Urine Immunofixation Electrophoresis Research Articles

Urine immunofixation electrophoresis and serum free light chain analyses benefit diagnosis of multiple myeloma in orthopedic patients with normal serum total proteins, creatinine, calcium, and hemoglobin.

A substantial number of patients with multiple myeloma (MM) who have bone destruction are initially admitted into the orthopedic service at the hospital. However, routine laboratory testing usually fails to identify these patients, thus delaying optimal therapy. Therefore, there is a clear medical need for early diagnosis of MM in these patients. Between 2019 and 2021, 42 patients receiving treatment for orthopedic conditions had normal hemoglobin (Hb), total protein (TP), albumin (ALB), creatinine (CREA), and blood calcium (Ca) levels before their surgical procedure(s) but were subsequently pathologically confirmed to have MM, based on their presenting orthopedic symptoms. During the same period, 52 patients with orthopedic conditions were pathologically excluded from the diagnosis of MM and were recruited into our control group. Serum free light chain (sFLC) testing was performed in 94 consecutive patients in the orthopedic service using Siemens N Latex FLC kits. The levels of Hb, TP, ALB, CREA, and Ca were also measured. All 42 patients with MM were divided into group A (n = 25: κ proliferation) and group B (n = 17: λ proliferation) by the pathology department. There were no significant differences in levels of Hb, TP, ALB, CREA, and Ca between group A and group B and the control group. However, the sFLC κ/λ ratio of group A and B was also significantly different from that of the control group (P < .001). The results of serum immunofixation electrophoresis (IFE) testing demonstrated negative results in 14 cases (58.3%) in group A and 4 cases (25.0%) in group B. Some patients with orthopedic conditions who do not have typical MM laboratory results, such as those with abnormal Hb, TP, ALB, CREA, and Ca levels before their operation(s), actually have MM. MM should be highly suspected in patients with unexplained bone lesions and with an abnormal sFLC κ/λ ratio. Further tissue or bone marrow biopsy is needed in these patients even if serum and urine IFE results are negative and light chain ratio is normal.

Serum-free light chain test utilisation at a South African academic laboratory and comparison with serum protein electrophoresis results.

Serum protein electrophoresis (SPE), urine protein electrophoresis and immunofixation electrophoresis were traditionally utilised for the diagnosis of monoclonal gammopathies. The quantitative serum-free light chain (SFLC) assay is reportedly more sensitive and has been introduced to recent clinical guidelines. This study aimed to investigate SFLC test utilisation and describe SPE findings in patients with abnormal SFLC ratios. A retrospective audit of SFLC analyses was conducted in Cape Town, South Africa, from May 2018 to April 2020. Agreement between abnormal SFLC ratios and SPE results was determined in a sub-group of patients screened for monoclonal gammopathies. Serum-free light chains were analysed using Freelite® Kappa and Lambda assays. Of the 1425 patients included in the audit, 741 (52%) had abnormal SFLC ratios; 636 (45%) had increased and 105 (7%) had decreased SFLC ratios. In a sub-group analysis of 117 new patients with an abnormal SFLC ratio, 57 had a monoclonal protein (M-protein) on SPE (49%), and 60 (51%) did not. Four out of 60 patients without M-protein had a plasma cell dyscrasia, while renal impairment or inflammatory response accounted for the rest. Of the 57 patients with a M-protein and abnormal SFLC ratio, 41 (72%) had a plasma cell dyscrasia, seven (12%) had lymphomas and nine patients (16%) were unclassifiable. Serum-free light chains should be requested when there is a high index of clinical suspicion. Neither SFLC nor SPE should be performed in isolation when screening patients for monoclonal gammopathy, to ensure that no patient is missed. The study adds to the evidence on SFLC test utilisation. Serum protein electrophoresis alone may miss cases of light chain myeloma, while SFLC performed in isolation may produce false positive results in the setting of inflammatory disorders or renal impairment, leading to unnecessary further investigation.

Complete blood and urine paraprotein tests as response assessments in multiple myeloma patients treated with bortezomib, cyclophosphamide, and dexamethasone.

This study assessed the effect of standardized efficacy markers on prognosis in patients with newly diagnosed multiple myeloma (MM) during the induction phase of treatment with bortezomib, cyclophosphamide, and dexamethasone (BCD). We retrospectively analyzed clinical data in 197 newly diagnosed MM patients treated with BCD as front-line regimen at Peking Union Medical College Hospital from January 1, 2013 to December 31, 2018. There were 107 patients with International Staging System (ISS) III and 51 with paraprotein of light chain. Of these, 77 completed nine cycles of the BCD regimen. As the number of treatment cycles increased, the proportions of serum and urine immunofixation electrophoresis (IFE) tests elevated from 40.39% to 62.22% and 16.75% to 37.78%, respectively. More than 90% of intact immunoglobulin chain MM patients were evaluated for blood M protein per cycle, but that of urinary M protein was less than 60%. The detection rate of urinary M protein in light chain MM was more than 70% per cycle. Patients with a very good partial response (VGPR) had longer progression-free survival (PFS) than those with uncertain VGPR (32 vs. 26 months, p = 0.0336). Of the 141 patients who completed at least four cycles without undergoing autologous hematopoietic stem cell transplantation, those who were regularly assessed at every other cycle showed more favorable PFS than those who visited irregularly (27 vs. 22 months, p = 0.059). Urinary M protein detection rate is significantly lower than that in serum, leading to an overestimation of efficacy, premature reduction of treatment intensity, and shortened PFS. Precise response assessments are critical to treatment decisions and clinical diagnoses.

Idiopathic multicentric castleman’s disease mimicking immunoglobulin G4-related disease responding well to Bortezomib: a case report

BackgroundCastleman’s disease (CD) is a rare disease that has clinical and pathological similarities to lymphoma and is characterized by a high frequency of associated immunological dysfunction. ImmunoglobulinG4-related disease (IgG4-RD) is a collection of systemic disorders that affect numerous organs and are also referred to as IgG4-associated sclerosing diseases. CD and IgG4-RD are difficult to separate because they may manifest similar commin clinical features.Case presentationThis case describes a 53-year-old female who, during routine medical check-up, exhibited a progressive increase in serum globulin levels and a simultaneous worsening of anemia symptoms, raising concern for a clonal plasma cell disease such as myeloma. However, bone marrow punctures did not reveal any abnormal plasma cells. Also, serum and urine immunofixation electrophoresis demonstrated no abnormal monoclonal protein bands. In addition, several laboratory findings excluded chronic liver disease, chronic infections caused by bacteria or viruses. Later, we found elevated serum IgG4 levels (10,700 mg/L), and identified multiple enlarged lymph nodes throughout the patient’s body. Axillary lymph node aspiration revealed no abnormal lymphocytes, ruling out the possibility of lymphoma. Pathological morphology of the axillary lymph revealed a large number of plasma cells in the lymphatic follicles. In addition, there was a reduction in lymphatic follicle size and apoptosis of the germinal centres. Immunohistochemistry revealed IgG4+/IgG + in > 40% of cells, and more than 100 IgG4 + cells per high powered field (HPF) of specimen. As of now, finding strongly suggested IgG4-RD. This patient was treated with glucocorticoids and various immunosuppressive drugs, such as prednisone, cyclosporine, methotrexate, cyclophosphamide, mycophenolate mofetil, azathioprine and hydroxychloroquine. Unfortunately, the patient did not recover. Ultimately, idiopathic multicentric Castleman disease (iMCD) was diagnosed in relation to the patient’s clinical presentation and laboratory tests, and after combination chemotherapy (VCD: Bortezomib, Cyclophosphamide and Dexamethasone), durable remission was achieved without serious adverse effects. During the follow-up period of one year and ten months, the patient remained stable.ConclusionThe diagnosis of Castleman must be distinguished from other disorders such as IgG4-RD, malignant lymphoma, reactive hyperplasia of various lymph nodes (mostly caused by viral infections), plasmacytoma, advanced HIV and rheumatic diseases. Besides observing systemic symptoms, laboratory tests such as immunoglobulin levels, complement levels, interleukin levels, and C-reactive protein levels should also be performed in order to determine a diagnosis.

First case report of PLA2R-related monotypic (IgG-κ positive) membranous nephropathy concurrent with leukocyte chemotactic factor 2 amyloidosis

BackgroundMembranous nephropathy (MN) is a major pattern of nephrotic syndrome (NS) in adults. Some MN have secondary causes and some may be accompanied with other glomerular diseases. MN patients coexisting with amyloidosis are very rare, and mostly was polytypic MN. Herein, we describe the first report which identifying monotype PLA2R-MN (κ light chain) concurrent with leukocyte chemotactic factor 2 amyloidosis (ALECT2). This rare case highlights the importance of renal pathology for diagnosis.Case presentationWe describe a case of a 60-year-old male patient with persistent proteinuria and low serum albumin for nine months. No monoclonal component was revealed by serum and urine immunofixation electrophoresis but serum PLA2R antibody was positive. The patient was empirically treated with Leflunomide and Losartan, but edema was not improved. The diagnosis of renal pathology is PLA2R-related monotypic (IgG-κ positive) MN concurrent with ALECT2. Methylprednisolone, cyclosporine A and anticoagulant (rivaroxaban) were prescribed resulting in a complete remission of NS.ConclusionsMN patients concurrent with ALECT2 presented massive proteinuria or NS. When nephrotic range proteinuria is present in ALECT2, it is important to consider that it may be due to a concomitant underlying nephropathy especially MN and treated according to MN will get good therapeutic effect.

Quantification of Free Immunoglobulin Light Chains in Urine.

The serum-free immunoglobulin light chain assay has been recommended as a screening test for monoclonal gammopathy. We evaluated the usefulness of urine free immunoglobulin light concentration for selection of specimens for immunofixation electrophoresis. Using kits from The Binding Site for Freelite ®, we validated examination of urine for measuring free κ and λ light chains. The results of urine free light chain concentrations were evaluated to ascertain if the results could be used to reduce the number of specimens requiring urine protein immunofixation electrophoresis. In the 515 specimens examined, there was no evidence of monoclonal gammopathy or history of monoclonal gammopathy in 331. Monoclonal κ or λ light chains were detectable in 42 and 30 specimens, respectively. There was history of κ or λ chain associated monoclonal gammopathy in 62 and 50 patients, respectively. In the 38 monoclonal κ positive urine specimens, with light chain data, κ/λ ratio was >5.83 in all specimens. In 27 specimens positive for monoclonal λ light chains, with light chain data, the urine λ/κ ratio was > 0.17 in 24 of 27 specimens and > 0.041 in all specimens. In patients without monoclonal gammopathy all specimens had a κ/λ ratio of >5.83 or λ/κ ratio >0.17. The Freelite ® assay from The Binding Site is suitable for quantification of free light chains in urine. In patients with known history of monoclonal gammopathy, urine immunofixation electrophoresis may be omitted in specimens with κ/λ ratio of <5.83 for κ associated lesions and λ/κ ratio of <0.041 for λ associated lesions. However, the results do not support using this test for first-time urine testing for monoclonal light chains as it is not predictive of positive result, nor does it exclude a monoclonal light chain in urine.

Multiple Myeloma-Associated Leukocytoclastic Vasculitis Mimicking Autoimmune Vasculitis.

A 52-year-old man was admitted because of complaints of swelling and skin rashes on the extremities, fever, and arthralgia. Physical examination revealed bilateral ankle and wrist joint tenderness and livedo racemosa and purpura on the lower extremities (Figure, A). Cutaneous lesion biopsy showed leukocytoclastic vasculitis (Figure, B). Laboratory testing revealed a hemoglobin level of 5.6 g/dL, mildly decreased glomerular filtration rate, and an immunoglobulin G level of 3,936 mg/dL. Serum and urine immunofixation electrophoresis showed monoclonal kappa light chains. Bone marrow biopsy revealed proliferation of monoclonal plasma cells (Figure, C). Finally, the patient was diagnosed with leukocytoclastic vasculitis as the initial presentation of multiple myeloma. Cutaneous symptoms resolved within 6 weeks following treatment with daratumumab, lenalidomide, and dexamethasone (Figure, D). Although leukocytoclastic vasculitis is commonly associated with immune-mediated systemic vasculitis, cutaneous leukocytoclastic vasculitis may be observed in case of malignancy. Monoclonal gammopathies should be considered in cases of leukocytoclastic vasculitis associated with renal and blood disorders.Differential diagnosis: immunoglobulin A vasculitis, microscopic polyarteritis, granulomatosis with polyangiitis, and eosinophilic granulomatosis with polyangiitis.

Cardiac Amyloidosis Imaging, Part 3: Interpretation, Diagnosis, and Treatment.

Cardiac amyloidosis was thought to be rare, undiagnosable, and incurable. However, recently it has been discovered to be common, diagnosable, and treatable. This knowledge has led to a resurgence in nuclear imaging with 99mTc-pyrophosphate-a scan once believed to be extinct-to identify cardiac amyloidosis, particularly in patients with heart failure but preserved ejection fraction. The renewed interest in 99mTc-pyrophosphate imaging has compelled technologists and physicians to reacquaint themselves with the procedure. Although 99mTc-pyrophosphate imaging is relatively simple, interpretation and diagnostic accuracy require an in-depth knowledge of amyloidosis etiology, clinical manifestations, disease progression, and treatment. Diagnosing cardiac amyloidosis is complicated because typical signs and symptoms are nonspecific and usually attributed to other cardiac disorders. In addition, physicians must be able to differentiate between monoclonal immunoglobulin light-chain amyloidosis (AL) and transthyretin amyloidosis (ATTR). Several clinical and noninvasive diagnostic imaging (echocardiography and cardiac MRI) red flags have been identified that suggest a patient may have cardiac amyloidosis. The intent of these red flags is to raise physician suspicion of cardiac amyloidosis and guide a series of steps (a diagnostic algorithm) for narrowing down and diagnosing the specific amyloid type. One element in the diagnostic algorithm is to identify monoclonal proteins indicative of AL. Monoclonal proteins are detected by serum or urine immunofixation electrophoresis and serum free light-chain assay. Another element is identifying and grading cardiac amyloid deposition using 99mTc-pyrophosphate imaging. When monoclonal proteins are present and the 99mTc-pyrophosphate scan is positive, the patient should be further evaluated for cardiac AL. The absence of monoclonal proteins and a positive 99mTc-pyrophosphate scan is diagnostic for cardiac ATTR. Patients with cardiac ATTR need to undergo genetic testing to differentiate between wild-type ATTR and variant ATTR. This article is the third in a 3-part series in this issue of the Journal of Nuclear Medicine Technology Part 1 reviewed amyloidosis etiology and outlined 99mTc-pyrophosphate study acquisition. Part 2 described 99mTc-pyrophosphate image quantification and protocol technical considerations. This article discusses scan interpretation along with cardiac amyloidosis diagnosis and treatment.

Utilizing Mass Spectrometry to Detect and Isotype Monoclonal Proteins in Urine: Comparison to Electrophoretic Methods.

Matrix assisted laser desorption ionization time of flight mass spectrometry coupled to immune enrichment (MASS-FIX) as an alternative to serum immunofixation electrophoresis has demonstrated increased sensitivity in monoclonal protein (MP) detection with improved laboratory workflow. This study explored similar replacement of urine immunofixation electrophoresis (u-IFE) with urine MASS-FIX (u-MASS-FIX) by method comparison. Residual urine (n = 1008) from Mayo Clinic patients with a known plasma cell disease were assayed neat by u-MASS-FIX analysis. Each sample was paired with the following: u-IFE, urine total protein, urine protein electrophoresis, serum κ/λ free light chain (LC) ratio (rFLC), and serum MASS-FIX (s-MASS-FIX). Analytical sensitivities were measured in pooled urine spiked with daratumumab. u-IFE and u-MASS-FIX had 91% agreement in determining the presence/absence of MPs (Cohen kappa = 0.8200). In discrepant cases, serum rFLC statistically aligned more closely with positive u-MASS-FIX cases than u-IFE. Patients positive by both s-MASS-FIX and u-MASS-FIX had matching MP masses (±20 daltons) in 94% of cases. The u-MASS-FIX spectra further identified κ/λ LC fragments and glycosylated LCs not appreciated on u-IFE. The unconcentrated u-MASS-FIX limit of detection of 0.156 mg/mL was determined equivalent to 100× concentrated u-IFE. u-MASS-FIX is a reliable alternative to u-IFE with the added benefits of LC glycosylation detection and MP mass tracking between serum and urine. Furthermore, u-MASS-FIX is performed using neat urine. Eliminating the need to concentrate urine for u-IFE has potential to increase productivity by decreasing labor minutes per test.

Evaluation of laboratory diagnostic tests for light-chain clonality and bone marrow findings in AL amyloidosis.

Light-chain amyloidosis (AL) is the most common form of systemic amyloidosis. This study aimed to evaluate the usefulness of laboratory tests for light-chain clonality and bone marrow (BM) findings in AL amyloidosis. We retrospectively enrolled patients newly diagnosed with AL amyloidosis on pathological examination who underwent a BM biopsy. Laboratory test data for light-chain clonality were collected and compared. Amyloid deposits were identified with H&E, Congo red, and PAS stains. We reviewed 98 patients with AL amyloidosis. Light chain clonality (λ, 64 cases; κ, 34 cases) was detected by serum immunofixation electrophoresis (IFE) (63.3%), urine IFE (70.8%), serum protein electrophoresis (PEP) (44.9%), urine PEP (44.8%), serum free light chain (SFLC) ratio (79.5%), and BM immunohistochemistry (IHC) (85.7%). Flow cytometric (FCM) assay identified aberrant BM plasma cells in 92.9% of cases. BM amyloid deposits were identified in 35 of the 98 cases (35.7%); 71.4% (25/35) were Congo red-positive, and 100.0% (35/35) were PAS-positive. Laboratory tests for detecting light-chain clonality in AL amyloidosis in order of sensitivity include FCM assay for aberrant plasma cells, IHC for light chains on BM biopsy or clot section, SFLC ratio, and serum and urine IFE. Congo red staining of BM samples remains an important tool for identifying amyloid deposits in BM. Periodic acid-Schiff (PAS) staining can be useful in diagnosing some cases of Congo red-negative amyloidosis.

Urine Protein Immunofixation Electrophoresis: Free Light Chain Urine Immunofixation Electrophoresis Is More Sensitive than Conventional Assays for Detecting Monoclonal Light Chains and Could Serve as a Marker of Minimal Residual Disease.

Immunoglobulin monoclonal light chains (MLCs) in serum and urine are markers for monoclonal gammopathy and could serve as markers of minimal residual disease (MRD) in multiple myeloma (MM). Excretion of MLCs in urine is known to result in renal damage and shorter survival in patients with LC-predominantMM. Retrospective review of urine immunofixation in 1738 specimens at 3 medical centers was conducted to assess the utility ofurinalysis for diagnosis and monitoring of monoclonal gammopathy. We tested 228 stored urine specimens via the modified urine immunofixation method, using antisera to assay free LCs (FLCs). Our review of urine immunofixation results and medical records validated the theory that the only meaningful value-added finding was detection of monoclonal free light chains. Examination of 228 urine specimens using our novel method revealed 18.4% additional positive results. The rate of incremental findings for lambda LCs was nearly 3-fold higher than for kappa LCs. The new method of urine immunofixation is significantly more sensitive and more efficient than the conventional method for detecting MLCs in urine. The new assay appears to be sensitive enough to prove that MLCs serve as a marker of MRD in MM.

Evaluating the screening value of serum light chain ratio, β2 microglobulin, lactic dehydrogenase and immunoglobulin in patients with multiple myeloma using ROC curves.

Several laboratory and imaging assays are required to diagnose multiple myeloma (MM). Serum and urine immunofixation electrophoresis are two key assays to diagnose MM, while they have not been extensively utilized in Chinese hospitals. Serum light chain (sLC), β2 microglobulin (β2-MG), lactic dehydrogenase (LDH), and immunoglobulin (Ig) are routinely measured in the majority of Chinese hospitals. Imbalance of sLC ratio (involved light chain/uninvolved light chain) is frequently observed in MM patients. This study aimed to evaluate the screening value of sLC ratio, β2-MG, LDH, and Ig in MM patients using receiver operating characteristic (ROC) curves. Data of 303 suspected MM patients, who were admitted to the Taizhou Central Hospital between March 2015 and July 2021, were retrospectively analyzed. In total, 69 patients (MM arm) met the International Myeloma Working Group (IMWG) updated criteria for the diagnosis of MM, while 234 patients were non-MM (non-MM arm). All patients' sLC, β2-MG, LDH, and Ig were measured using commercially available kits according to the manufacturer's instructions. The ROC curve analysis was employed to assess the screening value of sLC ratio, β2-MG, LDH, creatinine (Cr) and Ig. The statistical analysis was carried out by SPSS 26.0 (IBM, Armonk, NY, USA) and MedCalc 19.0.4 (Ostend, Belgium) software. There was no significant difference between the MM and non-MM arms in terms of gender, age and Cr. The median sLC ratio in the MM arm was 11.5333, which was significantly higher than that of 1.9293 in the non-MM arm (P<0.001). The area under the curve (AUC) of sLC ratio was 0.875, which indicated a robust screening value. The optimal sensitivity and specificity were 81.16% and 94.87% respectively, when the sLC ratio was set as 3.2121. The serum levels of β2-MG and Ig were higher in the MM arm than those in the non-MM arm (P<0.001). The AUC values of β2-MG, LDH, and Ig were 0.843 (P<0.001), 0.547 (P = 0.2627), and 0.723 (P<0.001), respectively. The optimal cutoff values of β2-MG, LDH, and Ig were 1.95 mg/L, 220 U/L, and 46.4 g/L respectively, in the context of screening value. The triple combination of sLC ratio (3.2121), β2-MG (1.95 mg/L), and Ig (46.4 g/L) yielded a higher screening value compared with that of sLC ratio alone (AUC, 0.952; P<0.0001). The triple combination had a sensitivity of 94.20% and a specificity of 86.75%. The addition of LDH to the triple combination and formation of quadruple combination did not optimize the screening value, with AUC, sensitivity, and specificity of 0.952, 94.20%, and 85.47%, respectively. The triple combination strategy (sLC ratio, 3.2121; β2-MG, 1.95 mg/L; Ig, 46.4 g/L) is accompanied by remarkable sensitivity and specificity for screening MM in Chinese hospitals.

The dark side of current analytic methods for Bence Jones Proteinuria.

Bence Jones proteinuria (BJP) refers to monoclonal free immunoglobulin light chains detected in urine, deriving from the clonal expansion of plasma cells in the bone marrow in patients with plasma cell dyscrasias, associated with monoclonal gammopathies of uncertain origin. This review summarizes routinely diagnostic procedures to assess BJP highlighting critical steps of pre-analytical, analytical, and post-analytical phases. The best option for BJP detection is the first morning void urine sample and immunofixation electrophoresis detection technique (IFE) the recommended method, with the employment of specific polyvalent antisera. Other qualitative tests for a quick evaluation of BJP are currently available. Densitometric analysis performed on the 24-hour urine is the recommended method to quantify BJP. To overcome the 24-hour collection, it is possible to use morning urine sample and correlate the assessed value of BJP to creatininuria. In addition to the traditional ones, we here reviewed screening methods currently used to avoid false negatives and reduce the time around test (TAT), together with immunochemical quantification methods for increased sensitivity, after checking BJP by IFE. Mass spectrometry emerges as a new challenge in the determination of BJP. The employment of different based-assays methods may be useful for diagnostic purposes to improve the accuracy of BJP monitoring in monoclonal gammopathies.

Application of urine immunofixation electrophoresis in prognostic evaluation of hematopoietic stem cell transplantation in patients with myeloma.

ABSTRACTObjectives:To investigate the value of urine immunofixation electrophoresis in prognostic evaluation of hematopoietic stem cell transplantation in patients with myeloma.Methods:Thirty-four patients with multiple myeloma admitted to Affiliated Hospital of Hebei University from November 2013 to December 2014 were included as research subjects. All patients received hematopoietic stem cell transplantation and were followed up for five years. Outcomes were evaluated according to the recovery status: complete response (CR), very good partial response (VGPR), partial response (PR), stable disease (SD), and progression disease (PD). In addition, the overall response rate (CR+VGPR) of patients was observed and their urine immunoglobulin status was measured by immunofixation electrophoresis. The Kaplan-Meier method was utilized to plot the survival curve, and the Log-rank method was adopted to analyze the relationship between CR+VGPR and PR and hematopoietic stem cell transplantation (HSCT) survival in patients with myeloma.Results:The basic clinical type of immunofixation electrophoresis was as follows: 19 cases (55.88%) of IgG, 7 cases (20.59%) of IgA, 6 cases (17.65%) of IgM, and 2 cases (5.88%) of light chain type. Outcomes: 13 cases (38.24%) of CR, 12 cases (35.29%) of VGPR, 9 cases (26.47%) of PR, and 25 cases (73.53%) of the overall response rate (CR+VGPR). Compared with IgG, CR, VGPR and PR of IgA, IgM and light chain had statistically significant differences in outcome (p<0.05), and CR+VGPR of patients with IgG was higher than that of patients with IgA, IgM and light chain type (p<0.05). Two of the 34 patients were lost to follow-up. The log-rank analysis showed that the survival rate of patients with CR+VGPR was higher than that of patients with PR (p<0.05). Patients with IgA, IgM, and light chain type had an increased number of prognostic death compared with those with IgG (p<0.05).Conclusion:Patients with IgG type myeloma are superior to those with IgA, IgM and light chain type in terms of the prognosis of hematopoietic stem cell transplantation, which has a certain clinical reference value.

M-Protein Sequencing and Monitoring in Serum of LC-Only Multiple Myeloma Patients

M-Protein Sequencing and Monitoring in Serum of LC-Only Multiple Myeloma Patients

Development of second primary multiple myeloma five years after treatment for limited-stage small cell lung cancer: a rare case report

Introduction. The development of a second primary malignancy (SPM) following small cell lung cancer (SCLC) has been previously reported in the literature. Especially smoking-related malignancy coupling is well known. The development of multiple myeloma (MM) in long-term survivors after treatment for SCLC is unknown. Here, we report the first case in the literature who developed MM 5 years after treatment for limited-stage SCLC. Case report. A 67-year-old male patient was diagnosed with limited-stage SCLC. After he received chemotherapy and radiotherapy, he was followed up without medication. He was admitted to the hospital with back pain and dyspnea 5 years after the diagnosis of small cell lung cancer. MRI revealed osteolytic lesions in the vertebrae. Laboratory testing revealed a markedly elevated serum IgA and an elevated serum beta-2 microglobulin level. Serum immunofixation revealed IgA lambda-type M-protein. Lambda excretion in urine immunofixation electrophoresis was observed. Bone marrow aspiration revealed the frequency of plasma cells to be 80% of all nucleated cells. Hence, the final diagnosis revealed IgA lambda free light chain MM. Treatment was given for multiple myeloma. In the follow-up, the patient experienced increased dyspnea and developed bilateral pleural effusion. The cytology sent from thoracentesis sampling was reported as plasmocyte-rich material. The patient fell into a coma and died in an intensive care unit. Conclusion. We presented the development of MM 5 years after treatment in a patient with SCLC who were treated for one year and then followed up with stable findings. It should be kept in mind that a patient with SCLC who is a long-term survivor and presents with back pain may have developed a primary malignancy originating from bone marrow rather than a bone metastasis. Patients should be advised smoking cessation after the treatment and diagnosis of SCLC. Also, the patients with SCLC who are long-term survivors should be closely monitored for the development of SPM.

Addendum to ASNC/AHA/ASE/EANM/HFSA/ISA/SCMR/SNMMI Expert Consensus Recommendations for Multimodality Imaging in Cardiac Amyloidosis: Part 1 of 2—Evidence Base and Standardized Methods of Imaging

There are 2 primary reasons for an addendum. The first is that the document reviewer list is being updated to include Dr Richard Cheng and Dr Roy John, who have critically reviewed the document, but were inadvertently not listed as reviewers. In addition, since the publication of this document and the introduction of approved therapies for transthyretin cardiac amyloidosis, the clinical use of bone tracer cardiac scintigraphy has been extended to populations with a lower prevalence of transthyretin cardiac amyloidosis. Numerous observations have raised concerns about (1) incorrect diagnosis of transthyretin cardiac amyloidosis based on 99mTc-pyrophosphate (PYP) planar imaging and heart-to-contralateral lung (H/CL) ratio without confirmation of diffuse myocardial uptake on single photon emission computed tomography (SPECT) imaging at some sites; (2) excess blood pool activity on the 1-hour planar and SPECT images being interpreted as positive scans; and (3) missed diagnosis of light chain amyloidosis, as serum-free light chain studies and serum and urine immunofixation electrophoresis studies may not be recommended in the 99mTc-PY P/-3,3-diphosphono-1,2-propanodicarboxylic acid/hydroxymethylene diphosphonate (99mTc-PYP/DPD/HMDP) report. Incorrect diagnosis leads to inappropriate therapy and worse patient outcomes. SPECT and planar imaging performed at 3-hour maximize specificity. 1 Sperry B.W. Burgett E. Bybee K.A. McGhie A.I. O’ Keefe J.H. Saeed I.M. et al. Technetium pyrophosphate nuclear scintigraphy for cardiac amyloidosis: imaging at I vs 3 hours and planar vs SPECT/CT. J Nucl Cardiol. 2020; 27: 1802—7https://doi.org/10.1007/s12350-020-02139-8 Crossref Scopus (20) Google Scholar , 2 Masri A. Bukhari S. Ahmad S. Nieves R. Eisele Y.S. Follansbee W. et al. Efficient 1-hour technetium-99m pyrophosphate imaging protocol for the diagnosis of transthyretin cardiac amyloidosis. Circ Cardiovasc Imaging. 2020; 13e010249https://doi.org/10.1161/CIRCIMAGING.119.010249 Crossref Scopus (27) Google Scholar , 3 Castano A. Haq M. Narotsky D.L. Goldsmith J. Weinberg R.L. Morgenstern R. et al. Multicenter study of planar technetium 99m pyrophosphate cardiac imaging: predicting survival for patients with ATTR cardiac amyloidosis. JAMA Cardiol. 2016; 1: 880-889https://doi.org/10.1001/jamacardio.2016.2839 Crossref PubMed Scopus (211) Google Scholar Additionally, technical parameters have been updated. ASNC/AHA/ASE/EANM/HFSA/ISA/SCMR/SNMMI Expert Consensus Recommendations for Multimodality Imaging in Cardiac Amyloidosis: Part 1 of 2—Evidence Base and Standardized Methods of ImagingJournal of Cardiac FailureVol. 25Issue 11PreviewCardiac amyloidosis is a form of restrictive infiltrative cardiomyopathy that confers significant mortality. Because of the relative rarity of cardiac amyloidosis, clinical and diagnostic expertise in the recognition and evaluation of individuals with suspected amyloidosis is mostly limited to a few expert centers. Electrocardiography, echocardiography, and radionuclide imaging have been used for the evaluation of cardiac amyloidosis for over 40 years.1–3 Although cardiovascular magnetic resonance (CMR) has also been in clinical practice for several decades, it was not applied to cardiac amyloidosis until the late 1990s. Full-Text PDF

Clinical Comparison of a New Serum Free Light Chain (FLC) Assay Based on the Seralite Monoclonal Anti-FLC Antibodies with the Freelite and N-Latex FLC Assays in the Diagnosis of AL Amyloidosis

Aims: Accurate quantitation of FLC is essential for the diagnosis and monitoring of patients with AL amyloidosis. Current assays, however, have their limitations. Recently a new assay based on monoclonal antibodies (Seralite, Abingdon Health Ltd, UK) has been developed which appears to have some analytical advantages over existing assays and has been clinically validated in patients with myeloma (BJH 2017;178:220). We compared the antibodies used in this novel assay for FLC quantitation to the established monoclonal (N-Latex) and polyclonal (Freelite) antibody-based assays in AL amyloidosis.Methods: 61 diagnostic samples from patients with AL amyloidosis were analysed. Serum FLC concentration was measured using Seralite monoclonal anti-FLC antibodies on an in-house ELISA platform in the Clinical Immunology Service Birmingham, and Freelite (The Binding Site, UK) and N-Latex (Siemens, Germany) immunoassays on a BNII nephelometer in the Pathology Queensland laboratory, Brisbane. Serum and urine immunofixation electrophoresis (IFE) were performed on Hydrasys gel systems (Sebia, France).Results: For AL of kappa type (n=18), the median involved FLC (iFLC) was non-significantly lower by the Seralite assay than by the N-Latex or Freelite assay (220 vs 289 vs 667mg/L, p=0.64 and 0.27 for Seralite vs N-Latex and Freelite, respectively). In AL of lambda type (n=43) the values were significantly different (37 vs 144 vs 156mg/L, p=0.005 and 0.006 for Seralite vs N-Latex and Freelite, respectively). Measurable disease is currently defined as a difference between the involved and uninvolved FLC (dFLC) of > 50mg/L. By these criteria, 54% of AL would be measurable by the Seralite FLC assay compared to 82% by the N-Latex assay and 89% by the Freelite assay indicating that different cut-offs are likely to be required for different FLC assays.In terms of the diagnostic sensitivity, the κ:λ FLC ratio was normal in 30%, 21% and 15% of patients by the Seralite, N- Latex and Freelite assays, respectively. All patients with AL amyloidosis of kappa type had an abnormal κ:λ ratio by all 3 assays. This was not the case for the 43 patients with lambda AL amyloidosis where the Seralite determined κ:λ FLC ratio was normal in 18 (42%) of cases compared with 30% and 21% for the N-Latex and Freelite assays, respectively. Providing greater detail of these 18 cases with a normal κ:λ ratio by the Seralite reagents: in 5 cases the κ:λ ratio was normal by all 3 assays; in 9 cases the κ:λ ratio was abnormal by both Freelite and N Latex assays; 1 case had a normal κ:λ ratio by Freelite and abnormal by N Latex; and 3 cases had an abnormal κ:λ ratio by Freelite and normal by N latex assays. For many of these cases the Seralite reagent appeared not to be reacting well with a lambda light chain clearly identifiable by one of the alternate assays. The combination of serum and urine IFE with either FLC assay, however, allowed identification of the amyloidogenic clone in 95%, 98% and 98% producing comparable overall diagnostic sensitivity for the methods. An attempt by the Birmingham laboratory to modify the assay to improve lambda FLC reactivity failed to improve the results.Conclusions: There are significant differences between iFLC as measured by this in-house ELISA assay using Seralite monoclonal antibodies as compared to the existing N Latex and Freelite assays. In particular, the Seralite assay appears to react poorly with amyloidogenic lambda light chains and the current in-house ELISA assay is not suitable for diagnosis or monitoring of AL amyloidosis. It may be that a combination of anti-FLC monoclonal antibodies is required to improve detection of lambda clones by the assay. This data also highlights that different cut-offs and response criteria will be required depending on the assay used in patients with AL amyloidosis which should be a focus of further research. DisclosuresDrayson:Abingdon Health: Equity Ownership, Membership on an entity's Board of Directors or advisory committees.

Comparison of Residual Neoplastic Plasma Cell Number Using Multicolor Flow Cytometry and Various Stages of International Myeloma Working Group-Defined Responses in Patients with Multiple Myeloma

【Introduction】Urine and serum immunofixation electrophoresis (IFE) and free light chain (FLC) are used for measuring paraprotein levels produced by neoplastic plasma cells and are widely accepted as standard tests for diagnosis and monitoring of multiple myeloma (MM). Treatment response criteria defined by the International Myeloma Working Group (IMWG) largely relies on the decrease in paraprotein levels of intact immunoglobulin with or without serum FLC. However, the paraprotein levels vary widely between patients and even in the same patient during the course of the disease. Therefore, considerable discrepancy often exists between the extents of decrease in neoplastic tumour cell burden and paraprotein levels in response to chemotherapy. We retrospectively compared the bone marrow plasma cell (BM-PC) levels using 6- to 8-color flow cytometry (FCM) with various levels of IMWG-defined responses after treating patients with MM.【Methods】We included patients with MM (light chain only multiple myeloma (LCMM), n =35 ; intact immunoglobulin multiple myeloma (IIMM), n =115 ) who were treated at Kameda Medical Center, Japan and Kanazawa University Hospital, Japan, between April 2007 and June 2017. Among them, 130 patients (LCMM; n=35 , IIMM; n=95 ) who achieved partial response (PR) or better response were selected on the basis of the co-availability of serum and urine test data, FLC data, and multicolor flow cytometry (MFC)-generated BM-PC quantitation data. MFC-mediated assessment of BM-PCs was performed during diagnosis and when each IMWG-defined treatment response was obtained. The residual BM-PC level was compared with the IMWG-defined responses using Kruskal-Wallis analysis. Oligosecretary and non-secretary myeloma were excluded from this study. This study conformed to the principles of the Declaration of Helsinki.【Result】Complete data set of IFE, FLC, and MFC during diagnosis, PR, very good partial response (VGPR), complete response (CR), and stringent CR (sCR) were available in 37, 58, 10, and 50 samples in IIMM and in 4, 21, 15, and 21 samples in LCMM. Mean BM-PCs during diagnosis in IIMM and LCMM was 2.1 x 10-1 and 2.2 x 10-1, respectively. In patients with IIMM, mean residual BM-PCs at PR, VGPR, CR, and sCR in IIMM were 1.8 × 10-2 (range: 1.4 × 10-5-7.5 × 10-2), 2.0 × 10-3 (range: 1.4 × 10-5-2.9 × 10-2), 4.4 × 10-4 (range: 2.1 × 10-5-2.0 × 10-3), and 4.8 × 10-4 (range: 2.0 × 10-6-5.3 × 10-3), respectively. Although significant difference in residual BM-PC levels was observed between PR vs. VGPR (P < 0.01), there were no statistically significant difference between VGPR vs. CR (P = 0.08) and CR vs. sCR (P = 0.9). Of note, 58% patients had residual MM cells ≥ 10-4 even when they achieved sCR. The amount of involved intact immunoglobulin at diagnosis was significantly higher in these patients than those who achieved residual MM cells <10-4 (mean: 5206.1 vs. 3954.7 p = 0.04).In patients with LCMM, mean residual BM-PCs cells at PR, VGPR, CR, and sCR were 3.5 × 10-2 (range: 5.1 × 10-3-7.7 × 10-2), 8.9 × 10-3 (range: 4.0 × 10-4-8.9 × 10-2), 2.0 × 10-3 (range: 4.0 × 10-5-1.0 × 10-2), and 1.1 × 10-4 (range: 2.0 × 10-6-7.0 × 10-4), respectively. Significant difference in the amount of residual BM-PC was only observed between CR and sCR, but not in PR vs. VGPR and VGPR vs. CR (PR vs. VGPR: p = 0.08, VGPR vs. CR: p = 0.08, CR vs. sCR: p = 0.03). Normal FLC ratio was highly predictive of lower residual BM-PCs (> 10-4) in LCMM. (Figure 1)Figure 2 shows the proportion of residual BM-PCs at various IMWG responses. The percentages of samples with residual BM-PCs at the levels of ≥ 10-3, 10-3 > - ≥ 10-4 , and < 10-4 in IIMM were 86.8% (n = 32/37), 7.8% (n = 3/37), and 5.2% (n = 2/37) for PR, 31.0% (n = 18/58), 56.8% (n = 33/58), and 12.0% (n = 7/58) for VGPR, 20% (n = 2/10), 40% (n = 4/10), and 40% (n = 4/10) for CR, and 12% (n = 6/50), 46% (n = 23/50), and 42% (n = 21/50) for sCR, respectively. In the case of LCMM, these figures were 100% (n = 4/4), 0% (n = 0/4), and 0% (n = 0/4) for PR, 66.6% (n = 14/21), 33.3% (n = 7/21), and 0% (n = 0/21) for VGPR, 20% (n = 3/15), 66.6% (n = 10/15), and 13.3% (n = 2/15) for CR, and 0% (n = 0/21), 23.8% (n = 5/21), and 76.1% (n = 16/21) for sCR, respectively.【Conclusion】The depth of residual BM-PCs response did not parallel that of IMWG response, and ~20% patients with CR had high level of residual BM-PCs (≥ 10-3). Although paraprotein-based assessment is feasible for disease monitoring in MM, our data indicates that response to treatment could be better assessed by BM-PC. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Updates in Cardiac Amyloidosis Diagnosis and Treatment.

Cardiac amyloidosis is an underrecognized cause of heart failure. We review clinical clues to the diagnoses, a rational approach to testing, and current and emerging therapies. Advances in the diagnosis of amyloid cardiomyopathy include (1) use of 99mtechnetium (99mTc) bone-avid compounds which allow accurate noninvasive diagnosis of transthyretin cardiac amyloidosis (ATTR-CM) in the context of a negative monoclonal light chain screen; and (2) the use of serum and urine immunofixation electrophoresis with serum free light chains as an accurate first diagnostic step for light chain cardiac amyloidosis (AL-CM). Advances in treatment include tafamidis for ATTR-CM and immunologic therapies for AL-CM. With the advent of accurate noninvasive diagnostic modalities and effective therapies, early recognition of cardiac amyloidosis is paramount to implement a diagnostic algorithm and expeditiously institute effective therapies to minimize morbidity and mortality.