Analysis of serum free light chains ratio (FLC-r, Freelite^TM), immunoglobulin heavy/light chain pairs ratio (HLC-r, Hevylite^TM) and the results of plasma cell multiparametric flow cytometry in relation to progression free survival in multiple myeloma

Czech version

Authors: V. Ščudla ^1,3; P. Lochman ²; M. Novák ³; T. Pika ³; J. Minařík ³; K. Langová ⁴
Authors‘ workplace: III. interní klinika – nefrologická, revmatologická a endokrinologická, Lékařská fakulta Univerzity Palackého a Fakultní nemocnice v Olomouci ¹; Oddělení klinické biochemie, Fakultní nemocnice v Olomouci ²; Hemato-onkologická klinika, Fakultní nemocnice a Lékařská fakulta Univerzity Palackého v Olomouci ³; Ústav lékařské biofyziky, Lékařská fakulta Univerzity Palackého v Olomouci ⁴
Published in: Transfuze Hematol. dnes,22, 2016, No. 1, p. 14-27.
Category: Comprehensive Reports, Original Papers, Case Reports

Overview

Introduction:
Assessment of serum free light chains (FLC) level and more recently of heavy/light chain immunoglobulin (HLC) pairs and analysis of plasma cells using multiparametric flow cytometry (MFC) have enriched the traditional standard algorithm of laboratory tests in multiple myeloma (MM). The aim of the presented study was to assess the relationship between modified indices FLC-r (ratio of involved-FLC/uninvolved-FLC κ and λ) and HLC-r (ratio of involved-HLC/uninvolved-HLC); the presence of plasma cells with normal (N-PC) and abnormal immunophenotype (A-PC) including their ratio (A/N-PC-r); the index of plasma cell clonality and stratification models based on the value of the HLC-r index with PFS (progression free survival).

Patients and methods:
In a cohort of 163 patients with MM, divided into a group treated with conventional chemotherapy (CT) and a group treated with high-dose chemotherapy with autologous peripheral stem cells (HDT/ASCT), we assessed the modified FLC-r (Freelite^TM) and HLC-r (Hevylite^TM) indices and the immunophenotype and monoclonality of plasma cells κ/λ with using MFC. Stratification into 3 risk groups was based, apart from the standard ISS system (International Staging System), also on stratification systems according to Avet-Loiseau (AL-SS) and Ludwig (L-SS).

Results:
The analysis revealed a signifiant relationship between HLC-r (but not of FLC-r) and PFS in the whole cohort (p = 0.016) and in the group treated with HDT/ASCT, documented by significant differences in the PFS medians and curves. There was no relationship between N-PC, A-PC, A/N-PC-r, the monoclonality index (κ/λ or λ/κ PC-r) and PFS. Analysis using L-SS and to a certain extent AL-SS of the whole group of MM patients showed a relationship between individual risk groups and PFS (p = 0.001 and p = 0.024), with stronger and clearer significance of standard staging systems ISS (p < 0.0001) and D-S (p = 0.005). Similarly as in the case of AL-SS and L-SS, we found differences in our own modified ISS (OL-SS) using the medians of modified HLC-r (measured as i-HLC/u-HLC ratio assessed separately in IgG and IgA type MM) as the cut-off for risk groups (p = 0.001).

Conclusions:
We confirmed a significant relationship between the modified HLC-r index (i-HLC/u-HLC, Hevylite^TM) and PFS but not between the modified FLC-r index (Freelite^TM) or the presence of plasma cells with abnormal or normal immunophenotype including their ratio and the pathological index of monoclonality assessed using MFC. The newly suggested risk stratification models of MM (1-3) according to AL-SS, L-SS and OL-SS, based on the value of HLC-r showed a significant relationship with PFS but one of lesser significance compared to standard ISS staging. The analyzed, newly introduced stratification systems are therefore not suitable for stratifying PFS in routine practice.

Key words:
multiple myeloma – free immunoglobulin light chain – immunoglobulin heavy/light chain pairs – multiparametric flow cytometry – prognostic stratification – progression free survival

Sources

1. Bradwell AR, Harding SJ, Fourrier NJ, et al. Assessment of monoclonal gammopathies by nephelometric measurement of individual immunoglobulin κ/λ ratios. Clin Chemistry 2009; 55: 1646–1655.

2. Ludwig H, Milosavljevic D, Zojer N, et al. Immunoglobulin heavy/light chain ratios improve paraprotein detection and monitoring, identify residual disease and correlate with survival in multiple myeloma patients. Leukemia 2013; 27: 213-219.

3. The Binding Site Group Ltd, editor. Serum free light chain analysis plus Hevylite. 7 th ed. Birmingham: The Binding site Ltd, 2015.

4. Hájek R, Adam Z, Ščudla V, et al. Doporučení České myelomové skupiny 2012: Diagnóza a léčba mnohočetného myelomu. Transfuze Hematol dnes 2012; 18: 5-89.

5. Keren DF. Heavy/light-chain analysis of monoclonal gammopathies. Clin Chemistry 2009; 55: 1606–1608.

6. Katzmann JA, Kyle RA, Benson J, et al. Screening panels for detection of monoclonal gammopathies. Clin Chemistry 2009; 55: 1517–1522.

7. Dispenzieri A, Kyle RA, Merlini G, et al. International Myeloma Working Group guidelines for serum-free light chain analysis in multiple myeloma and related disorders. Leukemia 2009; 23: 215–224.

8. Alexanian R. Blood volume in monoclonal gammopathy. Blood 1997; 49: 301–307.

9. Akilesh S, Christianson GJ, Roopenian DC, Shaw AS. Neonatal FcR expression in bone marrow-derived cell functions to protect serum IgG from catabolism. J Immunol 2007; 179: 4580–4588.

10. Avet-Loiseau H, Harousseau JL, Moreau P, et al. Heavy/light chain specific immunoglobulin ratios at presentation are prognostic for progression free survival in the IFM 2005-01 Myeloma Trial. Blood 2009; 114: 722.

11. Avet-Loiseau H, Mirbahai L, Harousseau JL, et al. Serum immunoglobulin heavy/light chain ratios are independent risk factors for predicting progression free survival in multiple myeloma. Haematologica 2010; 95: 395.

12. Ludwig H, Faint J, Zojer N, Bradwell AR. Serum heavy/light chain and free light chain measurements provide prognostic information, allow creation of a prognostic model and identify clonal changes (clonal tiding) through the course of multiple myeloma. Blood 2011; 118: 1244.

13. Ščudla V, Pika T, Minařík J. Význam vyšetření párů těžkých/lehkých řetězců imunoglobulinu (HevyliteTM) u mnohočetného myelomu. Trans Hematol dnes 2014; 12: 107–116.

14. Greipp PR, San Miguel JF, Fonseca R, et al. Development of an International prognostic index (IPI) for myeloma: report of the International Myeloma Working Group. Hemat J 2003; 4 (Suppl 1): S 42–43.

15. Bradwell AR, Harding S, Fourrier N, et al. Prognostic utility of intact immunoglobulin Ig´kappa/Ig´lambda ratios in multiple myeloma patients. Leukemia 2013; 27: 202–207.

16. International Myeloma Working Group criteria for the classification of monoclonal gammopathies, multiple myeloma and related disorders: a report of the International Myeloma Working Group. Brit J Haematol 2003; 121: 749–757.

17. Larsen JT, Kumar SK, Dispenzieri A, et al. Serum free light chain ratio as a biomarker for high-risk smoldering multiple myeloma. Leukemia 2013; 27: 941–946.

18. Kyrtsonis MCH, Theodoros P, Vassilakopoulos TP, et al. Prognostic value of serum free light chain ratio at diagnosis in multiple myeloma. Brit J Haematol 2007; 137: 240–243.

19. Rajkumar SV, Dimopoulos MA, Palumbo A, et al. International Myeloma Working Group updated criteria for the diagnosis of multiple myeloma. Lancet Oncol 2014; 15: 538–548.

20. Rawstron AC, Orfao A, Beksac M, et al. Report of the European Myeloma Network on multiparametric flow cytometry in multiple myeloma and related disorders. Haematologica 2008; 93: 431–438.

21. Paiva B, Almeida J, Perez-Andres M, et al. Utility of flow cytometry immunophenotyping in multiple myeloma and other clonal plasma cell-related disorders. Cytometry Part B (Clin Cytometry) 2010; 78: 239–252.

22. Říhová L, Varmužová T, Zarbochová O, et al. Průtoková cytometrie u monoklonálních gamapatií. Klin Onkol 2011 b; (Suppl 1:S24-29).

23. Kovářová L, Hájek R. Prognostický význam imunofenotypizace plazmocytů u monoklonální gamapatie nejistého významu a nemocných s mnohočetným myelomem. Klin Biochem metab2011; 19(40):96-100.

24. Perez-Persona E, Vidriales M-B, Mateo G, et al. New criteria to identify risk progression in monoclonal gammopathy of undetermined significance and smoldering multiple myeloma based on multiparameter flow cytometry analysis of bone marrow plasma cells. Blood 2007; 110: 2586–2592.

25. Durie BGM, Harousseau JL, Miguel JS, et al. International uniform response criteria for multiple myeloma. Leukemia 2006; 20: 1467–1473.

26. Ghobrial IM, Landgren O. How I treat smoldering multiple myeloma. Blood 2014; 124: 3380–3388.

27. Paiva B, Vidriales MB, Mateo G, et al. The persistence of immunophenotypically normal residual bone marrow plasma cells at diagnosis identifies a good prognostic subgroup of symptomatic multiple myeloma patients. Blood 2009; 114: 4369–4372.

28. Gaiser FA. Importance of the Hevylite-assay in the diagnosis and the relapse respectively progress control in multiple myeloma. Dostupné na www: http://www.freidok.uni-freiburg.de/volltexte/9848/.

29. Harding S, Young P, Di Fazio, et al. Intact immunoglobulin heavy/light chain paired assays. Biochem Clin 2013; 37: 365–369.

30. Harutyunyan NH, Vardanyan S, Ghermezi M, et al. Levels of uninvolved and involved immunoglobulin predict clinical status and progres-sion free survival for multiple myeloma patients. J Hematol Reports 2015; 7 (Suppl. 1): 25.

31. Koulieris E, Panayiotidis P, Harding SJ, et al. Ratio of involved/uninvolved immunoglobulin quantification by HevyliteTM assay: clinical and prognostic impact in multiple myeloma. Exp Hematol Oncol 2012; 1: 9–15.

32. Lopez-Anglada L, Cueto-Felqueroso C, Mateos MV, et al. Potential prognostic value of heavy-light chains ratio in symptomatic multiple myeloma. J Hematol Reports 2015; 7 (Suppl. 1): 27.

33. Batinic J, Perič Z, Šegulja D, et al. Immunoglobulin heavy/light chain analysis enhances the detection of residual disease and monitoring of multiple myeloma patients. Croat Med J 2015; 56: 263–271.

34. Scudla V, Lochman P, Pika T, et al. Relationship of differences in immunoglobulin heavy/light chain pairs (HevyliteTM), selected laboratory parameters and stratification systems in different immunochemical types of multiple myeloma. Biomed Pap Med Fac Univ Palacky Olomouc 2015; 159: (in press). Doi:10.5507/bp.2015.032 (Epub ahead of print).

35. Maisnar V, Pour L, Pika T, et al. The significance of Hevylite test for determination of prognosis in patients with asymptomatic multiple myeloma-the results of a new CMG project. Clin Lymphoma Myeloma Leukemia 2015; 15 (Suppl. 3): e120, P0–072.

36. Hari P, D´Souza A, Pasquini M, et al. Prognostic value of pre-transplant complete remission by free light chain and heavy/light chain ratios vs. conventional criteria-long term results of the BMT CTN 0102 study. J Hematol Reports 2015; 7 (Suppl. 1): 24–25.

37. Tovar N, Fernandez de Larrea C, Elena M, et al. Prognostic impact of serum immunoglobulin heavy/light chain ratio in patients with multiple myeloma in complete remission after autologous stem cell transplantation. Biol Blood Marrow Transpl 2012; 18: 1076–1079.

38. Katzmann JA, Clark R, Kyle RA, et al. Suppression of uninvolved immunoglobulins defined by heavy/light chain pair suppression is a risk factor for progression of MGUS. Leukemia 2013; 27: 208–212.

39. Espino M, Medina S, Blanchard MJ, et al. Involved/uninvolved immunoglobulin ratio identifies monoclonal gammopathy of undetermined significance patients at high risk of progression to multiple myeloma. Brit J Haematol 2014; 164: 752–755.

40. Pika T, Lochman P, Sandecka V, et al. Immunoparesis in MGUS – Relationship of uninvolved immunoglobulin pair suppression and polyclonal immunoglobulin levels to MGUS risk categories. Neoplasma 2015; 62: 827–832.

41. Mead GP, Carr-Smith HD, Drayson MT, et al. Serum free light chains for monitoring multiple myeloma. Brit J Haematol 2004; 126: 348–354.

42. Drayson M, Begum G, Basu S, et al. Effects of paraprotein heavy light chain types and free light chain load on survival in myeloma: an analysis of patients receiving conventional - dose chemotherapy in Medical Research Council UK multiple myeloma trials. Blood 2006; 108: 2013–2019.

43. Snozek CL, Katzmann JA, Kyle RA, et al. Prognostic value of the serum free light chain ratio in newly diagnosed myeloma: proposed incorporation into the International staging system. Leukemia 2008; 22: 1933–1937.

44. Brioli A, Giles H, Pawlyn Ch, et al. Serum free immunoglobulin light chain evaluation as a marker of impact from intraclonal heteroge-neity on myeloma outcome. Blood 2014; 123: 3414–3419.

45. Pika T, Zemanová M, Minařík J, et al. Vztah sérových hladin volných lehkých řetězců imunoglobulinu ke stupni pokročilosti mnohočetného myelomu. Transfuze Hematol dnes 2007; 13: 12–15.

46. Stadtmauer EA, Wang J, Offin MD. Very high serum free light chain concentrations (Above 10 000 mg/l) predict high early mortality from multiple myeloma. J Hematol Reports 2015; 7 (Suppl. 1): 29.

47. Kastritis E, Terpos E, Moulopoulos L, et al. Extensive bone marrow infiltration and abnormal free light chain ratio identifies patients with asymptomatic myeloma at high risk for progression to symptomatic disease. Leukemia 2013; 27: 947–953.

48. Matsue K, Sugihara H, Nishida Y, et al. Heterogeneity of IMWG defined response assessed by FLC assay, multicolor flow cytometry, and heavy/light chain analysis. Clin Lymphoma Myeloma Leukemia 2013; 13: P-203a.

49. Scudla V, Zemanova M, Minarik J, et al. International prognostic index (IPI) – a critical comparison with five multiple myeloma staging systems in the group of 270 patients treated by conventional chemotherapy. Neoplasma 2006; 53: 277–284.

50. Bataille R, Grenier J, Sany J. Beta2-microglobulin in myeloma: optimal use for staging, prognosis and treatment - a prospective study of 160 patients. Blood 1984; 63: 468–476.

51. Palumbo A, Avet-Loiseau H, Oliva S et al. Revised International staging system for multiple myeloma: A report from International Myeloma Working Group. J Clin Oncol 2015; 33: 2863–2869.

52. Koulieris E, Maltezas D, Eytychia N, et al. Impact of novel M- component based biomarkers on to progression free survival after treatment in intact immunoglobulin in multiple myeloma. Blood 2012; 120: 2927.

53. Katzmann JA, Willrich MAV, Kohlhagen MC, et al. Monitoring IgA multiple myeloma: immunoglobulin heavy/light chain assays. Clin Chemistry 2015; 61: 360–367.

54. Boyle EM, Fouquet G, Guidez S, et al. IgA kappa/IgA Lambda heavy/light chain assessment in the management of patients with IgA myeloma. Cancer 2014; 120: 3952–3957.