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Chow MBCY, Bushrow L, Siddiqui I, Chiu A, Hamirani M, Satoskar AA. Congophilic fibrils in the glomeruli with polyclonal immunoglobulin gamma staining - another cause for diagnostic overlap: A case report. World J Clin Cases 2024; 12:3200-3205. [DOI: 10.12998/wjcc.v12.i17.3200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/15/2024] [Accepted: 04/23/2024] [Indexed: 06/04/2024] Open
Abstract
BACKGROUND Glomerulopathy with fibrillary deposits is not uncommon in routine nephropathology practice, with amyloidosis and fibrillary glomerulonephritis being the two most frequently encountered entities. Renal amyloid heavy and light chain (AHL) is relatively uncommon and its biopsy diagnosis is usually limited to cases that show strong equivalent staining for a single immunoglobulin (Ig) heavy chain and a single light chain, further supported by mass spectrometry (MS) and serum studies for monoclonal protein. But polyclonal light chain staining can pose a challenge.
CASE SUMMARY Herein we present a challenging case of renal AHL with polyclonal and polytypic Ig gamma (IgG) staining pattern by immunofluorescence. The patient is a 62-year-old Caucasian male who presented to an outside institution with a serum creatinine of up to 8.1 mg/dL and nephrotic range proteinuria. Despite the finding of a polyclonal and polytypic staining pattern on immunofluorescence, ultrastructural study of the renal biopsy demonstrated the presence of fibrils with a mean diameter of 10 nm. Congo red was positive while DNAJB9 was negative. MS suggested a diagnosis of amyloid AHL type with IgG and lambda, but kappa light chains were also present supporting the immunofluorescence staining results. Serum immunofixation studies demonstrated IgG lambda monoclonal spike. The patient was started on chemotherapy. The chronic renal injury however was quite advanced and he ended up needing dialysis shortly after.
CONCLUSION Tissue diagnosis of AHL amyloid can be tricky. Thorough confirmation using other available diagnostic techniques is recommended in such cases.
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Affiliation(s)
- Maria Bernadette Che-Ying Chow
- Department of Pathology, The Ohio State University Medical Center, Columbus, OH 43210, United States
- Department of Pathology, North District Hospital, Sheung Shui, Hong Kong, China
| | - Lucas Bushrow
- Department of Pathology, The Ohio State University Medical Center, Columbus, OH 43210, United States
| | - Irmeen Siddiqui
- Department of Pathology, The Ohio State University Medical Center, Columbus, OH 43210, United States
| | - April Chiu
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, United States
| | - Mirza Hamirani
- Department of Internal Medicine, S. Joseph's Hospital, Parkersburg, WV 26101, United States
| | - Anjali A Satoskar
- Department of Pathology, The Ohio State University Medical Center, Columbus, OH 43210, United States
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2
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Jimenez A, Scholl AR, Wang B, Schilke M, Carlsen ED. Characteristics of isatuximab-derived interference in serum protein electrophoresis and immunofixation, and an absence of sustained in vivo interference due to belantamab mafodotin and denosumab. Clin Biochem 2024; 127-128:110761. [PMID: 38565341 DOI: 10.1016/j.clinbiochem.2024.110761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 03/18/2024] [Accepted: 03/30/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVES Some therapeutic monoclonal antibodies, like daratumumab and elotuzumab, produce interfering monoclonal bands on serum protein electrophoresis (SPEP) and immunofixation electrophoresis (IFE). Whether other common therapeutic antibodies also produce interference has not been systematically evaluated. DESIGN AND METHODS SPEP/IFE from patients receiving isatuximab (48 patients), belantamab mafodotin (BM; 41), and denosumab (41) were retrospectively reviewed for therapeutic antibody interference. Cases exhibiting isatuximab interference were quantified and the maximum duration of isatuximab effect was evaluated. To characterize band position, neat human serum was spiked with BM or denosumab at supratherapeutic concentrations. Band migration patterns were compared on SPEP and IFE, with band position expressed relative to other constant protein fractions. RESULTS Isatuximab-induced IFE interference was common (81.3 % of evaluated patients) with a maximum observed duration of 8 weeks. 10.4 % of isatuximab patients had IgG kappa monoclonal gammopathies that co-migrated with the drug; this subset could benefit from HYDRASHIFT 2/4 isatuximab testing. 8.3 % of IFE cases were negative for an isatuximab band but showed large, endogenous M-spikes migrating elsewhere. All patients in this group expired within 1 year of this finding. We hypothesize that an inability to detect isatuximab in this setting corresponds to a large residual myeloma burden that reduces isatuximab serum concentration. This observation may serve as a negative prognostic factor. Spiking studies demonstrated that BM and denosumab produce interference in vitro, but sustained interference was not observed in >40 treated patients. CONCLUSIONS Therapeutic antibody interference in patients receiving isatuximab is common, and can persist for at least 8 weeks after administration. >10 % of patients receiving isatuximab may benefit from HYDRASHIFT testing post-therapy. In contrast, BM and denosumab fail to produce sustained interference in treated patients.
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Affiliation(s)
- Adam Jimenez
- Department of Pathology, Duke University Medical Center, Durham, NC, USA
| | - Ashley Rose Scholl
- Department of Pathology, Duke University Medical Center, Durham, NC, USA
| | - Bangchen Wang
- Department of Pathology, Duke University Medical Center, Durham, NC, USA
| | - Michael Schilke
- Department of Pharmacy, Duke University Medical Center, Durham, NC, USA
| | - Eric D Carlsen
- Department of Pathology, Duke University Medical Center, Durham, NC, USA; Duke Cancer Institute, Durham, NC, USA.
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3
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Thoren K, Menad S, Nouadje G, Macé S. Isatuximab-Specific Immunofixation Electrophoresis Assay to Remove Interference in Serum M-Protein Measurement in Patients with Multiple Myeloma. J Appl Lab Med 2024:jfae028. [PMID: 38573925 DOI: 10.1093/jalm/jfae028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 02/26/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Isatuximab, an IgG-kappa (IgGκ) anti-cluster of differentiation 38 (CD38) monoclonal antibody approved for use in patients with relapsed or refractory multiple myeloma (MM), can potentially interfere with the visualization of endogenous monoclonal protein (M-protein) on standard immunofixation electrophoresis (IFE) and lead to inaccurate classification of a patient's response to therapy. The Hydrashift 2/4 isatuximab IFE assay (Hydrashift isatuximab assay) removes isatuximab interference from IFE. Using samples from patients enrolled in clinical trials of isatuximab-based therapy for MM, we demonstrate how the Hydrashift isatuximab assay improves the ability to detect residual M-protein and offer recommendations for when the assay is most useful. METHODS Samples from 141 patients with a variety of known M-protein isotypes were selected and analyzed by standard IFE and the Hydrashift isatuximab assay. A positive control containing isatuximab was run on every standard IFE and Hydrashift gel. RESULTS The Hydrashift isatuximab assay reliably shifted the migration of isatuximab in patient samples. Standard IFE was adequate for determining 104 patients' M-protein status, and the Hydrashift isatuximab assay confirmed these results. In samples from 37 patients with a history of IgGκ MM and a single IgGκ band visible on standard IFE near the isatuximab migration site, the Hydrashift isatuximab assay was able to separate isatuximab from endogenous M-protein, identifying residual M-protein in 17 samples and preventing false-positive interpretations of standard IFE in 20 samples. CONCLUSIONS The Hydrashift isatuximab assay is most useful in patients with known IgGκ MM when a single IgGκ band appears near the isatuximab migration site on standard IFE during isatuximab-based therapy. ClinicalTrials.gov Registration Numbers: NCT03275285 and NCT03319667.
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Affiliation(s)
- Katie Thoren
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
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4
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Wei C, Wang M, Li J, Su J, Huang J, Tong S, Yang D. Light chain deposition disease presenting with gastrointestinal disorder as primary manifestation: report of two cases and literature review. J Int Med Res 2024; 52:3000605241233972. [PMID: 38488658 PMCID: PMC10943736 DOI: 10.1177/03000605241233972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 01/29/2024] [Indexed: 03/18/2024] Open
Abstract
Light chain deposition disease (LCDD) is an under-recognized condition characterized by deposition of abnormal monoclonal light chains in tissues, leading to organ dysfunction. LCDD involving the gastrointestinal tract is very uncommon, and its diagnosis is challenging. We herein report two cases of LCDD that manifested as inflammatory bowel disease-like symptoms and protein-losing gastroenteropathy. Both patients were women in their early 60s. Tissue biopsies from the gastrointestinal mucosa demonstrated extracellular deposits, which were negative by Congo red staining but positive for κ-light chain by immunohistochemistry. The recent literature on LCDD was reviewed. When patients unexpectedly show extracellular deposits in gastrointestinal biopsy specimens, evaluation of immunoglobulin chains is recommended for diagnosis of LCDD after systemic amyloidosis has been excluded.
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Affiliation(s)
- Chenxiang Wei
- Division of Gastroenterology and Hepatology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, P.R. China
| | - Min Wang
- Division of Gastroenterology and Hepatology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, P.R. China
| | - Jiamin Li
- Department of Pathology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, P.R. China
| | - Jiajun Su
- Department of Pathology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, P.R. China
| | - Jing Huang
- Department of Hematology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, P.R. China
| | - Sunwing Tong
- Department of Pathology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, P.R. China
| | - Dongye Yang
- Division of Gastroenterology and Hepatology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, P.R. China
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5
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Muccio S, Hirtz C, Descloux S, Fedeli O, Macé S, Lehmann S, Vialaret J. A sensitive high-resolution mass spectrometry method for quantifying intact M-protein light chains in patients with multiple myeloma. Clin Chim Acta 2024; 552:117634. [PMID: 37980975 DOI: 10.1016/j.cca.2023.117634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 11/21/2023]
Abstract
To determine the disease status and the response to treatment for patients with multiple myeloma, measuring serum M-protein levels is a widely used alternative to invasive punctures to count malignant plasma cells in the bone marrow. However, the quantification of this monoclonal antibody, which varies from patient to patient, poses significant analytical challenges. This paper describes a sensitive and specific mass spectrometry assay that addresses two objectives: to overcome the potential interference of biotherapeutics in the measurement of M-proteins, and to determine the depth of response to treatment by assessing minimal residual disease. After immunocapture of immunoglobulins and free light chains in serum, heavy and light chains were dissociated by chemical reduction and separated by liquid chromatography. M-proteins were analyzed by high-resolution mass spectrometry using a method combining a full MS scan for isotyping and identification and a targeted single ion monitoring scan for quantification. This method was able to discriminate M-protein from the therapeutic antibody in all patient samples analyzed and allowed quantification of M-protein with a LLOQ of 2.0 to 3.5 µg/ml in 5 out of 6 patients. This methodology appears to be promising for assessing minimal residual disease with sufficient sensitivity, specificity, and throughput.
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Affiliation(s)
- Stéphane Muccio
- Sanofi, TMED-BCB, 371 rue du Professeur Blayac, 34184 Montpellier, France.
| | - Christophe Hirtz
- Montpellier Univ, IRMB CHU, INM INSERM, 80 avenue Augustin Fliche, 34295 Montpellier, France
| | - Sandrine Descloux
- Sanofi, TMED-BCB, 371 rue du Professeur Blayac, 34184 Montpellier, France
| | - Olivier Fedeli
- Sanofi, TMED-BCB, 371 rue du Professeur Blayac, 34184 Montpellier, France
| | - Sandrine Macé
- Sanofi, TMED-PMO, 1 avenue Pierre Brossolette, 91385 Chilly-Mazarin, France
| | - Sylvain Lehmann
- Montpellier Univ, IRMB CHU, INM INSERM, 80 avenue Augustin Fliche, 34295 Montpellier, France
| | - Jérôme Vialaret
- Montpellier Univ, IRMB CHU, INM INSERM, 80 avenue Augustin Fliche, 34295 Montpellier, France
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Cárdenas MC, García-Sanz R, Puig N, Pérez-Surribas D, Flores-Montero J, Ortiz-Espejo M, de la Rubia J, Cruz-Iglesias E. Recommendations for the study of monoclonal gammopathies in the clinical laboratory. A consensus of the Spanish Society of Laboratory Medicine and the Spanish Society of Hematology and Hemotherapy. Part I: Update on laboratory tests for the study of monoclonal gammopathies. Clin Chem Lab Med 2023; 61:2115-2130. [PMID: 37477188 DOI: 10.1515/cclm-2023-0326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/29/2023] [Indexed: 07/22/2023]
Abstract
Monoclonal gammopathies (MG) are characterized by the proliferation of plasma cells that produce identical abnormal immunoglobulins (intact or some of their subunits). This abnormal immunoglobulin component is called monoclonal protein (M-protein), and is considered a biomarker of proliferative activity. The identification, characterization and measurement of M-protein is essential for the management of MG. We conducted a systematic review of the different tests and measurement methods used in the clinical laboratory for the study of M-protein in serum and urine, the biochemistry and hematology tests necessary for clinical evaluation, and studies in bone marrow, peripheral blood and other tissues. This review included literature published between 2009 and 2022. The paper discusses the main methodological characteristics and limitations, as well as the purpose and clinical value of the different tests used in the diagnosis, prognosis, monitoring and assessment of treatment response in MG. Included are methods for the study of M-protein, namely electrophoresis, measurement of immunoglobulin levels, serum free light chains, immunoglobulin heavy chain/light chain pairs, and mass spectrometry, and for the bone marrow examination, morphological analysis, cytogenetics, molecular techniques, and multiparameter flow cytometry.
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Affiliation(s)
- María C Cárdenas
- Department of Clinical Analysis, Hospital Clinico San Carlos, Madrid, Spain
- Protein Commission, Spanish Society of Laboratory Medicine (SEQCML), Barcelona, Spain
| | - Ramón García-Sanz
- Hematology Department, University Hospital of Salamanca, Research Biomedical Institute of Salamanca (IBSAL), CIBERONC and Center for Cancer Research-IBMCC (University of Salamanca-CSIC), Salamanca, Spain
- Spanish Society of Hematology and Hemotherapy (SEHH), Madrid, Spain
| | - Noemí Puig
- Hematology Department, University Hospital of Salamanca, Research Biomedical Institute of Salamanca (IBSAL), CIBERONC and Center for Cancer Research-IBMCC (University of Salamanca-CSIC), Salamanca, Spain
- Spanish Society of Hematology and Hemotherapy (SEHH), Madrid, Spain
| | - David Pérez-Surribas
- Laboratori Pasteur, Andorra La Vella, Andorra
- Protein Commission, Spanish Society of Laboratory Medicine (SEQCML), Barcelona, Spain
| | - Juan Flores-Montero
- Hematology Department, University Hospital of Salamanca, Research Biomedical Institute of Salamanca (IBSAL), CIBERONC and Center for Cancer Research-IBMCC (University of Salamanca-CSIC), Salamanca, Spain
- Spanish Society of Hematology and Hemotherapy (SEHH), Madrid, Spain
| | - María Ortiz-Espejo
- Department of Clinical Analysis, Hospital Universitario Marqués de Valdecilla, Santander, Spain
- Protein Commission, Spanish Society of Laboratory Medicine (SEQCML), Barcelona, Spain
| | - Javier de la Rubia
- Hematology Department, Hospital Universitario y Politécnico La Fe & Universidad Católica de Valencia, Instituto de Investigación Sanitaria La Fe Centro de Investigación Biomédica en Red de Cáncer, CIBERONC CB16/12/00284, Instituto de Salud Carlos III, Valencia, Spain
- Spanish Society of Hematology and Hemotherapy (SEHH), Madrid, Spain
| | - Elena Cruz-Iglesias
- Department of Laboratory Medicine, Osakidetza Basque Health Service, Basurto University Hospital, Bilbao, Spain
- Protein Commission, Spanish Society of Laboratory Medicine (SEQCML), Barcelona, Spain
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7
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Marcon C, Simeon V, Deias P, Facchin G, Corso A, Derudas D, Montefusco V, Offidani M, Petrucci MT, Zambello R, Stocchi R, Fanin R, Patriarca F. Experts' consensus on the definition and management of high risk multiple myeloma. Front Oncol 2023; 12:1096852. [PMID: 36755858 PMCID: PMC9899889 DOI: 10.3389/fonc.2022.1096852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 12/16/2022] [Indexed: 01/24/2023] Open
Abstract
High risk multiple myeloma (HRMM) at diagnosis is currently recognized according to the Revised International Staging System (R-ISS) which was set up in 2015. Since then, new clinical and biological prognostic factors have been developed, which could implement the definition of High Risk (HR) category. We conducted a survey in order to identify which additional parameters, both clinical and biological, are considered more useful for the clinical practice and to evaluate if the management of Multiple Myeloma (MM) should change on the basis of the risk category. A questionnaire, consisting of 8 statements, was submitted to 6 Italian experts, from the European Myeloma Network (EMN) Research Italy, using the Delphi method. The colleagues were asked to answer each question using a scale between 0 and 100. If a statement did not reach at least 75 out of 100 points from all the participants, it was rephrased on the basis of the proposal of the experts and resubmitted in a second or further round, until a consensus was reached among all. From the first round of the survey a strong consensus was reached regarding the opportunity to revise the R-ISS including chromosome 1 abnormality, TP53 mutation or deletion, circulating plasma cells by next generation flow and extramedullary plasmacytomas. No consensus was reached for the definition of "double hit" MM and for the application in clinical practice of treatment strategies based on the risk category. In the second round of the Delphi questionnaire, "double-hit" MM was recognized by the association of at least two high-risk cytogenetic or molecular abnormalities. Moreover, the experts agreed to reserve an intensified treatment only to specific conditions, such as plasma cell leukaemia or patients with multiple extramedullary plasmacytomas, while they admitted that there are not sufficient real word data in order to modify treatment on the basis of MRD assessment in clinical practice. This survey suggests that the definition of HRMM should be implemented by additional clinical and biological risk factors, that will be useful to guide treatment in the future.
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Affiliation(s)
- Chiara Marcon
- Division of Hematology, S. Maria della Misericordia Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy,Department of Area Medica, Udine University, Udine, Italy,*Correspondence: Chiara Marcon,
| | - Valentina Simeon
- Division of Hematology, S. Maria della Misericordia Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy,Department of Area Medica, Udine University, Udine, Italy
| | - Paola Deias
- Division of Hematology and Bone Marrow Transplant Center, Department of Medical Science, R. Binaghi Hospital, Cagliari University, Cagliari, Italy
| | - Gabriele Facchin
- Division of Hematology, S. Maria della Misericordia Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | | | - Daniele Derudas
- Division of Hematology and Bone Marrow Transplant Center, A. Businco Cancer Hospital, Cagliari, Italy
| | - Vittorio Montefusco
- Division of Hematology, Azienda Socio Sanitaria Territoriale (ASST) Santi Paolo e Carlo, Milan, Italy
| | - Massimo Offidani
- Clinical Hematology, Azienda Ospedaliera Universitaria (AOU) Ospedali Riuniti di Ancona, Ancona, Italy
| | - Maria Teresa Petrucci
- Division of Hematology, Department of Translational and Precision Medicine, Azienda Ospedaliera Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Renato Zambello
- Clinical Hematology, Azienda Ospedaliera di Padova, Padua, Italy
| | - Raffaella Stocchi
- Division of Hematology, S. Maria della Misericordia Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Renato Fanin
- Division of Hematology, S. Maria della Misericordia Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy,Department of Area Medica, Udine University, Udine, Italy
| | - Francesca Patriarca
- Division of Hematology, S. Maria della Misericordia Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy,Department of Area Medica, Udine University, Udine, Italy
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8
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Irvin SC, D’Orvilliers A, Bloch N, Boccio K, Pennucci J, Brouwer-Visser J, Ullman E, Rajadhyaksha M, Hassanein M, Potocky T, Torri A, Hermann A, Partridge MA. Interference in a Neutralizing Antibody Assay for Odronextamab, a CD20xCD3 Bispecific mAb, from Prior Rituximab Therapy and Possible Mitigation Strategy. AAPS J 2022; 24:76. [DOI: 10.1208/s12248-022-00724-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 06/06/2022] [Indexed: 11/30/2022] Open
Abstract
AbstractA cell-based assay was developed to detect neutralizing anti-drug antibodies (NAbs) against odronextamab, a CD20xCD3 bispecific monoclonal antibody (mAb) under investigation for treatment of CD20+ B cell malignancies. In this assay, odronextamab bridges between two cell types, CD20-expressing HEK293 cells and CD3-expressing Jurkat T cells that generate a luciferase signal upon CD3 clustering. Patient samples containing NAbs directed to either arm of the bispecific drug block the odronextamab bridge formation between the cell lines thus preventing the generation of the luciferase signal. We determined that other anti-CD20 therapeutics also block bridge formation, resulting in false-positive results. In patient samples from odronextamab clinical trials, approximately 30% of baseline samples had a strong false-positive NAb signal that correlated with the presence of prior rituximab (anti-CD20) therapy. We determined that rituximab interference can be minimized by the addition of anti-rituximab antibodies in the NAb assay. Understanding and mitigating the impact of prior biologic exposure is increasingly important for implementing a successful bioanalytical strategy to support clinical drug development, especially in the immuno-oncology field.
Graphical Abstract
Odronextamab neutralizing antibody assay, interference, and mitigation. A Design of the odronextamab neutralizing antibody (NAb) assay where anti-CD20xCD3 drug bridges between CD20-expressing HEK293 cells and Jurkat T cells expressing an NFAT response element and luciferase reporter. True NAb prevents odronextamab from bridging between target and effector cells, thus preventing the expression of luciferase. B Interference with odronextamab from other anti-CD20 therapeutic antibodies (e.g., rituximab) from prior disease treatment generates a false-positive NAb result. Assay interference can be mitigated with an anti-idiotypic antibody against the interfering therapy.
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9
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Liang S, Feng W, Ma H, Zhang L, Jia C. False positive results: a challenge for laboratory physicians and hematologists in treating multiple myeloma with daratumumab. Hematology 2022; 27:332-336. [PMID: 35255237 DOI: 10.1080/16078454.2022.2045723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Daratumumab injection was approved by China in 2019 for the treatment of recurrent or refractory multiple myeloma. However, the molecular weight of daratumumab, an immunoglobin G1 kappa human monoclonal antibody, was similar to that of M protein and could not be distinguished from IgG κ M protein in SPEP and SIFE. It might lead to false-positive detection resulting in misdiagnose and confusing evaluation of therapeutic response, especially for patients with IgG κ M proteins. Herein, we reported two cases encountered in our daily clinical work. These two case reports could serve as a reminder to global hematologists who have not yet started or just begun to use the drug of daratumumab.
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Affiliation(s)
- Shanshan Liang
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Weihua Feng
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Hongbing Ma
- Department of Hematology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Li Zhang
- Department of Hematology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Chengyao Jia
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, People's Republic of China
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10
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Challenges with common laboratory tests in the adult cancer patient. Cancer Biomark 2022. [DOI: 10.1016/b978-0-12-824302-2.00002-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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11
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Satoskar AA, Ibrahim DY, Brodsky SV, Ayoub I, Nadasdy T, Rovin BH. Membranoproliferative glomerulonephritis with changing immunofluorescence pattern. Kidney Int Rep 2022; 7:1123-1127. [PMID: 35571003 PMCID: PMC9091588 DOI: 10.1016/j.ekir.2022.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 12/28/2021] [Accepted: 01/03/2022] [Indexed: 12/03/2022] Open
Affiliation(s)
- Anjali A. Satoskar
- Division of Renal and Transplant Pathology, Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- Correspondence: Anjali A. Satoskar, Division of Renal and Transplant Pathology, Department of Pathology, The Ohio State University Wexner Medical Center, M018 Starling Loving, 320 West, 10th Avenue, Columbus, Ohio 43210, USA.
| | - Dalia Y. Ibrahim
- Division of Renal and Transplant Pathology, Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Sergey V. Brodsky
- Division of Renal and Transplant Pathology, Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Isabelle Ayoub
- Division of Nephrology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Tibor Nadasdy
- Division of Renal and Transplant Pathology, Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Brad H. Rovin
- Division of Nephrology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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12
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Wheeler RD, Costa MV, Crichlow A, Willis F, Reyal Y, Linstead SE, Morris JE. Case report: Interference from isatuximab on serum protein electrophoresis prevented demonstration of complete remission in a myeloma patient. Ann Clin Biochem 2021; 59:144-148. [PMID: 34937410 DOI: 10.1177/00045632211062080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Multiple myeloma is a haematological cancer caused by malignant plasma cells in the bone marrow that can result in organ dysfunction and death. Recent novel treatments have contributed to improved survival rates, including monoclonal antibody therapies that target the CD38 protein on the surface of plasma cells. Anti-CD38 therapies are IgG kappa monoclonal antibodies that are given in doses high enough for the drug to be visible on serum protein electrophoresis as a small paraprotein. We present a case where isatuximab, the most recent anti-CD38 monoclonal antibody to be approved for treatment of myeloma, obscured the patient's paraprotein on gel immunofixation, so that complete remission could not be demonstrated. This was resolved using the isatuximab Hydrashift assay. The interference on gel immunofixation was unexpected because isatuximab migrated in a position distinct from the patient's paraprotein on capillary zone electrophoresis. We demonstrate the surprising finding that isatuximab migrates in a different position on gel electrophoresis compared to capillary zone electrophoresis. It is vital that laboratories are aware of the possible interference on electrophoresis from anti-CD38 monoclonal antibody therapies, and are able to recognise these drugs on protein electrophoresis. The difference in isatuximab's electrophoretic mobility on capillary and gel protein electrophoresis makes this particularly challenging. Laboratories should have a strategy for alternative analyses in the event that the drugs interfere with assessment of the patient's paraprotein.
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Affiliation(s)
- Rachel D Wheeler
- Protein Reference Unit, South West London Pathology, 4968St George's Hospital, London, UK
| | - Micsha V Costa
- Protein Reference Unit, South West London Pathology, 4968St George's Hospital, London, UK
| | - Asante Crichlow
- Protein Reference Unit, South West London Pathology, 4968St George's Hospital, London, UK
| | | | - Yasmin Reyal
- Clinical Haematology, 4968St George's Hospital, UK
| | - Sarah E Linstead
- Protein Reference Unit, South West London Pathology, 4968St George's Hospital, London, UK
| | - Joanne E Morris
- Protein Reference Unit, South West London Pathology, 4968St George's Hospital, London, UK
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13
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Muccio S, Tavernier A, Rouchon MC, Roccon A, Dai S, Finn G, Macé S, Boutet V, Fedeli O. Validated Method Based on Immunocapture and Liquid Chromatography Coupled to High-Resolution Mass Spectrometry to Eliminate Isatuximab Interference with M-Protein Measurement in Serum. Anal Chem 2021; 93:15236-15242. [PMID: 34762405 DOI: 10.1021/acs.analchem.1c03410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In multiple myeloma (MM) disease, malignant plasma cells produce excessive quantities of a monoclonal immunoglobulin (Ig), known as M-protein. M-protein levels are measured in the serum of patients with MM using electrophoresis techniques to determine the response to treatment. However, therapeutic monoclonal antibodies, such as isatuximab, may confound signals using electrophoresis assays. We developed a robust assay based on immunocapture and liquid chromatography coupled to high-resolution mass spectrometry (IC-HPLC-HRMS) in order to eliminate this interference. Following immunocapture of Ig and free light chains (LC) in serum, heavy chains (HC) and LC were dissociated using dithiothreitol, sorted by liquid chromatography and analyzed using HRMS (Q-Orbitrap). This method allowed the M-proteins to be characterized and the signals from isatuximab and M-proteins to be discriminated. As M-protein is specific to each patient, no standards were available for absolute quantification. We therefore used alemtuzumab (an IgG kappa mAb) as a surrogate analyte for the semiquantification of M-protein in serum. This assay was successfully validated in terms of selectivity/specificity, accuracy/precision, robustness, dilution linearity, and matrix variability from 10.0 to 200 μg/mL in human serum. This method was used for clinical assessment of samples and eliminated potential interference due to isatuximab when monitoring patients with MM.
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Affiliation(s)
- Stéphane Muccio
- Sanofi R&D, 371 Rue du Professeur Blayac, 34184 Montpellier, France
| | | | | | - Alain Roccon
- Sanofi R&D, 371 Rue du Professeur Blayac, 34184 Montpellier, France
| | - Shujia Dai
- Sanofi Translational Sciences, 640 Memorial Drive, Cambridge, Massachusetts 02139, United States
| | - Greg Finn
- Sanofi Oncology, 640 Memorial Drive, Cambridge, Massachusetts 02139, United States
| | - Sandrine Macé
- Sanofi R&D, 1 Avenue Pierre Brossolette, 91385 Chilly-Mazarin, France
| | - Valérie Boutet
- Sanofi R&D, 1 Avenue Pierre Brossolette, 91385 Chilly-Mazarin, France
| | - Olivier Fedeli
- Sanofi R&D, 371 Rue du Professeur Blayac, 34184 Montpellier, France
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14
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The Current Role of the Heavy/Light Chain Assay in the Diagnosis, Prognosis and Monitoring of Multiple Myeloma: An Evidence-Based Approach. Diagnostics (Basel) 2021; 11:diagnostics11112020. [PMID: 34829367 PMCID: PMC8620453 DOI: 10.3390/diagnostics11112020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 10/27/2021] [Accepted: 10/27/2021] [Indexed: 11/17/2022] Open
Abstract
Despite tremendous progress being made in recent years, multiple myeloma (MM) remains a challenging disease. The laboratory plays a critical role in the overall management of patients. The diagnosis, prognosis, clinical monitoring and evaluation of the response are key moments in the clinical care process. Conventional laboratory methods have been and continue to be the basis of laboratory testing in monoclonal gammopathies, along with the serum free light chain test. However, more accurate methods are needed to achieve new and more stringent clinical goals. The heavy/light chain assay is a relatively new test which can overcome some of the limitations of the conventional methods for the evaluation of intact immunoglobulin MM patients. Here, we report an update of the evidence accumulated in recent years on this method regarding its use in MM.
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15
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Xu S, Liu Y, Wen L, Zhao L, Deng X, Rong R, Lu J. [Application of Hydrashift 2/4 daratumumab assay in eliminating interference of daratumumab on serum immunofixation electrophoresis]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 42:840-845. [PMID: 34788924 PMCID: PMC8607023 DOI: 10.3760/cma.j.issn.0253-2727.2021.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Objective: To investigate the interference of daratumumab on immunofixation electrophoresis after treating plasma cell diseases and methods to eliminate the interference. Methods: Serum samples of eight patients with plasma cell diseases treated with daratumumab in Peking University People's Hospital from April 2020 to March 2021 were collected for standard immunofixation electrophoresis and Hydrashift 2/4 daratumumab assay. Results: After treatment, 81.3% (13/16) of the samples showed drug-induced monoclonal antibodies (IgG-κ) . The samples without drug-induced monoclonal bands were related to individual differences, administration intervals, and immunoglobulin levels. Among the samples with IgG-κ monoclonal bands, 76.9% (10/13) could be directly identified as endogenous or exogenous monoclonal bands by immunofixation electrophoresis, and the others (3/13) could be identified by Hydrashift 2/4 daratumumab assay. Conclusion: Hydrashift 2/4 daratumumab assay can remove the band of daratumumab on the immunofixation electrophoresis and help with efficacy evaluation.
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Affiliation(s)
- S Xu
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing 100044, China
| | - Y Liu
- Department of Hematology, Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing 100044, China
| | - L Wen
- Department of Hematology, Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing 100044, China
| | - L Zhao
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing 100044, China
| | - X Deng
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing 100044, China
| | - R Rong
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing 100044, China
| | - J Lu
- Department of Hematology, Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing 100044, China Center for Collaborative Innovation in Hematology, Suzhou 215006,China
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16
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Ackley J, Ochoa MA, Ghoshal D, Roy K, Lonial S, Boise LH. Keeping Myeloma in Check: The Past, Present and Future of Immunotherapy in Multiple Myeloma. Cancers (Basel) 2021; 13:4787. [PMID: 34638271 PMCID: PMC8507631 DOI: 10.3390/cancers13194787] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 09/21/2021] [Accepted: 09/22/2021] [Indexed: 02/06/2023] Open
Abstract
Multiple myeloma is an incurable disease of malignant plasma cells and an ideal target for modern immune therapy. The unique plasma cell biology maintained in multiple myeloma, coupled with its hematological nature and unique bone marrow microenvironment, provide an opportunity to design specifically targeted immunotherapies that selectively kill transformed cells with limited on-target off-tumor effects. Broadly defined, immune therapy is the utilization of the immune system and immune agents to treat a disease. In the context of multiple myeloma, immune therapy can be subdivided into four main categories: immune modulatory imide drugs, targeted antibodies, adoptive cell transfer therapies, and vaccines. In recent years, advances in all four of these categories have led to improved therapies with enhanced antitumor activity and specificity. In IMiDs, modified chemical structures have been developed that improve drug potency while reducing dose limiting side effects. Targeted antibody therapies have resulted from the development of new selectively expressed targets as well as the development of antibody drug conjugates and bispecific antibodies. Adoptive cell therapies, particularly CAR-T therapies, have been enhanced through improvements in the manufacturing process, as well as through the development of CAR constructs that enhance CAR-T activation and provide protection from a suppressive immune microenvironment. This review will first cover in-class breakthrough therapies for each of these categories, as well as therapies currently utilized in the clinic. Additionally, this review will explore up and coming therapeutics in the preclinical and clinical trial stage.
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Affiliation(s)
- James Ackley
- Department of Hematology and Medical Oncology, Emory University, Atlanta, GA 30322, USA; (J.A.); (S.L.)
| | - Miguel Armenta Ochoa
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA 30332, USA; (M.A.O.); (D.G.); (K.R.)
- NSF Engineering Research Center for Cell Manufacturing Technologies, The Marcus Center for Therapeutic Cell Characterization and Manufacturing and the Center for ImmunoEngineering, The Parker H. Petit Institute for Bioengineering & Bioscience, Georgia Institute of Technology, Atlanta, GA 30332, USA
| | - Delta Ghoshal
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA 30332, USA; (M.A.O.); (D.G.); (K.R.)
- NSF Engineering Research Center for Cell Manufacturing Technologies, The Marcus Center for Therapeutic Cell Characterization and Manufacturing and the Center for ImmunoEngineering, The Parker H. Petit Institute for Bioengineering & Bioscience, Georgia Institute of Technology, Atlanta, GA 30332, USA
| | - Krishnendu Roy
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA 30332, USA; (M.A.O.); (D.G.); (K.R.)
- NSF Engineering Research Center for Cell Manufacturing Technologies, The Marcus Center for Therapeutic Cell Characterization and Manufacturing and the Center for ImmunoEngineering, The Parker H. Petit Institute for Bioengineering & Bioscience, Georgia Institute of Technology, Atlanta, GA 30332, USA
- Winship Cancer Institute, Emory University, Atlanta, GA 30322, USA
| | - Sagar Lonial
- Department of Hematology and Medical Oncology, Emory University, Atlanta, GA 30322, USA; (J.A.); (S.L.)
- Winship Cancer Institute, Emory University, Atlanta, GA 30322, USA
| | - Lawrence H. Boise
- Department of Hematology and Medical Oncology, Emory University, Atlanta, GA 30322, USA; (J.A.); (S.L.)
- Winship Cancer Institute, Emory University, Atlanta, GA 30322, USA
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17
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Liyasova M, McDonald Z, Taylor P, Gorospe K, Xu X, Yao C, Liu Q, Yang L, Atenafu EG, Piza G, Ma B, Reece D, Trudel S. A Personalized Mass Spectrometry-Based Assay to Monitor M-Protein in Patients with Multiple Myeloma (EasyM). Clin Cancer Res 2021; 27:5028-5037. [PMID: 34210683 PMCID: PMC9401514 DOI: 10.1158/1078-0432.ccr-21-0649] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 04/27/2021] [Accepted: 06/24/2021] [Indexed: 01/07/2023]
Abstract
PURPOSE M-protein is a well-established biomarker used for multiple myeloma monitoring. Current improvements in multiple myeloma treatment created the need to monitor minimal residual disease (MRD) with high sensitivity. Measuring residual levels of M-protein in serum by MS was established as a sensitive assay for disease monitoring. In this study we evaluated the performance of EasyM-a noninvasive, sensitive, MS-based assay for M-protein monitoring. EXPERIMENTAL DESIGN Twenty-six patients enrolled in MCRN-001 clinical trial of two high-dose alkylating agents as conditioning followed by lenalidomide maintenance were selected for the study. All selected patients achieved complete responses (CR) during treatment, whereas five experienced progressive disease on study. The M-protein of each patient was first sequenced from the diagnostic serum using our de novo protein sequencing platform. The patient-specific M-protein peptides were then measured by targeted MS assay to monitor the response to treatment. RESULTS The M-protein doubling over 6 months measured by EasyM could predict the relapse in 4 of 5 relapsed patients 2 to 11 months earlier than conventional testing. In 21 disease-free patients, the M-protein was still detectable by EasyM despite normal FLC and MRD negativity. Importantly, of 72 MRD negative samples with CR status, 62 were positive by EasyM. The best sensitivity achieved by EasyM, detecting 0.58 mg/L of M-protein, was 1,000- and 200-fold higher compared with serum protein electrophoresis and immunofixation electrophoresis, respectively. CONCLUSIONS EasyM was demonstrated to be a noninvasive, sensitive assay with superior performance compared with other assays, making it ideal for multiple myeloma monitoring and relapse prediction.
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Affiliation(s)
| | | | - Paul Taylor
- Rapid Novor, Inc., Kitchener, Ontario, Canada
| | | | - Xin Xu
- Rapid Novor, Inc., Kitchener, Ontario, Canada
| | - Chenyu Yao
- Rapid Novor, Inc., Kitchener, Ontario, Canada
| | - Qixin Liu
- Rapid Novor, Inc., Kitchener, Ontario, Canada
| | | | | | - Giovanni Piza
- Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Bin Ma
- University of Waterloo, Waterloo, Ontario, Canada
| | - Donna Reece
- Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Suzanne Trudel
- Princess Margaret Cancer Centre, Toronto, Ontario, Canada.,Corresponding Author: Suzanne Trudel, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Toronto, ON, Canada M5G 2M9. E-mail:
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18
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El Hussein S, Wang W, Wang SA, Fang H, Garces S, Tashakori M, Lyapichev KA, Qiu L, Wang X, Loghavi S, Medeiros LJ, Challagundla P, Jorgensen JL. Hematogones with light chain restriction: A potential diagnostic pitfall when using flow cytometry analysis to assess bone marrow specimens. Leuk Res 2021; 111:106704. [PMID: 34735934 DOI: 10.1016/j.leukres.2021.106704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 08/30/2021] [Accepted: 09/02/2021] [Indexed: 12/20/2022]
Abstract
Light-chain restricted hematogones (LCR HGs) detected by flow cytometry analysis can mimic bone marrow involvement by B-cell lymphoma. This phenomenon can present a diagnostic pitfall and negatively impact patient management, as misinterpretation may upgrade disease stage. In this study, we characterized the immunophenotype of LCR HGs with an aim to differentiate them from B-cell lymphoma. We analyzed 24 patients with LCR HGs, 12 (50 %) were kappa light chain restricted and 12 (50 %) were lambda light chain restricted. LCR HGs account for 51 % (range, 1.5%-99%) of B cells, and 0.5 % (range, 0.1%-3.7%) of total cells. In 15 patients in whom multiple specimens were analyzed, 10 (67 %) showed persistent LCR HGs in more than 1 specimen, and the duration of the light chain restriction ranged from 4 months to 2 years. Among 24 patients, 4 (16.6 %) cases were concurrently involved by B-cell lymphoma/myeloma in addition to LCR HGs. With the exception of light chain restriction, LCR HGs showed a similar immunophenotype as normal HGs and had a distinct location on the CD45/Side Scatter (SSC) plot. They were also consistently positive for CD10, CD19, CD38 (bright), CD43, and CD200. CD20 expression showed a spectrum from dim/negative to positive.
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Affiliation(s)
- Siba El Hussein
- University of Rochester Medical Center, Department of Pathology, Rochester, New York, USA; The University of Texas MD Anderson Cancer Center, Department of Hematopathology, Houston, Texas, USA.
| | - Wei Wang
- The University of Texas MD Anderson Cancer Center, Department of Hematopathology, Houston, Texas, USA
| | - Sa A Wang
- The University of Texas MD Anderson Cancer Center, Department of Hematopathology, Houston, Texas, USA
| | - Hong Fang
- The University of Texas MD Anderson Cancer Center, Department of Hematopathology, Houston, Texas, USA
| | - Sofia Garces
- The University of Texas MD Anderson Cancer Center, Department of Hematopathology, Houston, Texas, USA
| | - Mehrnoosh Tashakori
- The University of Minnesota, Department of Pathology, Minneapolis, Minnesota, USA
| | - Kirill A Lyapichev
- University of Texas Medical Branch, Department of Pathology, Galveston, Texas, USA
| | - Lianqun Qiu
- The University of Texas MD Anderson Cancer Center, Department of Hematopathology, Houston, Texas, USA
| | - Xiaoqiong Wang
- The University of Texas MD Anderson Cancer Center, Department of Hematopathology, Houston, Texas, USA
| | - Sanam Loghavi
- The University of Texas MD Anderson Cancer Center, Department of Hematopathology, Houston, Texas, USA
| | - L Jeffrey Medeiros
- The University of Texas MD Anderson Cancer Center, Department of Hematopathology, Houston, Texas, USA
| | - Pramoda Challagundla
- Takeda Pharmaceutical International Co., OTAU Precision and Translation Medicine, Cambridge, Massachusetts, USA
| | - Jeffrey L Jorgensen
- The University of Texas MD Anderson Cancer Center, Department of Hematopathology, Houston, Texas, USA.
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19
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Noori S, Verkleij CPM, Zajec M, Langerhorst P, Bosman PWC, de Rijke YB, Zweegman S, VanDuijn M, Luider T, van de Donk NWCJ, Jacobs JFM. Monitoring the M-protein of multiple myeloma patients treated with a combination of monoclonal antibodies: the laboratory solution to eliminate interference. Clin Chem Lab Med 2021; 59:1963-1971. [PMID: 34392637 DOI: 10.1515/cclm-2021-0399] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 08/08/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVES The therapeutic monoclonal antibody (t-mAb) daratumumab, used to treat multiple myeloma (MM) patients, interferes with routine, electrophoretic based M-protein diagnostics. Electrophoretic response assessment becomes increasingly difficult when multiple t-mAbs are combined for use in a single patient. This is the first study to address the analytical challenges of M-protein monitoring when multiple t-mAbs are combined. METHODS In this proof-of-principle study we evaluate two different methods to monitor M-protein responses in three MM patients, who receive both daratumumab and nivolumab. The double hydrashift assay aims to resolve t-mAb interference on immunofixation. The MS-MRD (mass spectrometry minimal residual disease) assay measures clonotypic peptides to quantitate both M-protein and t-mAb concentrations. RESULTS After exposure to daratumumab and nivolumab, both t-mAbs become visible on immunofixation electrophoresis (IFE) as two IgG-kappa bands that migrate close to each other at the cathodal end of the γ-region. In case the M-protein co-migrates with these t-mAbs, the observed interference was completely abolished with the double IFE hydrashift assay. In all three patients the MS-MRD assay was also able to distinguish the M-protein from the t-mAbs. Additional advantage of the MS-MRD assay is that this multiplex assay is more sensitive and allows quantitative M-protein-, daratumumab- and nivolumab-monitoring. CONCLUSIONS Daratumumab and nivolumab interfere with electrophoretic M-protein diagnostics. However, the M-protein can be distinguished from both t-mAbs by use of a double hydrashift assay. The MS-MRD assay provides an alternative method that allows sensitive and simultaneous quantitative monitoring of both the M-protein and t-mAbs.
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Affiliation(s)
- Somayya Noori
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Christie P M Verkleij
- Department of Hematology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Marina Zajec
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of Clinical Chemistry, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Pieter Langerhorst
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Patricia W C Bosman
- Department of Hematology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Yolanda B de Rijke
- Department of Clinical Chemistry, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Sonja Zweegman
- Department of Hematology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Martijn VanDuijn
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Theo Luider
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Niels W C J van de Donk
- Department of Hematology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Joannes F M Jacobs
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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20
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Kirchhoff DC, Murata K, Thoren KL. Use of a Daratumumab-Specific Immunofixation Assay to Assess Possible Immunotherapy Interference at a Major Cancer Center: Our Experience and Recommendations. J Appl Lab Med 2021; 6:1476-1483. [PMID: 34293131 DOI: 10.1093/jalm/jfab055] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 05/03/2021] [Indexed: 11/12/2022]
Abstract
BACKGROUND The incorporation of monoclonal antibodies, such as daratumumab, into multiple myeloma treatment regimens has led to the issue of false-positive interference in both serum protein electrophoresis (SPEP) and immunofixation (IF). The Hydrashift assay removes daratumumab interference from IF, allowing for correct interpretation. Here, we retrospectively examined the use of the Hydrashift assay at a large cancer center and provide guidelines on its most appropriate use. METHODS 38 patients with distinct daratumumab peaks on their SPEP were selected and were used to quantify the daratumumab peak on SPEP using the Sebia Phoresis software. A retrospective review of all Hydrashift assays ordered at our institution from July 2018 to March 2020 was performed. Data collected included patient clone type, IF migration patterns, and Hydrashift result. Serial quantification of SPEP results was performed as the corresponding IF transitioned from a true positive to a false positive. RESULTS Daratumumab adds a maximum magnitude of 0.20 g/dL on SPEP. Serial SPEP quantification showed IF transitioned from true positive to false positive when M-spikes ranged from 0.09 g/dL to 0.11 g/dL. Over 20 months, our laboratory performed 280 Hydrashift assays on 96 patients, 43/96 of whom had comigrating daratumumab/IgG-K IF bands. CONCLUSIONS The Hydrashift assay is typically unnecessary in patients with large M-spikes, >0.25 g/dL, regardless of clone type. When patient history is available, we recommend the Hydrashift assay be used in patients with comigrating daratumumab/IgG-K bands with M-spikes of <0.25 g/dL.
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Affiliation(s)
- Daniel C Kirchhoff
- Clinical Chemistry Service, Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kazunori Murata
- Clinical Chemistry Service, Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Katie L Thoren
- Clinical Chemistry Service, Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
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21
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Liu L, Wertz WJ, Kondisko A, Shurin MR, Wheeler SE. Incidence and Management of Therapeutic Monoclonal Antibody Interference in Monoclonal Gammopathy Monitoring. J Appl Lab Med 2021; 5:29-40. [PMID: 32445341 DOI: 10.1373/jalm.2019.029009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 05/28/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND The treatment of multiple myeloma (MM) has been revolutionized by the introduction of therapeutic monoclonal antibodies (tmAbs). Daratumumab, a human IgG1/κ tmAb against CD38 on plasma cells, has improved overall survival in refractory MM and was recently approved as a frontline therapy for MM. Work on tmAb interference with serum protein electrophoresis (SPE) during MM monitoring has failed to provide information for laboratories on incidence of interference and effective methods of managing the interference at a practicable level. We aimed to evaluate daratumumab and elotuzumab interference in a large academic hospital setting and implement immediate solutions. METHODS We identified and chart reviewed all cases of possible daratumumab interference by electrophoretic pattern (120 of 1317 total cases over 3 months). We retrospectively reviewed SPE cases in our laboratory to assess clinical implications of tmAb interference before the laboratory was aware of tmAb treatment. We supplemented samples with daratumumab and elotuzumab to determine the limits of detection and run free light chain analysis. RESULTS Approximately 9% (120 of 1317) of tested cases have an SPE and/or immunofixation electrophoresis (IFE) pattern consistent with daratumumab, but only approximately 47% (56) of these cases were associated with daratumumab therapy. Presence of daratumumab led to physician misinterpretation of SPE/IFE results. Limits of daratumumab detection varied with total serum gammaglobulin concentrations, but serum free light chain analysis was unaffected. CONCLUSIONS Clinical laboratories currently rely on interference identification by electrophoretic pattern, which may be insufficient and is inefficient. Critical tools in preventing misinterpretation efficiently include physician education, pharmacy notifications, separate order codes, and interpretive comments.
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Affiliation(s)
- Li Liu
- Department of Pathology, Division of Clinical Immunopathology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - William J Wertz
- Department of Enterprise Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Anthony Kondisko
- Department of Enterprise Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Michael R Shurin
- Department of Pathology, Division of Clinical Immunopathology, University of Pittsburgh Medical Center, Pittsburgh, PA.,Department of Immunology, University of Pittsburgh Medical Center, Pittsburgh, PA.,Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Sarah E Wheeler
- Department of Pathology, Division of Clinical Immunopathology, University of Pittsburgh Medical Center, Pittsburgh, PA.,Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA
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22
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Abstract
The diagnosis of myeloma and other plasma cell disorders has traditionally been done with the aid of electrophoretic methods, whereas amyloidosis has been characterized by immunohistochemistry. Mass spectrometry has recently been established as an alternative to these traditional methods and has been proved to bring added benefit for patient care. These newer mass spectrometry-based methods highlight some of the key advantages of modern proteomic methods and how they can be applied to the routine care of patients.
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Affiliation(s)
- David L Murray
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA.
| | - Surendra Dasari
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
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Dimopoulos M, Bringhen S, Anttila P, Capra M, Cavo M, Cole C, Gasparetto C, Hungria V, Jenner M, Vorobyev V, Ruiz EY, Yin JY, Saleem R, Hellet M, Macé S, Paiva B, Vij R. Isatuximab as monotherapy and combined with dexamethasone in patients with relapsed/refractory multiple myeloma. Blood 2021; 137:1154-1165. [PMID: 33080623 PMCID: PMC7933767 DOI: 10.1182/blood.2020008209] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 09/18/2020] [Indexed: 01/09/2023] Open
Abstract
This phase 2 study evaluated isatuximab as monotherapy or combined with dexamethasone in relapsed/refractory multiple myeloma (RRMM). Patients had RRMM refractory to an immunomodulatory drug (IMiD) and a proteasome inhibitor (PI) or had received ≥3 prior lines of therapy incorporating an IMiD and PI. Patients received isatuximab either as monotherapy (20 mg/kg on days 1, 8, 15, and 22 [once weekly] of cycle 1 followed by 20 mg/kg on days 1 and 15 of subsequent cycles; Isa group) or in combination with dexamethasone (40 mg/d [20 mg/d in patients aged ≥75 years] once weekly; Isa-dex group). Treated patients (N = 164) had received a median of 4 (range, 2-10) prior treatment lines. Patients received a median of 5 (1-24) and 7 (1-22) treatment cycles; at data cutoff, 13 (11.9%) of 109 and 15 (27.3%) of 55 patients remained on treatment in the Isa and Isa-dex arms, respectively. Overall response rate (primary efficacy end point) was 23.9% in the Isa arm and 43.6% in the Isa-dex arm (odds ratio, 0.405; 95% confidence interval, 0.192-0.859; P = .008). Median progression-free survival and overall survival were 4.9 and 18.9 months for Isa, and 10.2 and 17.3 months for Isa-dex. Infusion reactions (mostly grade 1/2) and hematologic abnormalities were the most common adverse events. There was a similar incidence of grade 3 or higher infections in both groups (22.0% and 21.8%). In conclusion, addition of dexamethasone to isatuximab increased response rates and survival outcomes with no detrimental effect on safety. This trial was registered at www.clinicaltrials.gov as #NCT01084252.
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Affiliation(s)
- Meletios Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Sara Bringhen
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Pekka Anttila
- Division of Hematology, Comprehensive Cancer Center, Helsinki University and Helsinki University Hospital, Helsinki, Finland
| | | | - Michele Cavo
- "Seràgnoli" Institute of Hematology, Sant'Orsola-Malpighi University Hospital, Bologna, Italy
| | - Craig Cole
- Division of Hematology and Oncology, University of Michigan Comprehensive Cancer Center, Ann Arbor, MI
| | - Cristina Gasparetto
- Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, NC
| | - Vania Hungria
- Department of Hematology, Clínica São Germano, São Paulo, Brazil
| | - Matthew Jenner
- Department of Haematology, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | | | | | | | | | | | | | - Bruno Paiva
- Clinica Universidad de Navarra, Centro de Investigación Médica Aplicada (CIMA), Instituto de Investigación Sanitaria de Navarra (IdiSNA), CIBER-ONC number CB16/12/00369, Pamplona, Spain; and
| | - Ravi Vij
- Division of Medical Oncology, Washington University, St. Louis, MO
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Using MALDI-TOF mass spectrometry in peripheral blood for the follow up of newly diagnosed multiple myeloma patients treated with daratumumab-based combination therapy. Clin Chim Acta 2021; 516:136-141. [PMID: 33545108 DOI: 10.1016/j.cca.2021.01.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 12/31/2020] [Accepted: 01/25/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Daratumumab-based combination therapies have shown high rates of complete response (CR) and minimal residual disease negativity in patients with multiple myeloma. However, daratumumab, an IgGκ monoclonal antibody, interferes with electrophoretic techniques making it difficult to reliably define residual disease versus CR, especially in patients with IgGκ multiple myeloma. METHODS Enrichment with polyclonal sheep antibody-coated magnetic microparticles combined with MALDI-TOF mass spectrometry (MALDI-TOF MS) analysis was used to detect M-proteins in serial samples from newly diagnosed multiple myeloma patients treated with daratumumab-based therapy. The performance of the MALDI-TOF MS assay was compared to that of a routine test panel (serum protein electrophoresis (SPEP), immunofixation (IFE) and serum free light chain (FLC)). RESULTS Comparison of MALDI-TOF MS to SPEP/IFE/FLC showed a concordance of 84.9% (p < 0.001). When MALDI-TOF MS and FLC results were combined, the M-protein detection rate was the same or better than the routine test panel. For the 9 patients who obtained CR during follow-up, MALDI-TOF MS detected an M-protein in 46% of subsequent samples. Daratumumab could be distinguished from the M-protein in 215/222 samples. CONCLUSION MALDI-TOF MS is useful in assessing CR in patients treated with monoclonal antibody-based therapies.
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Chen S, Kiguchi T, Nagata Y, Tamai Y, Ikeda T, Kajiya R, Ono T, Sugiyama D, Nishikawa H, Akatsuka Y. A simple method to distinguish residual elotuzumab from monoclonal paraprotein in immunofixation assays for multiple myeloma patients. Int J Hematol 2021; 113:473-479. [PMID: 33507526 DOI: 10.1007/s12185-021-03088-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 01/14/2021] [Accepted: 01/15/2021] [Indexed: 11/24/2022]
Abstract
Negative immunofixation electrophoresis (IFE) of serum and/or urine is a diagnostic marker for determining a complete response (CR) after immunotherapy for multiple myeloma (MM). However, residual therapeutic antibodies such as elotuzumab (IgG-κ), can compromise IFE evaluation when the affected immunoglobulins belong to the same IgG-κ subclass. We thus sought to develop a simple and rapid method to treat patient serum before IFE to distinguish the residual elotuzumab. Serum samples from patients receiving elotuzumab were treated with a predetermined amount of soluble signaling lymphocyte activation molecule F7 (SLAMF7) protein and then subjected to conventional IFE testing. We tested our method in samples from 12 patients. The IgG-κ band in IFE disappeared or shifted after elotuzumab treatment in four patients with no bone marrow minimal residual disease and normalized free light chain, whereas seven patients with any sign of residual MM showed a remaining IgG-κ band after treatment. One-hour incubation of samples with 6-9 molar excess soluble SLAMF7 before IFE was sufficient to distinguish residual elotuzumab in 11 of 12 samples. This simple method does not require special reagents, can be performed in most clinical laboratories, and enables differentiation between patients with a CR and those requiring further treatment.
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Affiliation(s)
- Shurui Chen
- Department of Immunology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Toru Kiguchi
- Department of Hematology, Chugoku Central Hospital, Fukuyama, Japan
| | - Yasuyuki Nagata
- Division of Hematology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yotaro Tamai
- Division of Hematology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Takeshi Ikeda
- Division of Hematology and Stem Cell Transplantation, Shizuoka Cancer Center, Shizuoka, Japan
| | - Ryoko Kajiya
- Department of Immunology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Takaaki Ono
- Division of Hematology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Daisuke Sugiyama
- Department of Immunology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Hiroyoshi Nishikawa
- Department of Immunology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Yoshiki Akatsuka
- Department of Immunology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan.
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Santockyte R, Puig O, Zheng N, Ouyang Z, Titsch C, Zhang YJ, Pillutla R, Zeng J. High-Throughput Therapeutic Antibody Interference-Free High-Resolution Mass Spectrometry Assay for Monitoring M-Proteins in Multiple Myeloma. Anal Chem 2020; 93:834-842. [DOI: 10.1021/acs.analchem.0c03357] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Rasa Santockyte
- Department of Translational Medicine, Bristol Myers Squibb, Route 206 and Province Line Road, Princeton, New Jersey 08543, United States
| | - Oscar Puig
- Department of Translational Medicine, Bristol Myers Squibb, Route 206 and Province Line Road, Princeton, New Jersey 08543, United States
| | - Naiyu Zheng
- Department of Translational Medicine, Bristol Myers Squibb, Route 206 and Province Line Road, Princeton, New Jersey 08543, United States
| | - Zheng Ouyang
- Department of Translational Medicine, Bristol Myers Squibb, Route 206 and Province Line Road, Princeton, New Jersey 08543, United States
| | - Craig Titsch
- Department of Translational Medicine, Bristol Myers Squibb, Route 206 and Province Line Road, Princeton, New Jersey 08543, United States
| | - Yang J. Zhang
- Department of Translational Medicine, Bristol Myers Squibb, Route 206 and Province Line Road, Princeton, New Jersey 08543, United States
| | - Renuka Pillutla
- Department of Translational Medicine, Bristol Myers Squibb, Route 206 and Province Line Road, Princeton, New Jersey 08543, United States
| | - Jianing Zeng
- Department of Translational Medicine, Bristol Myers Squibb, Route 206 and Province Line Road, Princeton, New Jersey 08543, United States
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Singh G. Serum and Urine Protein Electrophoresis and Serum-Free Light Chain Assays in the Diagnosis and Monitoring of Monoclonal Gammopathies. J Appl Lab Med 2020; 5:1358-1371. [PMID: 33150391 DOI: 10.1093/jalm/jfaa153] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 08/14/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Laboratory methods for diagnosis and monitoring of monoclonal gammopathies have evolved to include serum and urine protein electrophoresis, immunofixation electrophoresis, capillary zone electrophoresis, and immunosubtraction, serum-free light chain assay, mass spectrometry, and newly described QUIET. CONTENT This review presents a critical appraisal of the test methods and reporting practices for the findings generated by the tests for monoclonal gammopathies. Recommendations for desirable practices to optimize test selection and provide value-added reports are presented. The shortcomings of the serum-free light chain assay are highlighted, and new assays for measuring monoclonal serum free light chains are addressed. SUMMARY The various assays for screening, diagnosis, and monitoring of monoclonal gammopathies should be used in an algorithmic approach to avoid unnecessary testing. Reporting of the test results should be tailored to the clinical context of each individual patient to add value. Caution is urged in the interpretation of results of serum-free light chain assay, kappa/lambda ratio, and myeloma defining conditions. The distortions in serum-free light chain assay and development of oligoclonal bands in patients' status post hematopoietic stem cell transplants is emphasized and the need to note the location of original monoclonal Ig is stressed. The need for developing criteria that consider the differences in the biology of kappa and lambda light chain associated lesions is stressed. A new method of measuring monoclonal serum-free light chains is introduced. Reference is also made to a newly defined entity of light chain predominant intact immunoglobulin monoclonal gammopathy. The utility of urine testing in the diagnosis and monitoring of light chain only lesions is emphasized.
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Affiliation(s)
- Gurmukh Singh
- Medical College of Georgia, Augusta University, Augusta, GA
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28
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Zajec M, Langerhorst P, VanDuijn MM, Gloerich J, Russcher H, van Gool AJ, Luider TM, Joosten I, de Rijke YB, Jacobs JFM. Mass Spectrometry for Identification, Monitoring, and Minimal Residual Disease Detection of M-Proteins. Clin Chem 2020; 66:421-433. [PMID: 32031591 DOI: 10.1093/clinchem/hvz041] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 09/13/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Monoclonal gammopathies (MGs) are plasma cell disorders defined by the clonal expansion of plasma cells, resulting in the characteristic excretion of a monoclonal immunoglobulin (M-protein). M-protein detection and quantification are integral parts of the diagnosis and monitoring of MGs. Novel treatment modalities impose new challenges on the traditional electrophoretic and immunochemical methods that are routinely used for M-protein diagnostics, such as interferences from therapeutic monoclonal antibodies and the need for increased analytical sensitivity to measure minimal residual disease. CONTENT Mass spectrometry (MS) is ideally suited to accurate mass measurements or targeted measurement of unique clonotypic peptide fragments. Based on these features, MS-based methods allow for the analytically sensitive measurement of the patient-specific M-protein. SUMMARY This review provides a comprehensive overview of the MS methods that have been developed recently to detect, characterize, and quantify M-proteins. The advantages and disadvantages of using these techniques in clinical practice and the impact they will have on the management of patients with MGs are discussed.
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Affiliation(s)
- M Zajec
- Department of Clinical Chemistry, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.,Department of Neurology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - P Langerhorst
- Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - M M VanDuijn
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - J Gloerich
- Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - H Russcher
- Department of Clinical Chemistry, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - A J van Gool
- Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - T M Luider
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - I Joosten
- Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Y B de Rijke
- Department of Clinical Chemistry, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - J F M Jacobs
- Department of Laboratory Medicine, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
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A dose-finding Phase 2 study of single agent isatuximab (anti-CD38 mAb) in relapsed/refractory multiple myeloma. Leukemia 2020; 34:3298-3309. [PMID: 32409691 PMCID: PMC7685976 DOI: 10.1038/s41375-020-0857-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 04/27/2020] [Accepted: 04/29/2020] [Indexed: 11/08/2022]
Abstract
A Phase 2 dose-finding study evaluated isatuximab, an anti-CD38 monoclonal antibody, in relapsed/refractory multiple myeloma (RRMM; NCT01084252). Patients with ≥3 prior lines or refractory to both immunomodulatory drugs and proteasome inhibitors (dual refractory) were randomized to isatuximab 3 mg/kg every 2 weeks (Q2W), 10 mg/kg Q2W(2 cycles)/Q4W, or 10 mg/kg Q2W. A fourth arm evaluated 20 mg/kg QW(1 cycle)/Q2W. Patients (N = 97) had a median (range) age of 62 years (38–85), 5 (2–14) prior therapy lines, and 85% were double refractory. The overall response rate (ORR) was 4.3, 20.0, 29.2, and 24.0% with isatuximab 3 mg/kg Q2W, 10 mg/kg Q2W/Q4W, 10 mg/kg Q2W, and 20 mg/kg QW/Q2W, respectively. At doses ≥10 mg/kg, median progression-free survival and overall survival were 4.6 and 18.7 months, respectively, and the ORR was 40.9% (9/22) in patients with high-risk cytogenetics. CD38 receptor density was similar in responders and non-responders. The most common non-hematologic adverse events (typically grade ≤2) were nausea (34.0%), fatigue (32.0%), and upper respiratory tract infections (28.9%). Infusion reactions (typically with first infusion and grade ≤2) occurred in 51.5% of patients. In conclusion, isatuximab is active and generally well tolerated in heavily pretreated RRMM, with greatest efficacy at doses ≥10 mg/kg.
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30
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Martins CO, Huet S, Yi SS, Ritorto MS, Landgren O, Dogan A, Chapman JR. Mass Spectrometry-Based Method Targeting Ig Variable Regions for Assessment of Minimal Residual Disease in Multiple Myeloma. J Mol Diagn 2020; 22:901-911. [PMID: 32302778 DOI: 10.1016/j.jmoldx.2020.04.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 03/25/2020] [Accepted: 04/01/2020] [Indexed: 12/11/2022] Open
Abstract
Multiple myeloma is a systemic malignancy of monoclonal plasma cells that accounts for 10% of hematologic cancers. With development of highly effective therapies for multiple myeloma, minimal residual disease (MRD) assessment has emerged as an important end point for management decisions. Currently, serologic assays lack the sensitivity for MRD assessment, and invasive bone marrow sampling with flow cytometry or molecular methods has emerged as the gold standard. We report a sensitive and robust targeted mass spectrometry proteomics method to detect MRD in serum, without the need of invasive, sequential bone marrow aspirates. The method detects Ig-derived clonotypic tryptic peptides predicted by sequencing the clonal plasma cell Ig genes. A heavy isotope-labeled Ig internal standard is added to patient serum at a known concentration, the Ig is enriched in a light chain type specific manner, and proteins are digested and analyzed by targeted mass spectrometry. Peptides from the constant regions of the λ or κ light chains, Ig heavy chains, and clonotypic peptides unique to the patient monoclonal Igs are targeted. This technique is highly sensitive and specific for the patient-specific monoclonal Igs, even in samples negative by multiparametric flow cytometry. Our method can accurately and precisely detect monoclonal protein in serum of patients treated for myeloma and has broad implications for management of hematologic patients.
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Affiliation(s)
- Carlo O Martins
- Hematopathology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sarah Huet
- Hematopathology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - San S Yi
- Hematopathology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Maria S Ritorto
- Hematopathology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ola Landgren
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ahmet Dogan
- Hematopathology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jessica R Chapman
- Hematopathology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.
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Complete Depletion of Daratumumab Interference in Serum Samples from Plasma Cell Myeloma Patients Improves the Detection of Endogenous M-Proteins in a Preliminary Study. Diagnostics (Basel) 2020; 10:diagnostics10040219. [PMID: 32295157 PMCID: PMC7235820 DOI: 10.3390/diagnostics10040219] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 03/11/2020] [Accepted: 04/08/2020] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Therapeutic humanized IgG1 kappa monoclonal antibody (t-mAb), daratumumab (DARA) is a Food and Drug Administration approved drug for the treatment of relapsed/refractory plasma cell myeloma (PCM). DARA appears on serum protein electrophoresis (SPEP) and on serum immunofixation (sIFE) as an IgG kappa monoclonal immunoglobulin protein (M-protein), complicating the assessment of the patients' response to therapy. A more ominous threat to patient safety can occur with the misinterpretation of the presence of a small t-mAb spike as being the residual product of the patient's neoplastic clone, presented either as oligoclonality or new clonality, which could result in incorrect interpretation of failure to achieve remission. METHODS In this report, we describe a novel and cost-effective technique based on biotinylated recombinant CD38 and streptavidin-coated magnetic beads to capture and remove residual DARA present in PCM patient serum samples. The treated samples are then run like regular samples on SPEP and sIFE. We validated this simple technique in DARA-spiked PCM samples and patient samples on DARA treatment. RESULTS Our simple capture technique completely extracted DARA in all of the tested serum specimens and allowed the assessment of residual M-protein without DARA interference. The results were reproducible and highly specific for DARA, and did not have any impact on endogenous M-protein migration and quantification by SPEP and sIFE. The cost of this technique is much lower and it can be performed in-house with a very short turnaround time compared to the currently available alternative methods. There is a great need for such reflex technologies to avoid interpretation errors. CONCLUSIONS This method is an effective way to eliminate DARA interference in SPEP and sIFE, and can be easily implemented in any clinical laboratory without any patent restriction. This simple technique can be adopted for other t-mAbs using their respective ligands and will help to reduce additional doses of toxic treatment and further testing in patients on t-mAbs with a false positive M-protein spike.
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Ho M, Bianchi G, Anderson KC. Proteomics-inspired precision medicine for treating and understanding multiple myeloma. EXPERT REVIEW OF PRECISION MEDICINE AND DRUG DEVELOPMENT 2020; 5:67-85. [PMID: 34414281 DOI: 10.1080/23808993.2020.1732205] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Introduction Remarkable progress in molecular characterization methods has led to significant improvements in how we manage multiple myeloma (MM). The introduction of novel therapies has led to significant improvements in overall survival over the past 10 years. However, MM remains incurable and treatment choice is largely based on outdated risk-adaptive strategies that do not factor in improved treatment outcomes in the context of modern therapies. Areas covered This review discusses current risk-adaptive strategies in MM and the clinical application of proteomics in the monitoring of treatment response, disease progression, and minimal residual disease (MRD). We also discuss promising biomarkers of disease progression, treatment response, and chemoresistance. Finally, we will discuss an immunomics-based approach to monoclonal antibody (mAb), vaccine, and CAR-T cell development. Expert opinion It is an exciting era in oncology with basic scientific knowledge translating in novel therapeutic approaches to improve patient outcomes. With the advent of effective immunotherapies and targeted therapies, it has become crucial to identify biomarkers to aid in the stratification of patients based on anticipated sensitivity to chemotherapy. As a paradigm of diseases highly dependent on protein homeostasis, multiple myeloma provides the perfect opportunity to investigate the use of proteomics to aid in precision medicine.
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Affiliation(s)
- Matthew Ho
- UCD School of Medicine, College of Health and Agricultural Sciences, University College Dublin, Dublin, Ireland
| | - Giada Bianchi
- LeBow Institute for Myeloma Therapeutics and Jerome Lipper Multiple Myeloma Center, Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Kenneth C Anderson
- LeBow Institute for Myeloma Therapeutics and Jerome Lipper Multiple Myeloma Center, Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
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Implications for the monitoring of patients with multiple myeloma undergoing treatment with the anti-CD38 monoclonal daratumumab. Ann Clin Biochem 2019; 57:178-181. [DOI: 10.1177/0004563219894354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background The novel daratumumab immunotherapy is a human IgG1 kappa antibody targeted against CD38, which is almost universally expressed on myeloma plasma cells. Daratumumab has efficacy in clinical trials for the treatment of multiple myeloma; however, it complicates laboratory monitoring of the serological response to treatment, as it is detected by serum electrophoresis and/or immunofixation. Methods Laboratory reports of electrophoresis patterns serially performed in a single laboratory of six patients with relapsed multiple myeloma receiving daratumumab therapy as part a clinical trial were reviewed retrospectively. Results Post administration of daratumumab therapy, an additional band was visible by serum electrophoresis, migrating to the mid-gamma region, which was confirmed as IgG kappa by immunofixation. In five out of the six patients, this band was quantified at <2.0 g/L. For one patient, this band co-migrated with the patient’s disease paraprotein band, so both bands were quantified together. The appearance of an apparent second paraprotein band while receiving treatment for multiple myeloma can cause anxiety for patients, confusion for healthcare workers and may also underestimate complete remission rates. Conclusions The clinical laboratory must be aware of the interference of daratumumab in serum electrophoresis. Effective communication between clinicians and the laboratory is essential for the production of clinically valuable, non-misleading reports for these patients.
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Moore LM, Cho S, Thoren KL. MALDI-TOF mass spectrometry distinguishes daratumumab from M-proteins. Clin Chim Acta 2019; 492:91-94. [PMID: 30790545 PMCID: PMC6524149 DOI: 10.1016/j.cca.2019.02.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 02/08/2019] [Accepted: 02/17/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Daratumumab, a therapeutic IgG kappa monoclonal antibody, can cause a false positive interference on electrophoretic assays that are routinely used to monitor patients with monoclonal gammopathies. In this study, we evaluate the ability of matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) to distinguish daratumumab from disease-related IgG kappa monoclonal proteins (M-protein). METHODS Waste clinical samples from 31 patients who were receiving daratumumab and had a history of IgG kappa monoclonal gammopathy were collected. Immunoglobulins were purified from serum and analyzed by MALDI-TOF MS. Mass spectra were assessed for the presence of distinct monoclonal proteins. For samples in which only one monoclonal peak was identified near the expected m/z of daratumumab, the Hydrashift 2/4 Daratumumab Assay was used to confirm the presence of an M-protein. RESULTS Using MALDI-TOF MS, daratumumab could be distinguished from M-proteins in 26 out of 31 samples (84%). Results from 2 samples were inconclusive since the M-protein was not detected by the Hydrashift assay and may also be undetectable by MALDI-TOF MS. Comparatively, daratumumab was distinguishable from M-proteins in 14 out of 31 samples (45%) by immunofixation. CONCLUSIONS MALDI-TOF MS offers greater specificity compared to immunofixation for distinguishing daratumumab from M-proteins.
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Affiliation(s)
- Lauren M Moore
- Clinical Chemistry Service, Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, 327 E. 64th St., New York, NY 10065, United States of America
| | - Sun Cho
- Clinical Chemistry Service, Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, 327 E. 64th St., New York, NY 10065, United States of America
| | - Katie L Thoren
- Clinical Chemistry Service, Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, 327 E. 64th St., New York, NY 10065, United States of America.
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35
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Chen PP, Tormey CA, Eisenbarth SC, Torres R, Richardson SS, Rinder HM, Smith BR, Siddon AJ. False-Positive Light Chain Clonal Restriction by Flow Cytometry in Patients Treated With Alemtuzumab: Potential Pitfalls for the Misdiagnosis of B-Cell Neoplasms. Am J Clin Pathol 2019; 151:154-163. [PMID: 30307483 DOI: 10.1093/ajcp/aqy129] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objectives To increase awareness of potential diagnostic test interference associated with alemtuzumab, which is a therapeutic immunoglobulin G1 κ monoclonal antibody used in hematologic malignancies, autoimmune diseases, and transplant-related disorders. Methods Bone marrow and blood from patients with T-cell prolymphocytic leukemia treated with alemtuzumab were evaluated by flow cytometry. Healthy donor blood was analyzed with or without in vitro treatment with alemtuzumab for comparison. Results Immunophenotypic analysis of bone marrow collected 4 weeks after alemtuzumab treatment demonstrated artifactual surface κ light chain restriction in CD19+ B cells and CD3+ T cells. Similar findings were observed in blood from another patient in a specimen collected 3 days after alemtuzumab treatment. These findings were recapitulated in healthy donor blood incubated with alemtuzumab. Conclusions Alemtuzumab can produce direct interference during flow cytometry analysis, resulting in false-positive evidence of light chain clonality. Clinicians and laboratorians should be cognizant of this risk to avoid misdiagnosis of B-cell neoplasms.
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Affiliation(s)
- Peter P Chen
- Department of Pathology, Yale School of Medicine, New Haven, CT
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT
| | - Christopher A Tormey
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT
- Pathology and Laboratory Medicine Service, VA Connecticut Healthcare System, West Haven
| | | | - Richard Torres
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT
| | - Susan S Richardson
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT
| | - Henry M Rinder
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT
| | - Brian R Smith
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT
| | - Alexa J Siddon
- Department of Pathology, Yale School of Medicine, New Haven, CT
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT
- Pathology and Laboratory Medicine Service, VA Connecticut Healthcare System, West Haven
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A universal solution for eliminating false positives in myeloma due to therapeutic monoclonal antibody interference. Blood 2018; 132:670-672. [DOI: 10.1182/blood-2018-05-848986] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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Tang F, Malek E, Math S, Schmotzer CL, Beck RC. Interference of Therapeutic Monoclonal Antibodies With Routine Serum Protein Electrophoresis and Immunofixation in Patients With Myeloma: Frequency and Duration of Detection of Daratumumab and Elotuzumab. Am J Clin Pathol 2018; 150:121-129. [PMID: 29901687 DOI: 10.1093/ajcp/aqy037] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES We investigated the frequency and pattern of detection of therapeutic monoclonal antibodies (t-mAbs) daratumumab and elotuzumab by routine serum protein electrophoresis (SPE) and immunofixation (IF) in treated patients with myeloma. METHODS Detection of t-mAb was assessed in 22 patients by retrospective review of SPE/IF ordered prior to, during, and after 26 individual courses of therapy. RESULTS t-mAb was distinguishable from M-protein in 16 of 26 courses, with daratumumab detected in nine of nine and elotuzumab in six of seven patients. t-mAb was detected on first follow-up SPE/IF in 12 patients, with earliest detection 7 days after therapy initiation and latest detection 70 days after therapy. t-mAb persisted throughout induction therapy in most patients, with loss of detection during maintenance daratumumab. CONCLUSIONS When distinguishable from M-protein, t-mAbs are detectable in 93% of treated patients as soon as 7 days after the initial dose and are consistently observed throughout induction therapy, warranting increased monitoring and careful interpretation of SPE/IF.
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Affiliation(s)
- Felicia Tang
- School of Medicine, Case Western Reserve University, Cleveland, OH
| | - Ehsan Malek
- School of Medicine, Case Western Reserve University, Cleveland, OH
- Department of Hematology/Oncology, University Hospitals of Cleveland Medical Center, Cleveland, OH
| | - Susan Math
- Department of Pathology, University Hospitals of Cleveland Medical Center, Cleveland, OH
| | - Christine L Schmotzer
- School of Medicine, Case Western Reserve University, Cleveland, OH
- Department of Pathology, University Hospitals of Cleveland Medical Center, Cleveland, OH
| | - Rose C Beck
- School of Medicine, Case Western Reserve University, Cleveland, OH
- Department of Pathology, University Hospitals of Cleveland Medical Center, Cleveland, OH
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Thoren KL, Pianko MJ, Maakaroun Y, Landgren CO, Ramanathan LV. Distinguishing Drug from Disease by Use of the Hydrashift 2/4 Daratumumab Assay. J Appl Lab Med 2018; 3:857-863. [PMID: 31639760 DOI: 10.1373/jalm.2018.026476] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 04/30/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Daratumumab, a monoclonal antibody used to treat relapsed or refractory multiple myeloma, can interfere with protein electrophoresis and immunofixation assays. False-positive immunofixation results due to daratumumab can cause uncertainty regarding the status of a patient's disease and lead to potential misclassification of their response to therapy. The Hydrashift 2/4 Daratumumab assay (Sebia) was recently cleared by the Food and Drug Administration for resolving daratumumab interference on immunofixation. Here, we evaluate the performance of the Hydrashift assay in multiple myeloma patients receiving treatment with daratumumab-based regimens. METHODS Waste serum samples from multiple myeloma patients (n = 40) receiving daratumumab were analyzed by standard immunofixation and the Hydrashift assay. Results from these tests were compared and were evaluated along with pretreatment serum protein electrophoresis and immunofixation results, if available. RESULTS The Hydrashift assay shifted the migration of daratumumab in patient samples. In 27 cases, the patient's M protein was distinguishable from daratumumab by standard immunofixation. In these cases, the Hydrashift assay confirmed that the IgGκ band was daratumumab and helped identify the presence of treatment-related oligoclonal bands. There were 11 instances in which the patient's IgGκ M protein comigrated with daratumumab. In all 11 cases, the Hydrashift assay confirmed the presence of residual M protein. Finally, in 2 patients whose pretreatment immunofixation results were not available, the Hydrashift assay confirmed that the IgGκ band visible on immunofixation was due to daratumumab alone. CONCLUSIONS The Hydrashift 2/4 Daratumumab assay is a useful tool to clarify the source of an IgGκ band on immunofixation and allow a patient's M protein to be viewed without interference.
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Affiliation(s)
- Katie L Thoren
- Clinical Chemistry Service, Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY;
| | - Matthew J Pianko
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - C Ola Landgren
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Lakshmi V Ramanathan
- Clinical Chemistry Service, Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
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Thoren KL. Mass spectrometry methods for detecting monoclonal immunoglobulins in multiple myeloma minimal residual disease. Semin Hematol 2018; 55:41-43. [PMID: 29759153 DOI: 10.1053/j.seminhematol.2018.02.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 02/21/2018] [Indexed: 01/24/2023]
Abstract
Mass spectrometry methods that can detect low levels of monoclonal immunoglobulin in serum have recently been developed. These assays are based on the principle that each immunoglobulin has a unique amino acid sequence and therefore, has a unique mass. This mass can be used as a surrogate marker in order to monitor a patient's disease over time and at low levels. Here, we explain these methods, discuss their advantages and disadvantages and how they may be used to monitor monoclonal immunoglobulins for minimal residual disease detection in multiple myeloma.
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Affiliation(s)
- Katie L Thoren
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY.
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Tate JR, Keren DF, Mollee P. A global call to arms for clinical laboratories – Harmonised quantification and reporting of monoclonal proteins. Clin Biochem 2018; 51:4-9. [DOI: 10.1016/j.clinbiochem.2017.11.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 11/05/2017] [Accepted: 11/13/2017] [Indexed: 12/11/2022]
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Genzen JR, Murray DL, Abel G, Meng QH, Baltaro RJ, Rhoads DD, Delgado JC, Souers RJ, Bashleben C, Keren DF, Ansari MQ. Screening and Diagnosis of Monoclonal Gammopathies: An International Survey of Laboratory Practice. Arch Pathol Lab Med 2017; 142:507-515. [DOI: 10.5858/arpa.2017-0128-cp] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context.—
Serum tests used for the screening and diagnosis of monoclonal gammopathies include serum protein electrophoresis (SPE; agarose gel or capillary zone), immunofixation (IFE) and immunosubtraction capillary electrophoresis, serum free light chains, quantitative immunoglobulins, and heavy/light–chain combinations. Urine protein electrophoresis and urine IFE may also be used to identify Bence-Jones proteinuria.
Objective.—
To assess current laboratory practice for monoclonal gammopathy testing.
Design.—
In April 2016, a voluntary questionnaire was distributed to 923 laboratories participating in a protein electrophoresis proficiency testing survey.
Results.—
Seven hundred seventy-four laboratories from 38 countries and regions completed the questionnaire (83.9% response rate; 774 of 923). The majority of participants (68.6%; 520 of 758) used agarose gel electrophoresis as their SPE method, whereas 31.4% (238 of 758) used capillary zone electrophoresis. The most common test approaches used in screening were SPE with reflex to IFE/immunosubtraction capillary electrophoresis (39.3%; 299 of 760); SPE only (19.1%; 145 of 760); SPE and IFE or immunosubtraction capillary electrophoresis (13.9%; 106 of 760); and SPE with IFE, serum free light chain, and quantitative immunoglobulins (11.8%; 90 of 760). Only 39.8% (305 of 767) of laboratories offered panel testing for ordering convenience. Although SPE was used by most laboratories in diagnosing new cases of myeloma, when laboratories reported the primary test used to follow patients with monoclonal gammopathy, only 55.7% (403 of 724) chose SPE, with the next most common selections being IFE (18.9%; 137 of 724), serum free light chain (11.7%; 85 of 724), and immunosubtraction capillary electrophoresis (2.1%; 15 of 724).
Conclusions.—
Ordering and testing practices for the screening and diagnosis of monoclonal gammopathy vary widely across laboratories. Improving utilization management and report content, as well as recognition and development of laboratory-directed testing guidelines, may serve to enhance the clinical value of testing.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Mohammad Q. Ansari
- From the Department of Pathology, University of Utah, Salt Lake City, and ARUP Laboratories, Salt Lake City, Utah (Drs Genzen and Delgado); the Department of Laboratory Medicine, Mayo Clinic, Rochester, Minnesota (Dr Murray); the Department of Laboratory Medicine, Lahey Hospital & Medical Center, Burlington, Massachusetts (Dr Abel); the Department of Laboratory Medicine, University of Texas MD An
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Offidani M, Corvatta L. A review discussing elotuzumab and its use in the second-line plus treatment of multiple myeloma. Future Oncol 2017; 14:319-329. [PMID: 29091475 DOI: 10.2217/fon-2017-0371] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Monoclonal antibodies (mAb) represent a new frontier to treat newly diagnosed and relapsed-refractory multiple myeloma (MM). Elotuzumab, an mAb targeted SLAM7 in the plasma cells and natural killer cells surface, is the first mAb approved for the treatment of relapsed-refractory MM in combination with lenalidomide and dexamethasone. This approval was the final result of several preclinical and Phase I-II clinical studies leading to ELOQUENT-2 Phase III trial that demonstrated that elotuzumab adds a significant and durable value to standard therapy, paved the way of this new treatment strategy for MM. In this review we will describe elotuzumab mechanisms of action, clinical pharmacology and clinical studies that have led to these developments.
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Affiliation(s)
- Massimo Offidani
- Clinica di Ematologia Azienda Ospedaliero-Universitaria Ospedali Riuniti di Ancona, Ancona, Italy
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Zhang Z, Hu W, Li L, Ding H, Li H. Therapeutic monoclonal antibodies and clinical laboratory tests: When, why, and what is expected? J Clin Lab Anal 2017; 32. [PMID: 28810082 DOI: 10.1002/jcla.22307] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 07/22/2017] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND We herein provide an overview of the clinical laboratory tests that should be performed before, during and after using therapeutic monoclonal antibodies (mAbs) and the clinical laboratory tests that may be affected by mAbs. METHODS The labels of FDA-approved therapeutic mAbs were downloaded from DailyMed (the official website for drug labels) and were used as the sources of data for this review. RESULTS It was found that most of the labels provided information relevant to the clinical laboratory tests, including the tests needed before mAbs treatment to check the patients' background status and to identify potentially sensitive patients, the tests needed during or after the treatment to evaluate the patients' response, and the mAbs that may lead to false positive or negative results for clinical laboratory tests. CONCLUSIONS The present findings will be of interest to physicians, laboratory scientists, those involved in drug development and surveillance and individuals making health care policy.
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Affiliation(s)
- Zhanhu Zhang
- Institute of Medical Genetics and Reproductive Medicine, Nantong Maternity and Child Health Hospital, Nantong, Jiangsu, China
| | - Wenjie Hu
- Department of Clinical Laboratory Medicine, Nantong Maternal and Child Health Hospital, Nantong, Jiangsu, China
| | - Linlin Li
- Department of Clinical Laboratory Medicine, Nantong Maternal and Child Health Hospital, Nantong, Jiangsu, China
| | | | - Haibo Li
- Department of Clinical Laboratory Medicine, Nantong Maternal and Child Health Hospital, Nantong, Jiangsu, China
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Singh G. Oligoclonal Pattern/Abnormal Protein Bands in Post-Treatment Plasma Cell Myeloma Patients: Implications for Protein Electrophoresis and Serum Free Light Chain Assay Results. J Clin Med Res 2017; 9:671-679. [PMID: 28725315 PMCID: PMC5505303 DOI: 10.14740/jocmr3049w] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2017] [Accepted: 05/02/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The impact of autologous stem cell transplantation (ASCT) in plasma cell myeloma patients on the frequency, quality, and timing of oligoclonal pattern in serum protein electrophoresis/immunofixation electrophoresis (SPEP/SIFE) and serum free light chain assay (SFLCA) was evaluated. METHODS Laboratory results and clinical data for 251 patients with plasma cell myeloma, who had SPEP/SIFE and/or SFLCA performed between January 2010 and December 2016 were reviewed. The results for SPEP/SIFE and SFLCA were compared in patients with ASCT to those without ASCT. The implications of oligoclonal pattern in interpretation of SPEP/SIFE and SFLCA - κ/λ ratio were addressed. RESULTS In 251 patients, a total of 3,134 observations, of either SPEP/SIFE and/or SFLCA, were reviewed. One hundred fifty-nine patients received ASCT. The incidence of oligoclonal patterns was significantly higher after ASCT. More than half of the oligoclonal patterns developed in the first year after transplantation. In 13 of the 84 patients with lambda chain restricted plasma cell myeloma, the κ/λ ratio was kappa dominant in the presence of oligoclonal pattern. There was no reversal of κ/λ ratio in patients with kappa chain restricted plasma cell myelomas. CONCLUSIONS ASCT is associated with significantly higher incidence of oligoclonal patterns than with chemotherapy alone. The presence of oligoclonal patterns has the potential to interfere with the interpretation of SPEP/SIFE and ascertainment of complete remission. At a minimum, the oligoclonal pattern caused an incorrect kappa dominant κ/λ ratio in 15.5% of patients with lambda chain restricted plasma cell myeloma. If a similar rate were to be applied to the 167 kappa chain myeloma patients, about 26 of these would have displayed an erroneous kappa chain dominant κ/λ ratio. The presence of oligoclonal pattern further degrades the performance of already dubious SFLCA. The need for recording the location of monoclonal spike in SPEP/SIFE and higher resolution protein electrophoresis methods are highlighted.
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Affiliation(s)
- Gurmukh Singh
- Department of Pathology, Medical College of Georgia at Augusta University, 1120 15th Street, BI 2008A, Augusta, GA 30912, USA.
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