）岁，其中IgG型27例（IgGκ 12例，IgGλ 15例），IgA型18例（IgAκ和IgAλ各9例）。②治疗前34例患者留取了血清标本，rHLC异常检出率为94.1%（32/34），2例rHLC正常的患者均为IgG型，部分缓解（PR）、非常好的部分缓解(VGPR)、完全缓解（CR）时rHLC异常检出率分别为81.8%（18/22）、50.0%（9/18）、16.0%（4/25），结果显示随着治疗后缓解程度的加深，rHLC异常率逐渐下降。③25例CR患者中IgG型13例，IgA型12例，其中有4例患者rHLC异常（IgG型和IgA型各2例）。④对同一患者进行HLC动态监测，发现rHLC恢复正常较M蛋白转阴（血清蛋白电泳、免疫固定电泳）及游离轻链恢复正常延迟。结论rHLC检测可以作为MM患者微小残留病的辅助评价手段。

Abnormal Heavy/Light Chain Ratio and Matched Pair Suppression Increase Residual Disease Detection Sensitivity in Patients With Multiple Myeloma With Deep Responses

BackgroundHeavy/light chain (HLC) assay can quantify involved as well as uninvolved immunoglobulin pairs and is used to detect monoclonal proteins. Patients and MethodsWe compared the sensitivity between HLC assay and serum protein electrophoresis, serum immunofixation electrophoresis (IFE), and free light chain (FLC) assay in patients with symptomatic multiple myeloma (n = 111) whose responses were stable disease or better. ResultsAmong patients with negative IFE and normal FLC ratios, 84.4% (38 of 45) and 80% (36 of 45) exhibited normal HLC ratios and no pair suppression, respectively (13.3% [6 of 45], moderate pair suppression and 6.7% [3 of 45], severe pair suppression). The lower the monoclonal protein levels, the more the possibility that the patients had normal HLC ratios and no matched pair suppression (both P < .000001). HLC ratios or pair suppression combined with IFE results and FLC ratios were more sensitive for detecting monoclonal proteins than were IFE results and FLC ratios alone (P = .016 and .0039, respectively). A combination of all 4 methods (IFE, FLC, HLC, and pair suppression) was far more sensitive than were IFE findings plus FLC ratios alone (P = .00024). ConclusionAbnormal HLC ratios and HLC-matched pair suppression can increase the sensitivity for detecting residual disease in patients with multiple myeloma with deep responses.

Analytical validation of the Hevylite assays for M-protein quantification.

The heavy/light chain (HLC) immunoassay quantifies the different heavy chain/light chain combinations of each immunoglobulin (Ig) class. This makes the HLC assay suited to quantify monoclonal immunoglobulins (M-protein) and for monitoring of patients with monoclonal gammopathies. This method is particularly advantageous for those samples in which electrophoretic quantification of the M-protein is not possible. In this study we tested the analytical performance of the HLC assay in 166 routine clinical samples and in 27 samples derived from the Dutch external quality assessment (EQA) for M-protein diagnostics (74 participating laboratories). Analytical accuracy was assessed by verification that the sum of the HLC-pairs equaled total Ig concentration. Sensitivity of the HLC assay was determined in a direct method comparison with immunofixation electrophoresis (IFE). Comparison of HLC data with routine Ig diagnostics in 27 EQA samples showed very good correlation for both the quantification of polyclonal and monoclonal IgG, IgA and IgM (Pearson correlations [r] were 0.94, 0.99 and 0.99, respectively; slopes were 0.94, 1.07 and 0.98, respectively). The overall concordance between IFE and the HLC ratio was high (93%) with a Cohen κ coefficient of 0.84. Discrepancies between both assays were mainly caused by the higher sensitivity of IFE to detect monoclonality. We conclude that the HLC assay is an accurate method to quantify M-proteins that can improve monitoring of M-proteins in the beta fraction that cannot be quantified using electrophoretic techniques.

Heavy+light chain monitoring correlates with clinical outcome in multiple myeloma patients

Novel anti-myeloma agents have improved patient response rates, which are historically based on reductions of the M-protein. These methods can be inaccurate for quantifying M-proteins at low concentrations. We compared the consistency and clinical impact of response assignment by electrophoretic and heavy+light chain (HLC) immunoassays post-consolidation in 463 newly diagnosed patients. The two methods gave similar assignments in patients with partial (PR; 79% agreement) or complete response (⩾CR; 92%). However, in patients achieving very good PR (VGPR) there was poor concordance between methods (45%). Median progression-free survival (PFS) for standard VGPR patients was 34.5 months; HLC responses stratified these patients further into PR, VGPR and ⩾CR, with median PFS of 21.3, 28.9 months and not reached, respectively; P<0.001. At this time, abnormal HLC ratios had better concordance with multiparametric flow cytometry (sensitivity 10−4) (37 and 34% positive, respectively), compared to immunofixation (62% positive). In addition, HLC-pair suppression was identified in 38% of patients and associated with shorter PFS (30.6 months vs not reached; P<0.001). We conclude that HLC monitoring could augment electrophoretic assessments in patients achieving VGPR. The prognostic significance of HLC responses might partly depend on the patients’ ability to recover their immune system, as determined by normalisation of HLC measurements.

Abnormal heavy/light chain ratio after treatment is associated with shorter survival in patients with IgA myeloma.

Immunoglobulin (Ig) heavy/light chain (HLC) assays enable the separate quantification of the different light chain types of each Ig class. We retrospectively analyzed the correlation of heavy/light chain ratio (HLCR) with clinical status and its impact on outcome in 120 patients with multiple myeloma (MM). Abnormal HLCR was seen more frequently in patients with poorer myeloma response, and it appeared to be more sensitive for detecting clonality in IgA myeloma compared to IgG myeloma after treatment. Among the 85 patients who achieved ≥VGPR, the patients remained HLCR abnormal were showed significantly shorter overall survival (OS) compared to those achieving a normal HLCR (not reached vs 55.5 months, P = 0.032). This correlation was seen in IgA myeloma patients (not reached vs 30.1 months, P = 0.014), but not in IgG myeloma patients when patients were analyzed separately. Univariate and multivariate analysis of factors that may affect survival identified abnormal HLCR at the best response as the only independent risk factor (hazard ratio, 4.7; 95% confidence interval, 1.4 – 15.26; P = 0.012) for shorter OS in this subset of patients. This study highlighted the HLC assay as a prognostic predictor in patients with IgA myeloma.

Hevylite and Freelite Tests in Newly Diagnosed Multiple Myeloma: Clinical Utility and Correlations with Clinical Features

Introduction Heavy light chain (HLC) assay is a recently developed method that separately quantifies the k and L-bounded amounts of a given intact immunoglobulin (Ig). It allows an accurate quantification of both the involved/uninvolved Ig and permits to quantify even small monoclonal protein. Free light chain (FLC) and HLC can provide prognostic information for multiple myeloma patients.We evaluated the role of HLC and FLC tests in the assessment and evolution of the disease in newly diagnosed multiple myeloma (MM) patients.Methods From February 2011 to April 2014, 1510 patients aged ≤65 years with symptomatic newly diagnosed MM were enrolled in the EMN02/HO95 study. Details about treatments and preliminary results of the main study were previously reported (Cavo M et al, abs8000, J Clin Oncol 34, 2016). In this analysis, we focused on patients enrolled in Italy (N=718). Serum samples from each enrolled patient were collected at diagnosis, before starting maintenance, and thereafter every 6 months. Samples from 665 patients at diagnosis and 156 at pre-maintenance were analyzed.Involved HLC ratio (iHLCR) was calculated with the involved Ig (either G or A) as numerator. Involved FLC ratio (iFLCR) was calculated as K/L or L/K with the monoclonal chain as numerator. FLC ratio (FLCR) and HLC ratio (HLCR) were calculated as K/L. The analyses were performed using Spearman correlation.Results Median follow-up was 32 months. At baseline the type of paraprotein was IgG in 428 (298 IgG-k, 130 IgG-L), IgΑ in 123 (77 IgΑ-k, 46 IgΑ-L) or light chain in 104 patients (k 73, L 31); 10 patients were IgD or IgM. International Staging System (ISS) stages were well distributed in all the isotypes.The median involved HLC values were IgG-K 28.97, IgG-L 30.6, IgA-K 41.7, IgA-L 35.7 g/L, light chain K 2719.58 mg/L, and light chain L 3369.75 mg/L.HLC IgG was significantly correlated with B2-microglobulin (r=0.31), extensive bone marrow infiltration >60% (r=0.31) and hemoglobin (r=-0.39). HLC IgA was not correlated with any disease parameter.In light chain MM, iFLC was correlated to B2-microglobulin (r=0.41), creatinine (r=0.39), extensive bone marrow infiltration >60% (r=0.39) and hemoglobin (r=-0.36).The increase of iFLCR (≥ median value) was significantly associated with IgG, ISS III, anemia, extensive bone marrow infiltration and higher creatinine (p<0.001), but not with the presence of high risk chromosomal abnormalities. High iFLCR (> third quartile) was significantly associated with inferior TTP (median 43.4 versus NR, HR 1.75 95% CI 1.22-2.53, p 0.003).The increase of iHLCR (≥ median value) was significantly associated with ISS III, anemia, and extensive bone marrow infiltration (p<0.001), whereas the presence of high risk chromosomal abnormalities was not.At pre-maintenance, 17% of patients had an abnormal HLCR, whereas 82% had a normalization of HLCR. The normalization of HLCR before starting maintenance was significantly related with the achievement of complete response (CR) (p=0.02) and a trend towards a longer 3-years TTP was observed (83% versus 74%, Log-rank test 0.05).Before start of maintenance, 27% of patients had a normalization of FLCR. No significant correlation with response or outcome was observed for patients who had a normalization of FLCR.At pre-maintenance, 67% IgG or IgA MM patients were immunofixation (IFX) negative. Among them, 8% had still an abnormal HLCR compared to IFX positive patients (8% versus 36%, p<0.001).Conclusions This preliminary analysis confirms the prognostic role of high iFLCR and iHLCR in newly diagnosed MM patients. HLCR normalization may be a valuable parameter to better define CR and predict outcome. HLC can quantify even small monoclonal protein when immunofixation is negative. Further follow-up is needed to assess the prognostic impact of HLC and FLC on survival outcome. Updated results will be presented at the meeting. DisclosuresLarocca:Janssen-Cilag: Honoraria; Bristol-Myers Squibb: Honoraria; Amgen: Honoraria; Celgene: Honoraria. Cavo:Janssen-Cilag: Consultancy, Honoraria; Bristol-Myers Squibb: Consultancy, Honoraria; Amgen: Consultancy, Honoraria; Celgene: Consultancy, Honoraria; Millennium: Consultancy, Honoraria. Petrucci:Bristol-Myers Squibb: Honoraria; Sanofi: Honoraria; Janssen-Cilag: Honoraria; Celgene: Honoraria. Patriarca:Bristol-Myers Squibb: Other: Advisory board; Mundipharma: Other: Advisory board; MSD: Consultancy; Janssen-Cilag: Other: Advisory board; Celgene: Consultancy. Corradini:Takeda: Consultancy, Speakers Bureau; Celgene: Honoraria; Janssen: Honoraria, Speakers Bureau; Novartis: Honoraria, Speakers Bureau; Roche: Honoraria, Speakers Bureau; Sanofi: Honoraria, Speakers Bureau; Servier: Honoraria; Gilead: Honoraria, Speakers Bureau; Gentium: Honoraria, Speakers Bureau. Sonneveld:Celgene: Other: Advisory board, Research Funding; Onyx: Other: Advisory board, Research Funding; Millennium: Other: Advisory board, Research Funding; Janssen-Cilag: Other: Advisory board, Research Funding. Boccadoro:Novartis: Honoraria, Research Funding; Janssen: Honoraria, Research Funding; Amgen: Honoraria, Research Funding; CELGENE: Honoraria, Research Funding; SANOFI: Honoraria, Research Funding; BMS: Honoraria, Research Funding; Abbivie: Honoraria; Mundipharma: Research Funding. Palumbo:Janssen Cilag: Honoraria; Takeda: Employment, Honoraria.

Abnormal Heavy/Light Chain Ratio after Treatment Is a Robust Predictor of Shorter Survival in Patients with IgA Myeloma

▪Accurate quantification of monoclonal protein (M-protein) is essential for response assessment, management, and prediction of prognosis in patients with multiple myeloma (MM). Serum protein electrophoresis (SPEP) is commonly used to determine the degree of M-protein reduction in intact immunoglobulin (Ig) MM. However, SPEP has limitations when M-protein comigrates into the beta-fraction or M-protein fails to show a distinct sharp spike on densitometry. Ig heavy/light chain (HLC) assay enables separate quantification of the different light chain types of each Ig class. Although HLC assay quantifies different light chain subtypes of Ig classes, the sensitivity for detecting M-protein clonality and its impact on outcome may differ between IgA and IgG myeloma.To investigate the clinical and prognostic impact of HLC assay, we retrospectively analyzed the correlation of heavy/light chain ratio (HLCR) with clinical status and its impact on outcome. A total of 402 frozen serum samples from 120 patients with MM (41 for IgA and 79 for IgG) treated at Kameda Medical Center (Kamogawa-shi, Chiba, Japan) and Kanazawa University Hospital (Kanazawa-shi, Ishikawa, Japan) at the times of various IMWG responses were collected. Samples were analyzed using the HLC assay, and the results were compared with serum protein electrophoresis (SPEP), free light chain ratio (FLCR), immunofixation, total IgG, IgA, and overall survival (OS).Percentages of samples with normal HLCR at presentation, PR, VGPR, CR, and sCR were 0%, 0%, 27.6%, 100%, and 88.9%, respectively, for IgA MM and 0%, 12.5%, 64.3%, 100%, and 84.3%, respectively, for IgG MM. Normalization of HLCR at VGPR was more frequent in IgG MM compared to IgA MM (PR; 12.5% vs. 0%, respectively, P = 0.169, VGPR; 64.3% vs. 27.6%, respectively, P = 0.004), which suggests the lower sensitivity of detecting clonality in patients with IgG MM than those with IgA MM. Abnormal HLCR was seen more frequently in patients with poorer myeloma response, and it appeared to be more sensitive for detecting clonality in IgA myeloma compared to IgG myeloma after treatment. No significant difference in OS was observed between patients with or without uninvolved Ig suppression and OS if they obtained ≥ VGPR. Among the 85 patients that achieved ≥ VGPR, those that remained HLCR abnormal showed significantly shorter overall survival (OS) compared to those achieving normal HLCR (not reached vs. 55.5 months, P = 0.032). This correlation was seen in IgA myeloma patients (not reached vs. 30.1 months, P = 0.014), but not in IgG myeloma patients when analyzed separately. Univariate and multivariate analyses of factors that may affect survival identified abnormal HLCR at the best response as the only independent risk factor (hazard ratio, 4.7; 95% confidence interval, 1.4 - 15.26; P = 0.012) for shorter OS in this subset of patients.In conclusion, HLC assay is useful for accurate monitoring of monoclonal protein in patients with myeloma. The results suggested that obtaining normal HLCR indicated a more favorable prognosis in patients with IgA myeloma, but not IgG myeloma, that achieved VGPR or better response. [Display omitted] DisclosuresTakamatsu:Celgene: Honoraria; Janssen Pharmaceuticals: Honoraria.

Immunoglobulin Heavy/Light Chain Ratio and Suppression of the Myeloma Non-Involved Heavy/Light Chain Pair Isotype Correlate with Poor Survival in Multiple Myeloma at Diagnosis and after Autologous Stem Cell Transplant

The outcome for patients with Multiple Myeloma (MM) is highly variable. Understanding the prognosis for a particular patient can help when selecting the intensity of treatment to be used and the frequency of reviews. The quantification of heavy/light chains pairs by the immunoassay Hevylite (HLC) allows us a precise measurement of monoclonal and non-monoclonal immunoglobulins of the same isotype. In this study we evaluate i) the impact of the "HLC ratio" defined as monoclonal immunoglobulin over isotype matched non-monoclonal immunoglobulin (involved/uninvolved HLC ratio or i/u HLC ratio), ii) the suppression of non-monoclonal pair denominated "HLC-matched pair suppression" and iii) the effect of "systemic immunoparesis", at diagnosis and at +100 days after autologous stem cell transplant (ASCT).Methods: 85 patients (50 M:35 F) with a median age of 70 years (56-78) were followed (35 IgGK, 18 IgGl, 17 IgAK and 15 IgAl) for a median of 19 (5-30) months. Sixteen patients (18%) presented ISS stage I, 15 (28%) stage II and 54 (64%) stage III. Thirty transplanted patients were evaluated at day +100 of ASCT. Serum free light chains (FLC) and immunoglobulin heavy/light chain pairs (HLC) were assessed by Freelite and Hevylite assays, respectively (The Binding Site, UK). FLC, HLC, b2-microglobulin, albumin, creatinine, hemogloblin, calcium, LDH, bone marrow plasma cell infiltration, presence of lytic bone lesions and ISS stage were evaluated for their impact on patient´s outcome. Statistical analysis with SPSS 23. Overall survival (OS) and progression-free survival (PFS) were evaluated by Kaplan-Meier method and Cox Regression.Results: The median OS of the 85 patients was 54% and 26 patients deceased during the study due to MM. The median value of i/u HLC ratio at diagnosis was 80 (31.5-319.71) and values >80 were significantly associated with worse OS (48 vs. 61%, p=0,005, fig.1A and Table 1) and shorter PFS (23% vs. 42%, p=0,006, fig.1B). Severe HLC-matched pair suppression (i.e. more than 50% below the lower reference range) was identified in 68% of the newly diagnosed patients and was associated with shorter OS (35% vs. 81%, p=0,004, fig. 1C) and PFS (21% vs. 50%, p=0,013, fig.1D). Severe (>50%) systemic immunoparesis was identified in 64% of the patients and was also significantly associated with shorter OS (32% vs. 81%, p=0,030, fig.1E) but not with shorter PFS (26% vs. 44%, p=0,306, fig. 1F). In a multivariate analysis, severe HLC-matched pair suppression and albumin were found as independent risk factors for OS whereas creatinine and i/u HLC ratio >80 were independent risk factors for PFS.In the post-ASCT evaluation of the patients (n=30), normalization of HLC Ig´k/Ig´l ratio was observed in 8 patients (27%). An altered HLC ratio was predictive of shorter PFS after ASCT (25% vs. 70%, HR: 3,42, 95%CI 1,12-11,97, p=0,039, fig. 2B) and with a trend towards a worse OS (p=0,072, fig. 2A). Severe HLC-matched pair suppression was found in 12 patients (40%) and was predictive of worse OS (0% vs 70%, HR: 10,63, 95%CI: 1,11-114,11, p=0,023, fig.2C) and shorter PFS (35% vs. 71%, HR: 8,87, 95%CI: 1,72-45,92, p=0,002, fig. 2D). The severe systemic immunoparesis observed in 17 patients (57%) was not associated with OS (p=0,644, fig.2E) or PFS (p=0,750, fig. 2F).Conclusions: Severe HLC-matched pair suppression and i/u HLC>80 are associated with worse OS and shorter PFS in MM patients suggesting a potential use of these parameters as prognostic biomarkers in newly diagnosed patients. Severe HLC-matched pair suppression is an independent risk factor for OS whereas i/u HLC>80 is independently associated with shorter PFS. In patients after ASCT, severe HLC-matched pair suppression reflects the persistence of clonal cells that is not associated with severe systemic immunoparesis. [Display omitted] [Display omitted] [Display omitted] DisclosuresBarbosa:The Binding Site: Employment. Pais:The Binding Site: Employment.

Responses Assigned Using Heavy+Light Chain Assessments Have Better Clinical Correlation with Outcome Than Those Using Current IMWG Criteria for Multiple Myeloma

Introduction: Stratification of multiple myeloma patient responses by reductions in monoclonal component is based upon reliable, historic outcome data. With the introduction of novel agents, a greater number of patients are achieving hitherto unthought-of responses, with many expecting to meet the requirement for VGPR or greater. Multiple factors can impact the quantification and assessment of response in patients achieving deep responses including the influence of IgG recycling, accuracy of quantitation against an increasing polyclonal background and the presence of monoclonal immunotherapies. Alternative strategies for monoclonal protein measurement include heavy+light chain (HLC) immunoassays. Here for the first time we compare the consistency of response assignment between the two methods and evaluate the clinical impact of discordance.Methods: Sera from 509 newly diagnosed intact immunoglobulin multiple myeloma (IIMM) patients enrolled onto IFM-2009 trial were available (median age was 59 (range: 33-66) years, follow-up 30 (3-56) months). Two patients arms were treated with RVDx3+ASCT+RVDx2 or RVDx8, followed by 12 months Lenalidomide maintenance. Responses were assigned at the end of consolidation therapy according to IMWG criteria using changes in monoclonal protein concentrations measured by either SPE or dHLC (clonal - non clonal). Complete response (CR) was assigned by either method by the absence of monoclonal protein on IFE or a normal HLC ratio (HLCr), respectively, and <5% BM plasma cells. HLC-pair suppression was defined as levels of the non-clonal HLC (e.g. IgGλ in an IgGκ patient) below the reference range (IgGκ <3.84g/L; IgGλ <1.91g/L; IgAκ <0.57g/L; IgAλ <0.44g/L). Minimal residual disease (MRD) was assessed by 7-color flow cytometry at the end of consolidation therapy.Results: IFE and HLCr concordantly identified clonality in 99% patients. In 463 patients followed until the end of consolidation we found moderate agreement in response assignment between the two tests. HLC gave similar response assignments to electrophoretic tests in patients with poor response (≤PR, 76/96; 79%) or complete response (≥CR, 130/142; 92%). However in patients achieving VGPR there was considerable discordance between methods for response assignment (102/225; 45%). Having identified discordant results for VGPR we sought to assess the clinical accuracy of the responses assigned within this group. Of the 225 patients with standard VGPR, HLC response assignment varied (PR (18/225), VGPR (102/225) and ≥CR (105/225)). Median PFS for patients achieving standard VGPR was 34.5 months; responses by HLC further described these patients into those with poorer PFS (PR, median PFS=21.3 months (95%CI: 9.0-33.7)); VGPR (PFS=28.9 months (95%CI: 25.1-32.6)), and those with improved outcomes (CR, median PFS not reached); p<0.0001 (Figure 1). This suggested that the response assigned by electrophoresis could be refined by HLC analysis. By contrast, responses assigned by electrophoretic methods offered no added clinical value in patients achieving VGPR (log-rank: p=0.724) or ≥CR (log-rank: p=0.402) by HLC assessment. Furthermore, an abnormal HLCr post-consolidation had a greater concordance with MRD+ assessment (78% positive) compared to IFE (51% positive); whereas both a normal HLCr and negative IFE displayed similar agreement with MRD- assessment (88% and 94% negative, respectively).Finally we assessed the clinical impact of recovering polyclonal immunoglobulin levels after consolidation therapy. In 142 patients with complete responses, HLC-pair suppression (n=15, median PFS=35.1 months (95%CI: 20.9-49.2) and severe suppression (n=7, median PFS=22.9 months (95%CI: 16.6-29.2)) were associated with poorer outcomes (p=0.060 and p=0.004, respectively).Conclusions: In patients achieving a poor or exceptional response there was good agreement between HLC and standard response assignment. For patients achieving a VGPR we suggest that HLC response assignment may be beneficial, therefore overall the assessment could be used to augment or replace electrophoresis. The prognostic significance of HLC responses seems to be partly dependent in the patient's ability to recover their immune system, as determined by normalisation of non-clonal HLC levels. [Display omitted] DisclosuresMichallet:Bristol-Myers Squibb: Consultancy, Honoraria, Research Funding; Pfizer: Consultancy, Honoraria; Novartis: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria; Astellas Pharma: Consultancy, Honoraria; MSD: Consultancy, Honoraria; Genzyme: Consultancy, Honoraria. Attal:sanofi: Consultancy; janssen: Consultancy, Research Funding; amgen: Consultancy, Research Funding; celgene: Consultancy, Research Funding. Moreau:Novartis: Honoraria; Celgene: Honoraria; Takeda: Honoraria; Janssen: Honoraria, Speakers Bureau; Amgen: Honoraria; Bristol-Myers Squibb: Honoraria. Avet-Loiseau:janssen: Consultancy; sanofi: Consultancy; amgen: Consultancy; celgene: Consultancy.