International consensus on serum free light chain analysis

1
International consensus on serum free light
chain analysis

• Alex Legg PhD
• Scientific Affairs Manager
• The Binding Site

Distributor in Poland BIOKOM beata.olsz_at_biokom.com
.pl
2
Serum free light chain immunoassay
Heavy chain
Kappa
Light chain
Exposed surface
Hidden surface
Lambda
3
Serum free light chain immunoassay
Heavy chain
Kappa
Light chain
Exposed surface
Hidden surface
Lambda
4
Sensitivity of light chain analysis techniques
1000
SPE
CZE
100
sIFE
Light chain concentration (mg/L)
10
UPE
Normal range in serum
uIFE
1
sFLC
5
Renal Metabolism of FLC
?FLC - 25 kDa ?FLC - 50 kDa
Glomerulus 40-60 kDa pores
10-30g/day reabsorption breakdown
Urine
6
Renal Metabolism of FLC
?FLC - 25 kDa ?FLC - 50 kDa
Glomerulus 40-60 kDa pores
Renal metabolism results in sFLC half-life of 2-6
hours This is in contrast to intact
immunoglobulins which have half-lives of 5-21 days
10-30g/day reabsorption breakdown
Urine
7
Light Chain Multiple Myeloma
Normal sera
Kappa LCMM
Lambda LCMM
Renal impairment (CKD2)
Hutchison, unpublished data Bradwell, Lancet
2003 361 489-491
8
LCMM Renal Threshold
Thalidomide
HDC ASCT
Patient 2
Patient 1
Severe osteolytic lesions
HDC ASCT
Patient 4
Patient 3
sFLC
24 hr urine BJP excretion
Alyanakian Am J. Hematol. 2004 75 246 248
9
Nonsecretory Multiple Myeloma
10000
VAD
ABCM
HDM/ PBSCT
1000
Kappa sFLC (mg/L)
100
10
0
40
30
20
10
0
90
80
60
50
100
70
Number of weeks since presentation
10
Intact Immunoglobulin MM
No correlation between Ig and sFLC
n 120 IgGl MM patients
Serum l FLC (mg/L)
Total IgG (g/L)
Mead et al. Br J Haematol 2004126 348 54
11
Rapid evaluation of response to chemotherapy

• Dispenzieri et al.
• Retrospective analysis of ECOG trial E9486
• VBMCP ? IFN? or ? cyclophosphamide
• 399 patients
• Assessed sFLC and M-protein responses
• to therapy

FLC response after 2 months of therapy was
superior to early M-protein measurement to
predict overall response.
Dispenzieri et al. Blood 2008 111 4908 - 4915
12
Light chain escape
Rising monoclonal free light chain production at
relapse without increased monoclonal intact
immunoglobulin

• Drayson et al.
• Myeloma IX trial
• Estimate incidence 5 for IgG MM
• 15 for IgA MM

Drayson, M.T., et al., Clin Lymphoma Myeloma,
2009. February 346a.
13
PD
No therapy
800
20
18
700
16
600
14
500
12
IgA? paraprotein Serum lambda FLC Creatinine
sFLC (mg/L)
IgA (g/L), creatinine (mg/dL)
400
10
8
300
6
200
4
100
2
BM infiltration rate
0
100
9/01
10/02
1/05
12/04
4/04
10/03
4/03
2/05
Date
K?hnemund, A., et al. J Cancer Res Clin Oncol,
2009. 135(3) p. 477-84
14
Dual plasma cell subsets
Stain with
Plasma cell Populations
Ayliffe Haematologica 2007 92 1135 - 1138
15
Model of light chain escape
IgA (g/L)
Serum kappa FLC (mg/L)
Time
16
International guidelines for sFLC analysis in MM
and related disorders

• Assessment of response
• Serial sFLC should be routinely performed in
• Oligosecretory MM/ NSMM
• AL amyloidosis
• LCDD (personal experience of authors)

• Periodic urine or sFLC assessment for LCE

Dispenzieri et al Leukemia (2009) 23, 215224
17
sFLC identify residual disease
Normal sera
IFE negative MM
Serum ? FLC (mg/L)
Normal ?/?
Abnormal ?/?
Serum ? FLC (mg/L)
18
International guidelines for sFLC analysis in MM
and related disorders

• Assessment of response
• All MM patients to define a stringent CR

CR Stringent CR
Negative S/U IFE BM plasma cells 5 Negative S/U IFE Normal sFLC ratio Absence of clonal cells in BM
Dispenzieri et al. Leukemia 2009 23,
215224 Durie et al., Leukemia, 2006. 20, 1467-73
19
Screening for Monoclonal Gammopathies

• Serum electrophoresis
• ? Monoclonal intact immunoglobulins
• Urine electrophoresis
• ? Monoclonal free light chains

Can the serum FLC assay replace urine
electrophoresis?
20
Screening for monoclonal gammopathy

• sFLC CZE
• 9 additional B-cell disorders identified from
  1003 consecutive unknown samples
• Bakshi et al. Am J Clin Path 2005 124 214-218
• Adding the serum FLC assay to screening protocol
  increased tumour detection rate by 56
• sFLC SPE
• 8 additional monoclonal gammopathies identified
  from 923 unknown samples
• Hill et al. Clin Chem 2006 52 1743-1748

21
Replacement of urine tests with sFLC

• 428 urine samples positive by uIFE
• On paired serum samples
• Serum electrophoresis sFLC missed only 2 urine
  positive light chain MGUS patients
• No significant pathology was missed

Katzmann et al. Mayo Clin Proc 2006 81 1575 -
1578
22
For AL screening, 24 h urine IFE still
recommended
Dispenzieri et al. Leukemia 2009 23, 215224
23

• MGUS progression
• Myeloma outcome
• Smouldering MM progression
• Plasmacytoma progression
• AL amyloidosis outcome
• B-CLL outcome
• Waldenstroms outcome

Serum FLCs are prognostic in
24
Risk of progression 1 per year
Follow up MGUS patients How frequently?
25
Monoclonal Gammopathy of Undetermined
Significance (MGUS)

• Risk Factors for progression
• Serum M protein gt15g/L
• Serum M protein NOT IgG

Kyle R. NEJM 2002 346 564-569
26
Monoclonal Gammopathy of Undetermined
Significance (MGUS)

• Risk Factors for progression
• Serum M protein gt15g/L
• Serum M protein NOT IgG
• sFLC ratio

Kyle R. NEJM 2002 346 564-569
Rajkumar Blood 2005 106 812-817
27
MGUS progression
Rajkumar Blood 2005 106 812-817
28
MGUS risk stratification model incorporating
M-protein size, type and FLC ratio
Risk of progression No. of abnormal risk factors No. patients Absolute risk of progression at 20 years
Low 0 449 2
Low-Intermediate 1 420 10
High-Intermediate 2 226 18
High 3 53 27
Accounting for death as a competing risk
Rajkumar Blood 2005 106 812-817
29
FLC-MGUS may evolve into LCMM
-16
- 8
0
Years prior to diagnosis of MM
No M-protein by sIFE, SPEP or sFLC sFLC
positive sFLC and sIFE positive
Weiss et al. , Blood ePub Feb 20, 2009
30
IgA paraprotein Serum kappa FLC Creatinine
PD
No therapy
5
20
4.5
18
4
16
3.5
14
3
12
IgA (g/L), creatinine (mg/dL)
sFLC (g/L)
2.5
10
2
8
1.5
6
1
4
20
0.5
2
60
BM infiltration rate
0
0
4/04
7/04
10/04
12/04
1/05
2/05
3/05
7/05
Date
K?hnemund, A., et al. J Cancer Res Clin Oncol,
2009. 135(3) p. 477-84
31
International guidelines for sFLC analysis in MM
and related disorders

• Prognosis
• sFLC should be measured at diagnosis for all
  patients
• with MGUS, SMM or MM, solitary plasmacytoma and
• AL amyloidosis

Dispenzieri et al. Leukemia 2009 23, 215224
32
Summary of IMWG sFLC Guidelines
Intact Ig MM Light chain MM Non secretory MM
Screening serum electrophoresis serum electrophoresis serum electrophoresis
Prognosis
Monitoring (Oligosecretory) (Oligosecretory)
Monitoring (LCE)
Monitoring (sCR) (sCR)
Dispenzieri, A., et al. Leukemia, 2009. 23(2) p.
215-24 Kyle, R.A. and S.V. Rajkumar. Leukemia,
2009. 23(1) p. 3-9
33
Any Questions?

• alex.legg_at_bindingsite.com

Distributor in Poland BIOKOM beata.olsz_at_biokom.com
.pl
34
Serum free light chain immunoassay platforms
BECKMAN COULTER IMMAGE, IMMAGE 800
BINDING SITE SPAPLUS
OLYMPUS AU400 / 640 / 2700 / 5400
ROCHE MODULAR P Cobas Integra 400 / 800 Cobas c501
ROCHE (Hitachi) 911, 912 , 917
SIEMENS (Bayer) ADVIA 1650 / 1800 / 2400
SIEMENS (Dade Behring) BNII, Prospec
35
MGUS progression
? ? ?
Normal
? ? ?
0.5 1.0 5.0 10.0 50.0 500.0

Relative Risk of Progression
0.01 0.10 0.26 1.0 1.65
10.00 100.00
Free Light Chain Ratio
Rajkumar Blood 2005 106 812-817
36
Multiple myeloma survival
sFLC ?/? lt0.03 or gt32, albumin lt 35 g/L, ?2MG
3.5 mg/L
Snozek, C.L., et al., Leukemia, 2008. 221933-7
37
Risk stratification summary
Risk Factors Risk Factors Risk Factors
No. Serum FLC ratio Other risk factors
MGUS 3 lt0.26 or gt1.65 M-protein size M-protein type
SPB 2 lt0.26 or gt1.65 M-protein size
SMM 3 lt0.125 or gt8 BM plasma cells M-protein size
MM 3 lt0.03 or gt32 Albumin ?2-microglobulin
38
Renal Metabolism of FLC
?FLC - 25 kDa ?FLC - 50 kDa
Glomerulus 40-60 kDa pores
10-30g/day reabsorption breakdown
Urine
39
Light chain escape
Rising monoclonal free light chain production at
relapse without increased monoclonal intact
immunoglobulin

• Kühnemund et al
• Largest case series of LCE
• Estimate incidence is 2.5 MM at relapse
• 5/10 cases of LCE had renal impairment

Kuhnemund, A., et al., J Cancer Res Clin Oncol,
2009. 135, 477-84
40
Light chain escape
IgA? paraprotein
Serum lambda FLC
Velcade
Courtesy of Effie Liakopoulou, Christies Hospital
41
Prevalence of MGUS
Prevalence of MGUS ()
Age (years)
Kyle NEJM 2006, 354 1362 1369