Table Of ContentEdinburgh 2015_cover dorso 4mm_Layout 1 16/03/15 11:49 Pagina 1
th
7 International Symposium on
Clinical Applications of Free Light Chain
and Heavy/Light Chain Analysis
Edinburgh, UK, 16-17 April 2015
Guest Editor: Stephen Harding
MKG794
h e m a t o l o g y r e p o r t s — v o l u m e 7 , 2 0 1 5 — s u p p l e m e n t 1
Edinburgh 2015_cover dorso 4mm_Layout 1 16/03/15 11:49 Pagina 2
HEMATOLOGY REPORTS
ISSN 2038-8322 - eISSN 2038-8330
Editor-in-Chief
Giovanni Martinelli, Italy
Deputy Editor HEMATOLOGY REPORTS
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Edinburgh_2015_interno_def_OR_MASTER 16/03/15 11:55 Pagina 1
th
7 International Symposium on
Clinical Applications of Free Light Chain
and Heavy/Light Chain Analysis
Edinburgh, United Kingdom, 16-17 April 2015
Guest Editor
Stephen Harding
Posters
Monitoring Monoclonal Gammopathies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Diagnostic Algorithms for Multiple Myeloma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Risk Stratification of Monoclonal Gammopathies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Case Reports. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Amyloid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Method Evaluation and Comparison. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Monoclonal Free Light Chains and Renal Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Other Uses of Free Light Chain and Heavy Light Chain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Free Light Chains in Multiple Sclerosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Polyclonal Free Light Chains . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Index of Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i
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th
7 International Symposium on Clinical Applications of Free Light Chain and Heavy/Light Chain Analysis
Edinburgh, United Kingdom, 16-17 April 2015
POSTERS
MONITORING MONOCLONAL 0.06,R2=0.91). Weighted Kappa (WK) analysis showed
substantial agreement between the responses assigned by
GAMMOPATHIES
CZE and dHLC (WK=0.91) and total IgM (WK=0.94).
Conclusions. HLC immunoassays provide an alternative
method of quantifying M-Ig in patients with IgM para-
A1 - HEAVY/LIGHT CHAIN IMMUNOASSAYS proteinemias. Larger clinical studies are required to con-
MEASURING IgMκ AND IgMλ FOR firm the clinical utility of these assays.
QUANTIFYING AND MONITORING MONOCLONAL
IgM IMMUNOGLOBULINS
1 2 2 2 3 A2 - HEAVY/LIGHT CHAIN IMMUNOASSAYS AS
A. Alvi, J. Kothari, S. D’Sa, R. Faisal, G. James,
3 4 4 4 AN USEFUL BIOMARKER TO FOLLOW-UP
A. Dawnay, M. Offer, Y. Gu, V. Robinson,
5 4 1 ACCURATE RESPONSE AFTER BORTEZOMIB
D. Simpson, T. Hunter, D. Powner
UPFRONT THERAPY IN MULTIPLE MYELOMA
1 2
The Binding Site Group Ltd, Birmingham, UK; WM
1,2,3 1
M.M. Andrade-Campos, I. Murillo-Flores,
Clinic, Cancer Division, University College London
1 1 2,3
N. Espinoza-Lara, E. Colorado, P. Giraldo
Hospitals NHS Foundation Trust, London, UK;
3 1
Department of Clinical Biochemistry, University College Hematology Department. Miguel Servet University
2
London Hospitals NHS Foundation Trust, London; Hospital; Traslational Research Unit IIS Aragon;
4 5 3
Wexham Park Hospital NHS Trust, UK; Churchill CIBER Enfermedades Raras (CIBERER) ISCIII,
Hospital Immunology Department, Oxford, UK Zaragoza, Spain
Background. Quantification of monoclonal IgM (M-IgM) Background. The objective of multiple myeloma (MM)
using electrophoretic techniques can be challenging. therapy is to achieve a deeper and durable response. The
Novel nephelometric/turbidimetric immunoassays meas- routinely follow-up is based in the M protein quantifica-
uring IgMκ and IgMλ (heavy/light chain, HLC) may pro- tion by serum and urine electrophoresis (SPE, UPE) with
vide a convenient alternative. Calculation of HLC immunofixation (IFX). The incorporation of Serum Free
IgMκ/IgMλ ratios can be used as an indicator of clonali- Light Chain Assay (FLC), and the quantification of paired
ty and may obviate the need for immunofixation assays. clonal and non-clonal immunoglobulins (HLC) in serum,
Objectives. To compare HLC assays with traditional tests offers the possibility to assess the response to therapy
for M-IgM protein quantification in patients with IgM more accurately detecting early biological relapses
paraproteinemias. Methods. We analysed 166 serum sam- (EBR). Aims. To analyze the usefulness of HLC and FLC
ples from 113 patients with IgM paraproteinemias. during MM follow-up to detect EBR after Bortezomib
Median age was 67(35-91) years and M/F ratio 68/45. first line therapy in MM patients in our centre. Patients
HLC IgMκ and IgMλ concentrations were measured with and Methods. Since January 2008 we have incorporate in
Hevylite on the SPAPLUS turbidimetric analyser. Results the protocol for M-components assessment the quantifi-
were compared to CZE and total IgM measurements by cation of FLC, HLC at baseline and in follow-up of MM.
turbidimetry. Results. 22 patients with diagnostic sera and We have analyzed these parameters in all consecutive
M-IgM identifiable by CZE had an abnormal IgMκ/IgMλ patients diagnosed as secretor MM who underwent
ratio (19 IgMκ: 81.33 (12.79-1608); 3 IgMλ: 0.04 (0.03- Bortezomib upfront therapy between Jan 2008-Jun 2014
0.14) and elevated levels of involved HLC (iHLC) and in our center. Results. 135 patients were registered.
total IgM. Median M-IgM concentrations as measured by Median follow-up 25 months. Females: 40.7%, mean age
the three tests were not significantly different (p=0.816, 69.6 y (32-91). Subtype: IgG-κ: 38.2%, IgG-λ: 9,8%,
Kruskal-Wallis test): CZE: 11.50 (3.0-31.0) g/L; total IgA-κ: 17.9%, IgA-λ: 15,4%, IgDL: 1.6%, Bence-Jones-
IgM: 14.75 (3.35-58.8) g/L; iHLC:15.73 (3.58-73.08) κ: 6,5%, Bence-Jones-λ: 8,9%, oligosecretor: 1.6%.
g/L. In all samples, there was good correlation between Stage: IA: 9.8%, IB: 1.6%, II-A: 27.6%, IIB: 8.9%, III-A:
summated IgMκ+IgMλ HLC and total IgM concentra- 21.1%, III-B: 21.1%. ISS(I: 25.2%, II: 32.5%, III:
tions (y=1.13x-0.70,R2=0.88). In agreement with Murray 23.6%). 21.1% were not included in the analysis of
et al. (Clin Chem 2009) both iHLC (y=1.91x- response by uncompleted treatment. Response at end of
0.09,R2=0.80) and total IgM measurements therapy: minimal response: 5.1%, PR: 44.3%, VGPR:
(y=1.66x+0.69, R2=0.92) showed a linear, systematically 16.5%, CR: 14.4% SR: 7.2%, Failure: 12.5%. During fol-
high correlation to CZE for IgM concentrations >8.5g/L. low-up 65.7% patients, who achieved at least PR had
There was no correlation for IgM concentrations <8.5g/L. clinical relapsed/progressed, in 86.9% of them previous
In 10 Waldenstrom’s macroglobulinemia patients with EBR were detected (mean 4.4 months before) by FLCr
longitudinal samples (median number of samples: 3(2-9), (28.8%), HLCr (13.5%), FLC+SPE (9.6%), FLC+IFX
follow-up: 373 (18-713) days), there was good correla- (5.8%), FLC+HLC+SPE (28.8%), FLC+HLC+SPE+
tion for M-Ig% change relative to baseline between CZE UPE (5.7%). Median PFS 20 months (12.8-27.1)
and difference HLC (dHLC: involved-uninvolved HLC; Biological PFS: 18 m (12.1-23.8). Conclusions. Both
y=0.92x-0.12,R2=0.85) and total IgM (y=0.93x- FLCr and HLCr are sensitive and precise tools to assess-
Hematology Reports 2015; 7 (s1) | 1 |
Edinburgh_2015_interno_def_OR_MASTER 16/03/15 11:55 Pagina 2
Posters
ment response in MM detecting 42.3% EBR ahead other A4 - IMMUNOGLOBULIN HEAVY AND LIGHT
techniques. CHAIN ISOTYPE PAIRS IN MONITORING
This work had been partially sponsored by a grant from MULTIPLE MYELOMA PATIENTS
FEHHA. 1 2 2 3
N. Bangia, S. George, C. Hamilton, G. Talamo,
2
M. Creer
1 2
A3 - EARLY BIOLOGICAL RELAPSE AFTER ASCT Binding Site, San Diego, CA, USA; Penn State
IN MULTIPLE MYELOMA. USEFULNESS OF University Hershey Medical Center, Clinical Pathology,
3
Hershey, PA, USA; Penn State Hershey Cancer
HEAVY/LIGHT CHAIN IMMUNOASSAYS
Institute, Hershey, PA, USA
1,2,3 1
M.M. Andrade-Campos, I. Murillo-Flores,
1 1 2,3
E. Colorado, N. Espinoza-Lara, P. Giraldo Background. Diagnosis and monitoring of disease activi-
1 ty in Multiple Myeloma patients are generally based on
Hematology Department. Miguel Servet University
2 quantitative measurements of the monoclonal
Hospital; Traslational Research Unit IIS Aragon;
3 immunoglobulin (MIg) concentration in plasma and/or
CIBER Enfermedades Raras (CIBERER) ISCIII,
urine. Methods for MIg quantitation include densitomet-
Zaragoza, Spain
ric scanning of electrophoresis gels and immunoassay
Background. There are new tools for accurate assessment measurements of total polyclonal+monoclonal
in multiple myeloma (MM). While the Free Light chain immunoglobulins (total IgG, IgA or IgM). Hevylite is a
immunoassay (FLC) (Bindingsite, Birmingham, UK) is more specific method to identify electrophoretically “dif-
part of the mandatory response assessment according to ficult-to-detect” MIg (i.e. IgA) and to more specifically
IMWG-criteria, promissory results have obtained using quantify the tumor-derived heavy chain and light chain
Heavy/Light Chain (HLC) immunoassay. We hypothesized isotype pair. Aims. We compared serial Hevylite measure-
that the combination of these techniques could permit to ments to other techniques for MIg quantitation to monitor
detect early biological relapses (EBR). Aims. To analyze disease activity in MM patients. Results. From December,
the usefulness of HLC and FLC to detect EBR in MM after 2012 to July, 2014, forty-four MM patients were evaluat-
Autologous Stem Cell Transplantation (ASCT) in our hos- ed at various times during therapy. Thirty patients were
pital. Patients and Methods. A retrospective study was per- IgG isotype (20 IgG κ, 10 IgG λ) and 14 IgA isotype (4
formed including all consecutive patients following these IgA κ, 10 IgA λ). Median follow up time was 336 days
criteria: Diagnosed of secretory MM and underwent ASCT (range 77-526) for patients with IgG MM and 287 days
between May 2011-Jun 2014, assessed with our protocol (range 41-505) for patients with IgA MM. Hevylite IgG
including FLC, HLC, serum and urine electrophoresis λ, IgA λ and IgA κ corresponded well with quantitative
(SPE, UPE) with immunofixation (IFX), previous to immunoglobulin measurements. However, in some
ASCT, after 12 weeks and every 3 months later. Results. patients with high IgG κ monoclonal protein, Hevylite
Fifty-five patients were registered. Median follow-up 21 IgG κ (+IgG λ) measured lower than total quantitative
months. MF ratio: 29/26, mean age 59.5 y (33-71). IgG. This lower reading appeared to be patient specific, in
Immunoglobulin subtype: IgG-κ: 41.8% (23), IgG-λ: that the ratio of Hevylite:Total IgG was consistent for a
23.6% (13), IgA-κ: 16.4% (9), IgA-λ: 7.3% (4), Bence- given patient. In monitoring patients, normalization to
Jones-κ: 3.6% (2), Bence-Jones-λ: 7.3% (4). Durie-Salmon their own baseline value showed comparable results
Stage: IA: 13.5% (7), II-A: 32.7% (17), III-A: 44.2% (23), between Hevylite IgG κ and total IgG. Conclusions. In
III-B: 9.6% (5), missing-data 3 case. All patients received the MM patients studied here, Hevylite corresponded
Bortezomib based therapy and MEL200 as conditioning well with total immunoglobulins for IgA λ, IgA κ and IgG
regimen, assessment before ASCT: minimal response: λ. Variances in high IgG κ MIg can be normalized to
12%, Partial Response (PR): 50.0%, VGPR: 28.0%, CR: baseline to obtain better agreement with total IgG
6% SR: 4.0%. After ASCT, evaluation reveals that 13.0% immunoglobulins. In general, once adopted and a base-
achieved SR, 13.0% CR, 30.4% VGPR and 39.1% PR. line set, results should always be compared from the same
During follow-up 27/50(54.0%) patients, who achieved at method to assess disease progression indicating need for
least PR after ASCT had clinical relapse/progress, median method standardization.
PFS 24 months (19.8-28.1). EBR were detected in 19/27
patients at median time 7 (2-19) months before sympto-
matic relapse. The EBR were detected by FLCr (31.6%),
HLCr (21.0%), FLC+SPE (10.5%), FLC+IFX (5.2%),
FLC+HLC+SPE (15.8%), FLC+HLC+SPE+UPE
(15.8%). Conclusions. Both FLCr and HLCr are useful
tools to detect EBR in more than 50% of patients in our
cohort.
This work had been partially sponsored by a grant from
FEHHA.
| 2 | Hematology Reports 2015; 7 (s1)
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th
7 International Symposium on Clinical Applications of Free Light Chain and Heavy/Light Chain Analysis
Edinburgh, United Kingdom, 16-17 April 2015
A5 - ROLE OF THE HEAVY/LIGHT CHAIN Background. Monitoring oligosecretory multiple myelo-
IMMUNOASSAY IN THE ASSESSMENT OF ma (MM) patients whose serum monoclonal free light
COMPLETE RESPONSE IN MULTIPLE MYELOMA chains (FLC) levels are low can be challenging. Newly
PATIENTS available heavy/light chain (HLC) immunoassays allow
1,2 1,2 3 5 4 quantifying Ig’κ and Ig’λ levels, from which HLC
J. Batinić, Z. Perić, D. Šegulja, J. Last, S. Prijić,
4 3 2 2 Ig’κ/Ig’λ ratios are calculated to identify clonality.
K. Dubravčić, L. Volarić, D. Sertić, I. Radman,
2 3 1,4 1,2 Objectives. To evaluate the role of HLC immunoassays
S. Bašić-Kinda, D. Matišić, D. Batinić, B. Labar,
1,2 for monitoring oligosecretory MM patients. Methods.
D. Nemet
HLC Ig’κ and Ig’λ were measured in sequential sera from
1
School of Medicine, University of Zagreb, Zagreb,
2-IgG and 6-IgA oligosecretory patients with non-meas-
2
Croatia; University Hospital Center Zagreb, Department
urable disease by FLC. Serum M-protein changes during
of Internal Medicine, Division of Hematology, Zagreb,
monitoring as determined by HLC, total immunoglobulin
3
Croatia; University Hospital Center Zagreb, Department
(tIg) and SPEP, were compared. Results. At presentation
of Laboratory Diagnostics, Clinical Unit of Special
2/8 patients (both IgA) had non-quantifiable M-Ig levels
4
Biochemistry, Zagreb, Croatia; University Hospital
by SPEP. By contrast HLC ratio was abnormal in all
Center Zagreb, Department of Laboratory Diagnostics,
patients. 2/2 IgG patients had tIgG levels within the nor-
Clinical Unit of Cellular Immunodiagnostics and In Vitro
mal range. In one of these patients HLC ratio normalised
5
Procedures, Zagreb, Croatia; The Binding Site Group
after 237 days, whereas SPEP became negative 175 days
Ltd, Birmingham, UK
later. 6/6 IgA patients had tIgA levels above normal. In
Background. Achieving complete response (CR) and strin- 4/6 patients HLC ratio remained abnormal throughout
gent complete response (sCR), defined as negative serum monitoring; by contrast in 2/4 patients tIgA normalised,
immunofixation analysis and normalization of serum free including an IgAκ patient achieving a first response after
light chain ratio analysis, has become one of the main objec- 284 days when SPEP became (and stayed) negative and
tives in treatment strategies for multiple myeloma patients, tIgA normalised, whilst HLC ratio remained abnormal.
since it is associated with longer progression free survival. Subsequently tIgA and dHLC (involved-uninvolved
The recent introduction of a novel heavy/light chain (HLC) HLC) levels increased, indicating progression after 452
immunoassay provides an opportunity to define further the days. Following a second response, dHLC levels steadily
depth of response to myeloma treatment. Objectives. To eva- increased signifying another relapse, which was not iden-
lute the utility of the novel heavy/light chain immunoassay tified by tIgA until 147 days later (Figure 1a). In another
in the assessment of complete response in multiple myeloma patient (IgAλ) with non-quantifiable M-protein by SPEP,
patients. Methods. Serum samples of 23 multiple myeloma tIgA levels normalised with therapy before increasing to
patients (15 IgG and 8 IgA) in CR or sCR were analysed: 8 g/L after 426 days; seemingly indicating progression.
standard laboratory procedures (serum protein electrophore- At this time HLC ratio had normalised and both IgAκ and
sis, serum immunofixation, serum free light chain assay, IgAλ levels were elevated; remaining so throughout most
quantitative immunoglobulins, serum β-2-microglobulin) of follow-up and suggesting tIgA elevation was due to
were performed in addition to heavy/light chain assay polyclonal IgA expansion (Figure 1b). Conclusions. HLC
(HLC). Results. 18 patients were in sCR and 5 were in CR. immunoassays may aid monitoring oligosecretory MM
HLC analysis revealed 3/23 patients had immunoglobulin patients where traditional techniques have limited utility.
monoclonal isotypes values above normal (2 IgG and 1
IgA), 1 of whom (IgA) also had abnormal heavy/light chain
ratio value. An additional 4/23 patients (3 IgG and 1 IgA)
with monoclonal isotype and polyclonal isotype pair values
within normal ranges were found to have abnormal HLC
ratio values In the follow up period, 2/5 patients with abnor-
mal HLC ratio values experienced relapse. Conclusions. The
novel heavy/light chain immunoassay, especially the
heavy/light chain ratio value, allows accurate detection and
measurement of monoclonal immunoglobulins, even in mul-
tiple myeloma patients who achieved a complete response. It Figure 1.
seems that the new assay is a sensitive tool for detecting
minimal residual disease and can detect relapse earlier, com-
pared with traditional methods. As far as its definite role in A7 - FOLLOW UP OF PATIENTS AFTER ASCT BY
assessing the depth of response is concerned, further studies
HEVYLITE AND FREELITE ASSAYS IMPROVE
on larger groups of patients are needed.
SENSITIVITY IN THE IDENTIFICATION OF
SEROLOGICAL RELAPSE
1 1 2
A6 - HEAVY/LIGHT CHAIN IMMUNOASSAYS FOR L. Bernasconi, P. Fernandez, M. Heizmann,
2 1 2
MONITORING PATIENTS WITH OLIGOSECRETORY M. Bargetzi, A.R. Huber, N. Cantoni
1 2
MULTIPLE MYELOMA Institute of Laboratory Medicine; Division of
1 1 2 2 Hematology, University Clinic for Medicine,
O. Berlanga, L. Adie, N. Zojer, D. Milosavljevic,
2 2 Kantonsspital Aarau, Aarau, Switzerland
W. Hübl, H. Ludwig
1
The Binding Site Group Ltd, Birmingham, UK; Introduction. Serological follow up of patients undergo-
2
Department of Medicine I and Centre for Oncology and ing autologous stem-cell transplantation (ASCT) is cur-
Haematology, Wilhelminenspital, Vienna, Austria rently based on the measurement of the monoclonal com-
Hematology Reports 2015; 7 (s1) | 3 |
Edinburgh_2015_interno_def_OR_MASTER 16/03/15 11:55 Pagina 4
Posters
ponent using serum protein electrophoresis (SPE) and urable disease as presently defined, may be monitored by
immunofixation electrophoresis (IFE). Hevylite (HLC) is free light chain assay, able to reveal small amounts of
a new assay allowing the quantification of intact monoclonal proteins. The availability of a more sensitive
heavy/light-bounded chains of a given immunoglobulin. technique for the detection of monoclonal components in
Our study aimed to compare the sensitivity of conven- biological fluids is quite important, because it may help to
tional techniques (SPE, IFE) to nephelometric/turbidi- make an earlier diagnosis and may represent another
metric assays (HLC and free light chain assay, FLC) in parameter of measurable disease, useful to monitor the
detecting serological relapse in patient after ASCT. patients for the optimal drug treatment.
Methods. Consecutive routine sera submitted to our labo-
ratory during follow up of 21 myeloma patients (16 IgG,
A9 - COMPARISON OF POLYCLONAL AND
1 IgM, 4 IgA) after ASCT were examined with SPE, IFE,
HLC, FLC. 15 patients (4 IgA and 11 IgG) relapsed. Time MONOCLONAL ANTIBODY BASED FREE LIGHT
to serological relapse was determined using conventional CHAIN ASSAYS FOR MONITORING MULTIPLE
methods (SPE, IFE) and compared to relapse indicated by MYELOMA PATIENTS IN DIFFERENT CLINICAL
HLC and FLC. Results. In 7 patients (3 IgA and 4 IgG) SETTINGS
HLC measurements indicated serological relapse earlier 1 2 2 1
J. Cavenagh, A. Alvi, O. Berlanga, H. Oakervee,
than conventional techniques (mean: 4 months earlier). In 1
R. Popat
two of these cases FLC indicated a serological relapse
1 2
St Bartholomew’s Hospital, London, UK; The Binding
earlier than HLC. In two cases (1 IgA and 1 IgG), which
Site Group Ltd, Birmingham, UK
reached serological complete remission, IFE detected the
reappearance of the original monoclonal component 1, Background. International guidelines for monitoring
respectively 2 months earlier than HLC. In all remaining serum free light chains (FLC) in patients with monoclon-
cases serological relapse was detected simultaneously by al gammopathies enrolled in clinical trials rely on the
conventional and nephelometric/turbidimetric tech- polyclonal antibody-based assay Freelite. A novel mono-
niques. Conclusions. HLC and FLC are valuable comple- clonal antibody-based assay (N-Latex-FLC) recognising
mentary methods to conventional techniques (IFE, SPE) single epitopes has become available for measuring
and improve sensitivity in the identification of serological serum FLC. Objectives. To compare the suitability of
relapse during follow up of patients after ASCT. Freelite and N-Latex-FLC for monitoring MM patients
according to international guidelines and clinical prac-
tice. Methods. FLC were measured by Freelite and N-
A8 - FREE LIGHT CHAINS ARE NEEDED FOR THE
Latex-FLC in sera samples from 59 bortezomib-treated
FOLLOW UP OF MULTIPLE MYELOMA
MM patients (21 newly diagnosed, 38 relapsed; median
1 2 1 2
G. Buda, L. Caponi, E. Orciuolo, A. Paolicchi, number of samples/patient: 6(3-17); median follow-up:
1
M. Petrini 206(7-819) days). Results were compared to serum pro-
1 2 tein electrophoresis (SPEP) and total serum immunoglob-
Section of Hematology; Dept of Experimental
ulin (tIg). IMWG defines measurable disease by serum
Pathology, AOUP, Pisa, Italy
FLC as monoclonal FLC (iFLC) levels >100mg/L pro-
Abstract. Nonsecretory multiple myeloma (NSMM) is vided FLC ratio is abnormal. iFLC >50mg/L was consid-
considered a rare variant of the classic form of MM that ered to reflect monoclonal FLC production with clinical
has a similar clinical and radiologic presentation and lack utility for monitoring outside trials. Results. Following
of M-protein in serum and/or urine on electrophoresis and IMWG guidelines, 18(31%) patients had measurable dis-
immunofixation. We describe here, a case of a 29-year- ease by Freelite only, 2(3%) by N-Latex-FLC only,
old woman who came in our Hospital in 2010 with back 20(34%) by both assays and 19(32%) by neither. 5/18
pain and multiple osteolytic bone lesions. This woman patients with measurable disease by Freelite had non-
had no other symptoms. A CT guide biopsy from the L1 quantifiable paraprotein by SPEP and normal tIg levels,
vertebra showed massive infiltration of plasmocytes con- whereas in 13/18 N-Latex-FLC failed to detect mono-
firming the diagnosis of suspected NSMM, because she clonal FLC production as defined. By contrast Freelite
had normal serum and urine protein electrophoresis and reported iFLC>50mg/L in 2 patients with measurable dis-
immunofixation, without apparent bone marrow involve- ease by N-Latex-FLC, demonstrating clinical utility. In
ment. After a chemotherapy induction with VTD and 19 patients with non-measurable disease by either assay,
autologous peripheral bone marrow transplant, she Freelite reported iFLC>50mg/L in 3 and N-Latex-FLC in
obtained an apparent complete remission for two years, none; importantly, 1/3 had neither quantifiable parapro-
when in 2012, routinary blood tests showed normal serum tein nor elevated tIg, making Freelite the only available
basic analyses but an excess of κ monoclonal free light tool for monitoring. Finally, in 20 patients with measura-
chains (this parameter was not available at time of diag- ble disease by both assays, agreement between assays for
nosis) One month later, the patient developed an aggres- response assignment was only moderate (Weighted
sive and diffuse clinical bone relapse and, due to the κ=0.54(0.30-0.79)). Conclusions. Freelite allowed moni-
young age, she was treated with second line chemothera- toring of a substantial higher number of MM patients than
py and allogeneic bone marrow transplant. There are N-Latex-FLC, both when following guidelines for clini-
studies showing that a cytoplasmic M-protein can be cal trials and in clinical practice; suggesting a limitation
identified in nearly 85% of patients initially classified as in recognising epitope variety and/or FLC levels by N-
NSMM. A lot of these patients, even in absence of meas- Latex-FLC.
| 4 | Hematology Reports 2015; 7 (s1)
Edinburgh_2015_interno_def_OR_MASTER 16/03/15 11:55 Pagina 5
th
7 International Symposium on Clinical Applications of Free Light Chain and Heavy/Light Chain Analysis
Edinburgh, United Kingdom, 16-17 April 2015
A10 - HEVYLITE MEASUREMENT IS POTENTIALLY The female patient had been diagnosed two years earlier
HELPFUL FOR DIAGNOSIS AND FOLLOW UP OF with Multiple Myeloma and Multiple Plasmacytomas in
PATIENTS WITH POEMS SYNDROME association with Gamma Heavy Chain Disease.
1 2 1 1 Electrophoretically the patient had a triple gammopathy
C. Cousin, S. Choquet, P. Ghillani-Dalbin, L. Dufat,
2 1 (IgGκ, 26g/L; IgGκ+Free κ, 4g/L; Free Gamma, 5g/L).
V. Leblond, L. Musset
The κ serum free light chain was grossly elevated at
1
Department of Immunology, Laboratory of
24677mg/L. The earliest indicator of relapse was a pro-
2
Immunochemistry and Autoimmunity; Department of
gressively rising involved free light chain which was
Clinical Hematology, APHP, Pitié-Salpêtrière Hospital,
identified four months prior to its detection by
Paris, France
immunofixation electrophoresis (Figure 1). A skeletal
Background. POEMS syndrome is an acronym which survey showed new lytic lesions in the skull, pelvis and
stands for polyneuropathy (P), organomegaly (O), left humerus and the bone marrow aspirate revealed a
endocrinopathy (E), monoclonal gammopathy (M) and marked infiltration (50%) of abnormal plasma cells. The
skin changes (S). The quantification of serum monoclon- emerging role of the Hevylite assay includes its ability to
al proteins (mainly of IgA or IgG λ isotype) is difficult as detect the presence of minimal residual disease and early
these components are present at low level, and sometimes relapse and the measurement of some paraproteins diffi-
could be missed on serum electrophoresis. Objectives of cult to quantify by electrophoresis. A further role of the
®
the study. Hevylite was developed by The Binding Site assay utilizes its inability to react with free truncated
(Birmingham, UK) to quantify the κ- and λ- bounded gamma heavy chains (Hevylite antibodies are directed
amounts of serum circulating IgG and IgA. With this against junctional epitopes on the intact immunoglobulin
method, the involved and uninvolved Ig in the disease molecule) and thus the sum of the IgGκ/IgGλ matched
could be measured and a ratio named HLCR (heavy light pair reflects the concentration of the intact IgG present in
chain ratios) is calculated. The purpose of this work was the patient’s serum. An increasing gamma heavy chain
to investigate the contribution of this measurement and excess was evidenced by the difference between the total
the deriving ratios (HLCR) in a series of patients with IgG and the sum of the IgGκ/IgGλ matched pair. At the
POEMS syndrome at diagnosis and/or during the evolu- peak of biochemical relapse the free κ light chains rose to
tion of the disease. Methods. We have analyzed retrospec- 6602mg/L and the free gamma heavy chains to 4.2g/L.
tively 136 sera from 18 patients with POEMS syndrome This strategy could be incorporated into the diagnostic
recruited in the Pitié-Salpétrière hospital between 2001 workup of any patient who has suspected Heavy Chain
®
and 2014 and performed Hevylite testing at different Disease.
times during the follow up of the disease (before and after
relapse, stem cells autologous transplantation or
chemotherapy). Results. On the 18 patients, 11 have a
monoclonal IgA, 7 an IgG. During the curse of their dis-
ease, 10/18 (55%) patients have an elevation of the
involved Ig level and 13/18 (72%) have an abnormal
HLCR. During clinical follow up of the patients, analysis
of involved and uninvolved Ig levels and HLCR show
kinetic changes of their immunological status for 12/18
®
(66%) patients and a potential interest of the Hevylite
®
test. Conclusions. Even if Hevylite applications need
more studies, our results were correlated with the curse of
the disease in two third of patients. This test could be a
biologic weapon to follow patients with POEMS syn-
drome.
Figure 1.
A11 - THE FIRST REPORTED CASE OF HEAVY
CHAIN ESCAPE IN A PATIENT WITH FIRST A12 - BIOLOGICAL ROLE OF IMMUNOGLOBULIN
RELAPSE OF MULTIPLE MYELOMA: THE ROLE FREE LIGHT CHAINS INTERACTOMES
OF THE HEVYLITE® AND FREELITE® ASSAYS G. Di Noto, A. Bugatti, M. Bertuzzi, A. Dossi, F. Maffina,
1 1 2
W.I. Deighan, M.J. O’Kane, F.G.P. McNicholl L. Paolini, A. Radeghieri, L. Caimi, M. Rusnati,
1 2 D. Ricotta
Department of Clinical Chemistry; Department of
Haematology, Altnagelvin Hospital, Londonderry, Department of Molecular and Traslational Medicine,
Northern Ireland, UK Faculty of Medicine, Brescia, Italy
We report the first case of heavy chain escape occurring Background. Monoclonal Gammopathy of Undetermined
simultaneously with light chain escape in an unusual Significance (MGUS) is a plasma cell disorder that could
plasma cell neoplasm. We highlight the role that the be diagnosed incidentally and behave like a benign,
® ®
Freelite assay (directly) and the Hevylite assay (indi- asymptomatic entity or progress (1% per year) to different
rectly) had in identifying monoclonal free κ light chains haematologic malignancies such as multiple myeloma
and monoclonal free gamma heavy chains at first relapse. (MM). Monoclonal plasma cells often secrete high
Hematology Reports 2015; 7 (s1) | 5 |
Edinburgh_2015_interno_def_OR_MASTER 16/03/15 11:55 Pagina 6
Posters
amounts of immunoglobulin free light chains (FLCs) that NDMM patients from a phase I/II trial using a modified
could induce tissue damage. Recently we showed (Di model that predicts achievement of at least very good par-
Noto et al., 2013) that FLCs are internalized in endothelial tial response at the end of induction treatment if at least
and myocardial cell lines and secreted in extracellular one of the following has occurred: ≥90% reduction of
vesicles (EVs). Our data show that MM EVs internaliza- iFLC, normalization of free light κ/λ ratio (FLCr), or dis-
tion is FLCs and GAGs mediated and we could demon- appearance of M-protein (Dytfeld et al., Leuk
strate that MM EVs induce NfkB nuclear translocation. Lymphoma, 2012). Results. Changes in iFLC and M-pro-
Blocking FLCs with anti FLCs antibodies or masking the tein after 1 cycle of KRd treatment had a positive predic-
GAGs recognition with heparin altered the EVs intracellu- tive rate for CR/sCR achievement in 23/32 pts, with false
lar uptake and NfkB nuclear translocation (Di Noto et al., positive rate in 1/19 pts, i.e. 72% sensitivity (95% CI
2014). EVs carry determinant information about the onset 0.53-0.82) and 94% specificity (95% CI 0.72-1.00). After
of MGUS-MM switching which can be exploited for early 2 cycles, sensitivity increased to 94% (32/34 CR/sCR pts,
assessment of MM onset and progression. Objectives. We 95% CI 0.79-0.99) and specificity remained at 94% (95%
aim to identify binding partners that associate with the CI 0.72-1.00). Updated PFS and OS based on level of
FLCs in the blood stream (FLCs interactome) and are response after 4 years of median follow-up further sup-
involved in the EVs generation and cellular uptake. port the role of achievement of CR to KRd and will be
Methods. EVs, purified from serum of control, MGUS and presented at the meeting. Conclusions. Considering the
MM patients, were analyzed by a blend of conventional significance of achieving CR/sCR to initial treatment, this
analytical techniques, MALDI TOF analysis and surface model may be used as proof of principle for future stud-
plasmon resonance (SPR). Results and Conclusions. In a ies to individualize therapy and optimize disease control.
previous proteomic study immuno-purified FLCs isolated
from patients with monoclonal gammopathies were char-
acterised and some proteins such as clusterin and albumin A14 - INVOLVED/UNINVOLVED RATIO CAN BE
associated with FLCs were identified. We then tracked the AN EARLY PREDICTOR OF PROGRESSION IN
binding isotherms of EVs to a heparin-coated sensorchips. TRANSPLANTED MULTIPLE MYELOMA PATIENTS
The results show a marked difference between the binding
M. Espiño, S. Medina, M.J. Blanchard, F.J. López,
isotherms of EVs from healthy individuals and from MM
L.M. Villar
and MGUS patients.
Hospital Ramón y Cajal, Madrid, Spain
Methods. Twenty patients with MM of IgG isotype under-
A13 - LIGHT CHAIN-BASED MODEL PREDICTING
going SCT (8 with IgG-λ and 12 IgG-κ) were included in
COMPLETE RESPONSE TO INITIAL
the study. Patients were followed prospectively for
TREATMENT WITH CARFILZOMIB, LENALIDOMIDE,
19±2.1 months. We studied in serum samples collected at
AND DEXAMETHASONE IN PATIENTS WITH variable times during follow-up: protein electrophoresis,
NEWLY DIAGNOSED MULTIPLE MYELOMA immunofixation, total immunoglobulin levels, serum
1 2 3 3 heavy/light chains (HLC) and free light chains (FLC).
D. Dytfeld, K.A. Griffith, J. Jasielec, K. McDonnell,
2 2 4 5 FLC, HLC and Involved/Uninvolved ratios were calcu-
D. Lebovic, M. Kandarpa, D.H. Vesole, S. Jagannath,
2 6 2 3 lated. Results. Five transplanted patients relapsed, other
M. Mietzel, R. Vij, M. Kaminski, S. Rosebeck,
3 four showed a stable monoclonal immunoglobulin peak
A.J. Jakubowiak
1 with no clinical progression and 11 achieved complete
Poznan University of Medical Sciences, Poznan,
2 remission. We studied the best factors to anticipate
Poland; University of Michigan Comprehensive Cancer
3 relapse by measuring all the afore mentioned variables in
Center, Ann Arbor, MI, USA; University of Chicago
4 samples obtained every 3 months. We identified the sam-
Medical Center, Chicago, IL, USA; John Theurer
ples obtained at disease relapse and studied the variable
Cancer Center at Hackensack UMC, Hackensack, NJ,
5 that gave clearer differences in previous samples. The
USA; Mount Sinai Medical Center, New York, NY, USA;
6 higher differences were found in the I/U ratio. Values of
Washington University School of Medicine, St. Louis,
basal and pre-relapse samples were 1.36 (0.98-5.51) vs
MO, USA
10.36 (5.8-84.13), median (25-75 percentile), p=0.03. By
Background. KRd is active in NDMM, producing overall contrast, this index remained stable in patients with MM
response rates of 98%, CR/nCR up to 72%, and stringent in complete remission [1.10 (0.86-1.26) vs 1.27 (0.77-
CR (sCR) rates up to 55% (Jakubowiak et al., Blood 1.43), first and last sample obtained during follow-up,
2012, Jasielec et al., Blood 2013). Achieving CR during p=0.84] or in those with stable monoclonal immunoglob-
initial treatment with KRd is associated with prolonged ulin peak without clinical progression [4.1 (2.7-4.78) vs
overall survival (OS) and/or progression-free survival 4.3 (3.7-5.0)]. Conclusions. Our data strongly suggest
(PFS). Therefore, strategies, such as early modification of that quantification of involved and uninvolved chains of
therapy in patients unlikely to achieve CR, can be the monoclonal isotype can early predictors of progres-
explored as ways of improving treatment outcome in sion in MM transplanted patients.
NDMM. Objectives. Establish predictive model of CR
achievement to KRd treatment based on early changes in
involved serum free light chains (iFLC) and serum M-
protein levels. Methods. We analyzed iFLC and M-pro-
tein levels during the first 2 cycles of KRd treatment in 53
| 6 | Hematology Reports 2015; 7 (s1)
Edinburgh_2015_interno_def_OR_MASTER 16/03/15 11:55 Pagina 7
th
7 International Symposium on Clinical Applications of Free Light Chain and Heavy/Light Chain Analysis
Edinburgh, United Kingdom, 16-17 April 2015
1
A15 - FREE LIGHT CHAIN ESCAPE IN PATIENTS Service des Maladies du Sang, Hopital Claude Huriez,
2
SUFFERING FROM MULTIPLE MYELOMA: CHRU Lille, Lille, France; Service de biochimie pro-
THE EXPERIENCE OF THE TOULOUSE TEACHING téines, Hôpital Huriez, CHRU Lille, Lille, France;
3
Centre Hospitalier Lyon-Sud, Pierre-Benite, France;
HOSPITAL
4
Hematology, Hôpital Côte de Nacre, CHU, Caen,
1 2 1,3
C. Farges, M. Roussel, A. Blancher, 5
France; Service d’Hématologie, CHU Nancy–Brabois,
1,3
B. Puissant-Lubrano 6
Vandoeuvre, France; Hematology, Centre Hospitalier
1
Laboratoire d’Immunologie, CHU de Toulouse,
Universitaire Hopital St-Antoine, Paris, France;
2
Toulouse Cedex 9, France; Service d’Hématologie, 7
Hématologie Clinique, CHU Purpan, Toulouse, France;
Institut Universitaire du Cancer-Oncopôle, Toulouse, 8 9
Hôpital Saint-Louis, Paris, France; Hôpital A.
3
France; Laboratoire d’Immunogénétique Moléculaire, 10
Michallon, CHU Grenoble, Grenoble, France; Hôpital
Université Paul Sabatier, Toulouse III, Toulouse, France 11
Robert Debré, CHU, REIMS, France; Hematology,
Institut Paoli Calmettes, Marseille, France;
Background. Serum free light-chain (FLC) assay is a diag-
12
Hematologie Clinique, Hopital Avicenne APHP
nostic and prognostic factor in the management of patients
13
Université Paris 13, Bobigny, France; Hematology,
suffering from multiple myeloma, and is useful for the mon-
14
Edouard Herriot Hospital, Lyon, France; Service
itoring of oligosecretory myeloma and for the assessment of
d’Hématologie et de Thérapie Cellulaire, University
a stringent complete response. Some patients, who are sta-
15
Hospital of Bordeaux, Pessac, France; Institut Curie,
ble or in remission from a myeloma secreting intact mono-
16
APHP, paris, France; Centre Hospitalier de la Côte
clonal immunoglobulin, relapse with production of FLC
17
Basque, Bayonne, France; Departemental Medecine
only. This “FLC escape” illustrates the fact that multiple
Interne Les Oudairies, Centre Hospitalier, La Roche sur
myeloma is a heterogeneous disease with intraclonal het-
18
Yon, France; CHRU Hopital du bocage, Dijon,
erogeneity. FLC escape is observed in 2.5 to 8% of myelo-
19 20
France; CH de l’Archet, Nice, France; Hematology,
ma. Objectives. We report the experience of the Toulouse
21
Centre Hospitalier, Perigueux, France; CHD
Teaching Hospital for FLC escape in myeloma disease.
22
Dunkerque, Dunkerque, France; Département d’héma-
Methods. We retrospectively reviewed our patient’ database
tologie clinique, Centre hospitalier universitaire,
between 2007 and 2014. Results. We identified seven cases
23
Amiens, France; University Hospital Tours, Tours,
of FLC escape: one case (IgA myeloma) occurred after a
24
France; Hematology, CHU Rennes, Rennes, France;
stringent complete response, four cases (IgA, IgD myelo-
25
Hematology Department, CHU de Dijon - Hospital ‘Le
ma) after a partial response, and two cases (IgA, IgG myelo-
26
Bocage’, Dijon, France; Service d’Immuno-
ma) during a stable disease. The median age at diagnosis
Hematologie, Hôpital Saint-Louis, Paris, France;
was 58 years. All patients were treated with bortezomib and
27
University Hospital of Nantes, Nantes, France;
dexamethasone. Four patients received autologous periph-
28
Hematology, CHU RANGUEIL, Toulouse, France;
eral blood stem cell transplantation. The median time from
29
Hopital Claude Huriez, CHRU Lille, Lille, France
initial diagnosis to the occurrence of FLC escape was 35
months. During relapse, the renal impairment increased in
Background. The depth of hypogammaglobulinemia has
parallel with the rise of the involved free light chain. Four
been related to adverse prognosis in multiple myeloma
patients died of myeloma progression after a median of 2
(MM), and it has been suggested that its recovery following
months from FLC escape and of 79 months from diagnosis.
treatment was associated with good outcome and prolonged
We report the first description of FLC escape in a patient
survival. However, traditional techniques do not allow pre-
with IgD myeloma. This patient was a 50-year old man,
cise measurement of isotype-matched hypogammaglobu-
who died one month after FLC escape and 30 months after
linemia (i.e. concentrations of IgGκ in an IgGλ MM).
autograft. Conclusions. The experience of the Toulouse
Recently, a new test quantifying paired clonal and non-clon-
Hospital confirms the importance of monitoring FLC in
al immunoglobulins (heavy/light chains HLC i.e.
patients with myeloma. FLC monitoring may allow more
IgGκ/IgGλ) in serum was developed. Here we aim to assess
rapid diagnosis of FLC escape which is of poor prognostic,
the new HLC assay as a tool to assess hypogammaglobu-
in order to adjust the different treatment options.
linemia. Materials and Methods. 107 MM patients treated
with pomalidomide and dexamethasone in two IFM studies
were included (IFM2009-02 in end-stage RRMM, and
A16 - HEVYLITE® TO MONITOR
IFM2010-02 in del17p and t(4;14) RRMM). Patients solely
HYPOGAMMAGLOBULINEMIA, A PREDICTOR OF
measurable on UPEP and sFLC were excluded. All sera
RESPONSE TO THERAPY IN MULTIPLE MYELOMA
were collected centrally before treatment and sequentially
1 2 2 3
G. Fouquet, S. Schraen, J.-L. Faucompré, L. Karlin, every cycle until progression. Results. 98 (92%) patients
4 5 2 6
M. Macro, C. Hulin, B. Onraed, L. Garderet, had an abnormal suppressed uninvolved HLC level at base-
7 8 9 10
M. Roussel, B. Arnulf, B. Pegourie, B. Kolb, line and as much as 94 (87%) at the time of best response.
11 12 13
A.-M. Stoppa, S. Brechignac, M. Michallet, The median uninvolved IgG and IgA HLC concentrations at
14 15 16 17 18
G. Marit, C. Mathiot, A. Banos, M. Tiab, M. Dib, baseline were 0.62 and 0.2 g/L respectively (range: 05-
19 1 20
J.-G. Fuzibet, M.-O. Petillon, P. Rodon, 6.9;0.01-5.6). 55% of responders had improved levels (by at
21 22 19
M. Wetterwald, B. Royer, L. Legros, least 20%) of the uninvolved paired isotype HLC compared
23 24 25
L. Benboubker, O. Decaux, D. Caillot, to 18.5% of the non-responders (p=0.001). This data strong-
24 26 27
M. Escoffre-Barbe, J.-P. Fermand, P. Moreau, ly correlated to the depth of response, since 75% of patients
7 28 29 1
M. Attal, H. Avet-Loiseau, T. Facon, X. Leleu in VGPR or better had improved levels of uninvolved
Hematology Reports 2015; 7 (s1) | 7 |
