1
|
Giles HV, Karunanithi K. Performance Characteristics and Limitations of the Available Assays for the Detection and Quantitation of Monoclonal Free Light Chains and New Emerging Methodologies. Antibodies (Basel) 2024; 13:19. [PMID: 38534209 DOI: 10.3390/antib13010019] [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: 02/01/2024] [Revised: 02/26/2024] [Accepted: 03/05/2024] [Indexed: 03/28/2024] Open
Abstract
Light chain measurements form an essential component of the testing strategy for the detection and monitoring of patients with suspected and/or proven plasma cell disorders. Urine-based electrophoretic assays remain at the centre of the international guidelines for response assessment but the supplementary role of serum-free light chain (FLC) assays in response assessment and the detection of disease progression due to their increased sensitivity has been increasingly recognised since their introduction in 2001. Serum FLC assays have also been shown to be prognostic across the spectrum of plasma cell disorders and are now incorporated into risk stratification scores for patients with monoclonal gammopathy of undetermined significance (MGUS), smouldering multiple myeloma, and light chain amyloidosis (AL amyloidosis), as well as being incorporated into the criteria for defining symptomatic multiple myeloma. There are now multiple different commercially available serum FLC assays available with differing performance characteristics, which are discussed in this review, along with the implications of these for patient monitoring. Finally, newer methodologies for the identification and characterisation of monoclonal FLC, including modifications to electrophoretic techniques, mass spectrometry-based assays and Amylite, are also described along with the relevant published data available regarding the performance of each assay.
Collapse
Affiliation(s)
- Hannah V Giles
- Department of Clinical Haematology, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2SY, UK
- Instute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
| | - Kamaraj Karunanithi
- Department of Clinical Haematology, University Hospitals North Midlands NHS Trust, Royal Stoke Hospital, Newcastle Road, Stoke-on-Trent ST4 6QG, UK
- School of Medicine, Keele University, Keele, Newcastle-under-Lyme ST5 5BG, UK
| |
Collapse
|
2
|
Jia Z, Xia J, Lu Q. Urine immunofixation electrophoresis and serum free light chain analyses benefit diagnosis of multiple myeloma in orthopedic patients with normal serum total proteins, creatinine, calcium, and hemoglobin. Lab Med 2023:lmad104. [PMID: 38141202 DOI: 10.1093/labmed/lmad104] [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: 12/25/2023] Open
Abstract
BACKGROUND A substantial number of patients with multiple myeloma (MM) who have bone destruction are initially admitted into the orthopedic service at the hospital. However, routine laboratory testing usually fails to identify these patients, thus delaying optimal therapy. Therefore, there is a clear medical need for early diagnosis of MM in these patients. METHODS Between 2019 and 2021, 42 patients receiving treatment for orthopedic conditions had normal hemoglobin (Hb), total protein (TP), albumin (ALB), creatinine (CREA), and blood calcium (Ca) levels before their surgical procedure(s) but were subsequently pathologically confirmed to have MM, based on their presenting orthopedic symptoms. During the same period, 52 patients with orthopedic conditions were pathologically excluded from the diagnosis of MM and were recruited into our control group. Serum free light chain (sFLC) testing was performed in 94 consecutive patients in the orthopedic service using Siemens N Latex FLC kits. The levels of Hb, TP, ALB, CREA, and Ca were also measured. All 42 patients with MM were divided into group A (n = 25: κ proliferation) and group B (n = 17: λ proliferation) by the pathology department. RESULTS There were no significant differences in levels of Hb, TP, ALB, CREA, and Ca between group A and group B and the control group. However, the sFLC κ/λ ratio of group A and B was also significantly different from that of the control group (P < .001). The results of serum immunofixation electrophoresis (IFE) testing demonstrated negative results in 14 cases (58.3%) in group A and 4 cases (25.0%) in group B. CONCLUSIONS Some patients with orthopedic conditions who do not have typical MM laboratory results, such as those with abnormal Hb, TP, ALB, CREA, and Ca levels before their operation(s), actually have MM. MM should be highly suspected in patients with unexplained bone lesions and with an abnormal sFLC κ/λ ratio. Further tissue or bone marrow biopsy is needed in these patients even if serum and urine IFE results are negative and light chain ratio is normal.
Collapse
Affiliation(s)
- Zhongwei Jia
- Clinical Laboratory Department, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jinxing Xia
- Clinical Laboratory Department, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Qiong Lu
- Clinical Laboratory Department, First Affiliated Hospital of Anhui Medical University, Hefei, China
| |
Collapse
|
3
|
Omosule CL, Hock KG, Dalton C, Scalpati A, Gronowski AM, Brants A, Farnsworth CW. Method Comparison and Workflow Differences Using the Same Free Light Chain Assay on 2 Analyzer Platforms. J Appl Lab Med 2023; 8:689-699. [PMID: 37186660 DOI: 10.1093/jalm/jfad020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 02/13/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND The Freelite assay (The Binding Site) is utilized to quantify serum immunoglobulin free light chains (sFLC), which is crucial for diagnosing and monitoring plasma cell dyscrasias (PCDs). Using the Freelite test, we compared methods and evaluated workflow differences across two analyzer platforms. METHODS sFLC concentrations were measured in 306 fresh serum specimens (cohort A) and 48 frozen specimens with documented sFLC >20 mg/dL (cohort B). Specimens were analyzed on the Roche cobas 8000 and Optilite analyzers using the Freelite κ and λ assays. Performance was compared using Deming regression. Workflow was compared by assessing turnaround time (TAT) and reagent usage. RESULTS For cohort A specimens, Deming regression revealed a slope of 1.04 (95% CI, 0.88-1.02) and an intercept of -0.77 (95% CI, -0.57 to 1.85) for sFLCκ and a slope of 0.90 (95% CI, -0.04 to 1.83) and intercept of 1.59 (95% CI, -3.12 to 6.25) for sFLCλ. Regression of the κ/λ ratio revealed a slope of 2.44 (95% CI, 1.47-3.41) and intercept of -8.13 (95% CI, -16.82 to 0.58) with a concordance kappa of 0.80 (95% CI, 0.69-0.92). The proportion of specimens with TAT >60 min was 0.33% and 8% for the Optilite and cobas, respectively (P < 0.001). The Optilite required 49 (P < 0.001) and 12 (P = 0.016) fewer tests for sFLCκ and sFLCλ relative to the cobas. Cohort B specimens showed similar but more dramatic results. CONCLUSIONS Analytical performance of the Freelite assays was comparable on the Optilite and cobas 8000 analyzers. In our study, the Optilite required less reagent, had a slightly reduced TAT, and eliminated manual dilutions for samples with sFLC concentrations >20 mg/dL.
Collapse
Affiliation(s)
- Catherine L Omosule
- Department of Pathology & Immunology, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
| | - Karl G Hock
- Department of Pathology & Immunology, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
| | - Claire Dalton
- Department of Pathology & Immunology, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
| | | | - Ann M Gronowski
- Department of Pathology & Immunology, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
| | - Aigars Brants
- The Binding Site, Inc., San Diego, CA, United States
| | - Christopher W Farnsworth
- Department of Pathology & Immunology, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
| |
Collapse
|
4
|
Yun SY, Rim JH, Park H, Kang H, Lee SG, Lim JB. Clinical implication by differential analytical performances of serum free light chain quantitation analysis using fully automated analyzers. Clin Chem Lab Med 2023; 61:1288-1299. [PMID: 37015073 DOI: 10.1515/cclm-2023-0050] [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: 07/18/2022] [Accepted: 03/14/2023] [Indexed: 04/06/2023]
Abstract
OBJECTIVES Free light chain (FLC) is used for the diagnosis and prediction with regard to the progression risk of plasma cell disorders and Freelite reagent using the SPAplus analyzer (The Binding Site) has been one of the widely used option. However, N Latex FLC reagent with the Atellica CH 930 analyzer (Siemens Healthineers) has shown the advantages of automation and high throughput. We aimed to evaluated clinical implication by differential analytical performances of two assays. METHODS A total of 322 serum samples were collected from 193 patients requested for FLC analysis including 131 multiple myeloma patients. The precision, linearity, dilution recovery of N Latex FLC assay was evaluated. We compared the two assays and analyzed the monomer-dimer pattern for discrepant results. RESULTS The precision, linearity, and dilution recovery performance was appropriate for the routine use in clinical laboratories. Despite the good correlation within normal range, proportional bias up-to 170% was observed in samples with high concentrations especially for lambda. The higher value samples with N Latex FLC assay contained more monomer forms than controls. All opposite changes of FLC burden by the N Latex FLC assay proved to present concordant dynamic changes when assessed by serum protein electrophoresis. CONCLUSIONS Clinical laboratories should be aware of the inter-assay variability of FLC quantitative measurements using different platforms, especially for high concentrations of both kappa and lambda measurements, possibly due to monomer/dimer ratio diversity. Clinical interpretations for multiple myeloma disease status might not be dramatically affected only when the same assay is utilized during follow-up periods.
Collapse
Affiliation(s)
- Shin Young Yun
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - John Hoon Rim
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hak Park
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hyein Kang
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Sang-Guk Lee
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jong-Baeck Lim
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Korea
| |
Collapse
|
5
|
Krieter DH, Rüth M, Lemke HD, Wanner C. Clinical performance comparison of two medium cut-off dialyzers. Ther Apher Dial 2023; 27:284-292. [PMID: 36858049 DOI: 10.1111/1744-9987.13919] [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: 04/25/2022] [Revised: 08/02/2022] [Accepted: 08/05/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Medium-cut-off (MCO) dialyzers may beneficially impact outcomes in patients on hemodialysis. METHODS In a randomized, controlled trial in maintenance hemodialysis patients, the new Nipro ELISIO-17HX MCO dialyzer was compared to the Baxter Theranova 400 filter regarding middle molecule removal. Furthermore, the suitability of two assays for free lambda-light chain (λFLC) detection (Freelite vs. N-Latex) was verified. RESULTS ELISIO-HX achieved slightly lower reduction ratios for β2 -microglobulin (71.8 ± 6.0 vs. 75.3 ± 5.8%; p = 0.001), myoglobin (54.7 ± 8.6 vs. 64.9 ± 8.7%; p < 0.001), and kappa-FLC (62.1 ± 8.8 vs. 56.3 ± 7.7%; p = 0.021). λFLC reduction ratios were more conclusive with the Freelite assay and not different between ELISIO-HX and Theranova (28.4 ± 3.9 vs. 38.7 ± 13.4%; p = 0.069). The albumin loss of Theranova was considerably higher (2.14 ± 0.45 vs. 0.77 ± 0.25 g; p = 0.001) and the Global Removal ScoreLoss alb largely inferior (30.6 ± 7.4 vs. 82.4 ± 29.2%/g; p = 0.006) to ELISIO-HX. CONCLUSIONS The new ELISIO-HX expands the choice of dialyzers for MCO hemodialysis.
Collapse
Affiliation(s)
- Detlef H Krieter
- Division of Nephrology, University Hospital Würzburg, Würzburg, Germany
| | | | | | - Christoph Wanner
- Division of Nephrology, University Hospital Würzburg, Würzburg, Germany
| |
Collapse
|
6
|
Cowan A, Ferrari F, Freeman SS, Redd R, El-Khoury H, Perry J, Patel V, Kaur P, Barr H, Lee DJ, Lightbody E, Downey K, Argyelan D, Theodorakakou F, Fotiou D, Liacos CI, Kanellias N, Chavda SJ, Ainley L, Sandecká V, Pospíšilová L, Minarik J, Jungova A, Radocha J, Spicka I, Nadeem O, Yong K, Hájek R, Kastritis E, Marinac CR, Dimopoulos MA, Get G, Trippa L, Ghobrial IM. Personalised progression prediction in patients with monoclonal gammopathy of undetermined significance or smouldering multiple myeloma (PANGEA): a retrospective, multicohort study. Lancet Haematol 2023; 10:e203-e212. [PMID: 36858677 PMCID: PMC9991855 DOI: 10.1016/s2352-3026(22)00386-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 11/30/2022] [Accepted: 12/02/2022] [Indexed: 03/03/2023]
Abstract
BACKGROUND Patients with precursors to multiple myeloma are dichotomised as having monoclonal gammopathy of undetermined significance or smouldering multiple myeloma on the basis of monoclonal protein concentrations or bone marrow plasma cell percentage. Current risk stratifications use laboratory measurements at diagnosis and do not incorporate time-varying biomarkers. Our goal was to develop a monoclonal gammopathy of undetermined significance and smouldering multiple myeloma stratification algorithm that utilised accessible, time-varying biomarkers to model risk of progression to multiple myeloma. METHODS In this retrospective, multicohort study, we included patients who were 18 years or older with monoclonal gammopathy of undetermined significance or smouldering multiple myeloma. We evaluated several modelling approaches for predicting disease progression to multiple myeloma using a training cohort (with patients at Dana-Farber Cancer Institute, Boston, MA, USA; annotated from Nov, 13, 2019, to April, 13, 2022). We created the PANGEA models, which used data on biomarkers (monoclonal protein concentration, free light chain ratio, age, creatinine concentration, and bone marrow plasma cell percentage) and haemoglobin trajectories from medical records to predict progression from precursor disease to multiple myeloma. The models were validated in two independent validation cohorts from National and Kapodistrian University of Athens (Athens, Greece; from Jan 26, 2020, to Feb 7, 2022; validation cohort 1), University College London (London, UK; from June 9, 2020, to April 10, 2022; validation cohort 1), and Registry of Monoclonal Gammopathies (Czech Republic, Czech Republic; Jan 5, 2004, to March 10, 2022; validation cohort 2). We compared the PANGEA models (with bone marrow [BM] data and without bone marrow [no BM] data) to current criteria (International Myeloma Working Group [IMWG] monoclonal gammopathy of undetermined significance and 20/2/20 smouldering multiple myeloma risk criteria). FINDINGS We included 6441 patients, 4931 (77%) with monoclonal gammopathy of undetermined significance and 1510 (23%) with smouldering multiple myeloma. 3430 (53%) of 6441 participants were female. The PANGEA model (BM) improved prediction of progression from smouldering multiple myeloma to multiple myeloma compared with the 20/2/20 model, with a C-statistic increase from 0·533 (0·480-0·709) to 0·756 (0·629-0·785) at patient visit 1 to the clinic, 0·613 (0·504-0·704) to 0·720 (0·592-0·775) at visit 2, and 0·637 (0·386-0·841) to 0·756 (0·547-0·830) at visit three in validation cohort 1. The PANGEA model (no BM) improved prediction of smouldering multiple myeloma progression to multiple myeloma compared with the 20/2/20 model with a C-statistic increase from 0·534 (0·501-0·672) to 0·692 (0·614-0·736) at visit 1, 0·573 (0·518-0·647) to 0·693 (0·605-0·734) at visit 2, and 0·560 (0·497-0·645) to 0·692 (0·570-0·708) at visit 3 in validation cohort 1. The PANGEA models improved prediction of monoclonal gammopathy of undetermined significance progression to multiple myeloma compared with the IMWG rolling model at visit 1 in validation cohort 2, with C-statistics increases from 0·640 (0·518-0·718) to 0·729 (0·643-0·941) for the PANGEA model (BM) and 0·670 (0·523-0·729) to 0·879 (0·586-0·938) for the PANGEA model (no BM). INTERPRETATION Use of the PANGEA models in clinical practice will allow patients with precursor disease to receive more accurate measures of their risk of progression to multiple myeloma, thus prompting for more appropriate treatment strategies. FUNDING SU2C Dream Team and Cancer Research UK.
Collapse
Affiliation(s)
- Annie Cowan
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Federico Ferrari
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; Biostatistics and Research Decision Sciences, Merck & Co, Rahway, NJ, USA
| | - Samuel S Freeman
- Bioinformatics Program, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Robert Redd
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Habib El-Khoury
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - Vidhi Patel
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Priya Kaur
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Hadley Barr
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - David J Lee
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - Katelyn Downey
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - David Argyelan
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Foteini Theodorakakou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Despina Fotiou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Christine Ivy Liacos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Kanellias
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Louise Ainley
- UCL Cancer Institute, University College London, London, UK
| | - Viera Sandecká
- Department of Internal Medicine, Hematology and Oncology, University Hospital Brno, Brno, Czech Republic
| | | | - Jiri Minarik
- Department of Hemato-Oncology, University Hospital Olomouc, Olomouc, Czech Republic
| | - Alexandra Jungova
- Department of Hematology and Oncology, University Hospital Pilsen, Pilsen, Czech Republic
| | - Jakub Radocha
- Fourth Department of Internal Medicine Hematology, Faculty of Medicine in Hradec Kralove, University Hospital Hradec Kralove, Charles University, Czech Republic
| | - Ivan Spicka
- First Department of Medicine, Department of Hematology, First Faculty of Medicine, Charles University and General Hospital in Prague, Czech Republic
| | - Omar Nadeem
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Kwee Yong
- UCL Cancer Institute, University College London, London, UK
| | - Roman Hájek
- Fourth Department of Internal Medicine-Hematology, University Hospital in Ostrava, Ostrava, Czech Republic
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Meletios A Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Gad Get
- Bioinformatics Program, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Lorenzo Trippa
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Irene M Ghobrial
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
| |
Collapse
|
7
|
Rollborn N, Jakobsson J, Campbell A, Nordin G, Karlsson M, Larsson A, Kultima K. Accuracy of determination of free light chains (Kappa and Lambda) in plasma and serum by Swedish laboratories as monitored by external quality assessment. Clin Biochem 2023; 111:47-53. [PMID: 36241061 DOI: 10.1016/j.clinbiochem.2022.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 09/07/2022] [Accepted: 10/07/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Free light chain (FLC) measurements are important in diagnosing monoclonal gammopathies. As FLC are heterogeneous, different reagents and instruments for measuring FLC concentrations may give diverging results that affect assessment of patients with monoclonal gammopathies. Here we investigated agreement between different FLC methods using data from the Swedish external quality assurance (EQA) programme. METHODS The two main FLC assays, N Latex FLC (Siemens) and Serum Freelite (The Binding Site), using four nephelometric or turbidimetric instrument platforms, were compared. Results from 27 EQA rounds distributed to 11-16 Swedish hospital laboratories during 2015-2020 were investigated. RESULTS The kappa (κ) FLC measurements deviated significantly over time, but when only nephelometry was used, deviation from the mean was lower (median ranges: -5% to 13 %). The CV was significantly higher for the Freelite assay (mean CV = 8.7) than for the N latex assay (mean CV = 5.7) (p < 0.0001). The coefficient of determination between all combinations of reagents and instrument platforms used was generally good (r2 = 0.76-0.87), and the correlation slope acceptable (0.81-1.2). For lambda (λ) FLC measurements, no concordance between combinations of instruments and reagents is apparent, deviating between -40 % to + 48 % from the mean. The CV was significantly higher for the combination with nephelometry and the Freelite assay (CV mean = 13.9 %) than nephelometry and the N latex assay (CV mean = 9.9 %) (p <0.001). The coefficient of determination varied between combinations of reagents and instrument platforms (r2 = 0.59-0.89) and the slope ranged between 0.48 and 1.5. Significant differences between the two reagents used were sometimes noted. CONCLUSIONS Imprecision in λFLC affects the κFLC/λFLC ratio. This may be important in clinical assessment of patients, especially differentiating between monoclonal and polyclonal gammopathies.
Collapse
Affiliation(s)
- Niclas Rollborn
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden
| | - Jenny Jakobsson
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden
| | | | | | - Mathias Karlsson
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden; Equalis AB, Uppsala, Sweden
| | - Anders Larsson
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden
| | - Kim Kultima
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden.
| |
Collapse
|
8
|
L'Imperio V, Cazzaniga G, Vergani B, Smith AJ, Alberici F, Pagni F. Monoclonal Gammopathy of Renal Significance: A Molecular Middle Earth between Oncology, Nephrology, and Pathology. KIDNEY DISEASES (BASEL, SWITZERLAND) 2022; 8:446-457. [PMID: 36590677 PMCID: PMC9798844 DOI: 10.1159/000527056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 09/06/2022] [Indexed: 11/05/2022]
Abstract
Background The renal biopsy represents a cornerstone in the definition of monoclonal gammopathy of renal significance (MGRS), helping in identifying patients with sub-detectable neoplastic clones (MGUS) that would deserve aggressive chemotherapies. However, the rising complexity of this onco-nephrology field is significantly challenging the daily work of nephrologists and nephropathologists, leading to the formation of ultra-specialized international centers with dedicated personnel/instrumentation and stressing the need for a better understanding of the underlying molecular landscape of these entities. Summary In this setting, the application of proteomic techniques, some with in situ capabilities (e.g., MALDI-MS imaging), for the investigation of the most challenging MGRS is progressively shedding light on the pathobiology of these diseases, providing new insights in the diagnosis and prognosis of these cases. This transformation is further enhanced by the application of next-generation digital pathology platforms, leading to a significant improvement of the cultural background for physicians thanks to second opinions, database and atlas creation, enhancement of diagnostic reports, with obvious repercussions for patients both in terms of turnaround time and appropriateness. Key Messages The present review is aimed at bridging the gap between clinical questions (i.e., a better characterization of MGRS) and the molecular landscape of onco-nephrology entities.
Collapse
Affiliation(s)
- Vincenzo L'Imperio
- Department of Medicine and Surgery, Pathology, ASST Monza, San Gerardo Hospital, University of Milan-Bicocca, Monza, Italy
| | - Giorgio Cazzaniga
- Department of Medicine and Surgery, Pathology, ASST Monza, San Gerardo Hospital, University of Milan-Bicocca, Monza, Italy
| | - Barbara Vergani
- Department of Medicine and Surgery, Pathology, ASST Monza, San Gerardo Hospital, University of Milan-Bicocca, Monza, Italy
| | - Andrew James Smith
- Department of Medicine and Surgery, Clinical Proteomics and Metabolomics Unit, University of Milano - Bicocca, Monza, Italy
| | - Federico Alberici
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy,Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Fabio Pagni
- Department of Medicine and Surgery, Pathology, ASST Monza, San Gerardo Hospital, University of Milan-Bicocca, Monza, Italy,*Fabio Pagni,
| |
Collapse
|
9
|
Deng X, Zhang M, Zhou J, Xiao M. Next-generation sequencing for MRD monitoring in B-lineage malignancies: from bench to bedside. Exp Hematol Oncol 2022; 11:50. [PMID: 36057673 PMCID: PMC9440501 DOI: 10.1186/s40164-022-00300-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 08/21/2022] [Indexed: 12/02/2022] Open
Abstract
Minimal residual disease (MRD) is considered the strongest relevant predictor of prognosis and an effective decision-making factor during the treatment of hematological malignancies. Remarkable breakthroughs brought about by new strategies, such as epigenetic therapy and chimeric antigen receptor-T (CAR-T) therapy, have led to considerably deeper responses in patients than ever, which presents difficulties with the widely applied gold-standard techniques of MRD monitoring. Urgent demands for novel approaches that are ultrasensitive and provide sufficient information have put a spotlight on high-throughput technologies. Recently, advances in methodology, represented by next-generation sequencing (NGS)-based clonality assays, have proven robust and suggestive in numerous high-quality studies and have been recommended by some international expert groups as disease-monitoring modalities. This review demonstrates the applicability of NGS-based clonality assessment for MRD monitoring of B-cell malignancies by summarizing the oncogenesis of neoplasms and the corresponding status of immunoglobulin (IG) rearrangements. Furthermore, we focused on the performance of NGS-based assays compared with conventional approaches and the interpretation of results, revealing directions for improvement and prospects in clinical practice.
Collapse
Affiliation(s)
- Xinyue Deng
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, China.,Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Wuhan, Hubei, 430030, China
| | - Meilan Zhang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, China.,Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Wuhan, Hubei, 430030, China
| | - Jianfeng Zhou
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, China.,Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Wuhan, Hubei, 430030, China
| | - Min Xiao
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, China. .,Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Wuhan, Hubei, 430030, China.
| |
Collapse
|
10
|
Willrich MAV, Murray DL, Rajkumar SV, Bryant SC, Larson D, Pazdernik V, Snyder MR, Kyle RA, Dispenzieri A. Comparison of two free light chain assays: performance of the involved free light chain ratio and implications for diagnosis of multiple myeloma. Blood Cancer J 2022; 12:127. [PMID: 36055996 PMCID: PMC9440004 DOI: 10.1038/s41408-022-00722-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 08/02/2022] [Accepted: 08/18/2022] [Indexed: 12/02/2022] Open
Affiliation(s)
| | - David L Murray
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, US
| | | | - Sandra C Bryant
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, US
| | - Dirk Larson
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, US
| | - Vanessa Pazdernik
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, US
| | - Melissa R Snyder
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, US
| | - Robert A Kyle
- Division of Hematology, Mayo Clinic, Rochester, MN, US
| | - Angela Dispenzieri
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, US. .,Division of Hematology, Mayo Clinic, Rochester, MN, US.
| |
Collapse
|
11
|
Abroud H, Beldi‐Ferchiou A, Audard V, Lemonnier F, Le Bras F, Belhadj K, Moktefi A, Poullot E, El Karoui K, Dupuis J, Maarek A, Roulin L, Delfau‐Larue M, Oghina S, Kharoubi M, Bézard M, Zaroui A, Damy T, Molinier‐Frenkel V. Evaluation of a new ELISA assay for monoclonal free‐light chain detection in patients with cardiac amyloidosis. EJHAEM 2022; 3:828-837. [PMID: 36051065 PMCID: PMC9421952 DOI: 10.1002/jha2.516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 06/08/2022] [Accepted: 06/10/2022] [Indexed: 11/27/2022]
Abstract
The causal protein of amyloid light‐chain (AL) amyloidosis is a monoclonal immunoglobulin free light chain (mFLC), which must be quantified in the serum for patient diagnosis and monitoring. Several manufacturers commercialize immunoassays that quantify total kappa (κ) and lambda (λ) FLC, but results can differ greatly between these tests. Here, we compared a recently developed enzyme‐linked immunosorbent assay (ELISA) (Sebia) with N‐Latex immunonephelometry (Siemens) in 96 patients diagnosed with AL amyloidosis (histologically confirmed) and 48 non‐AL patients sent to our referral center for suspicion of cardiac amyloidosis. ELISA free‐light chain difference (dFLC) were lower than N‐Latex values, and agreement between methods was reduced in the case of involved λ FLC. Diagnosis sensitivity and specificity were >85% with both assays. A receiver operating characteristic analysis indicated that ELISA performances could be improved by using a higher value for the lower limit of the κ/λ ratio. We also assessed Freelite (The Binding Site) in a subgroup of these same AL patients, including 18 cases with normal κ/λ ratio by at least one assay. Only two patients had normal κ/λ ratio with all three assays. Overall, ELISA demonstrated slightly lower sensitivity than N‐Latex but may be an alternative to nephelometry/turbidimetry in certain difficult cases.
Collapse
Affiliation(s)
- Hajer Abroud
- Département d'Hématologie‐Immunologie AP‐HP, Hopital Henri Mondor Creteil France
| | - Asma Beldi‐Ferchiou
- Département d'Hématologie‐Immunologie AP‐HP, Hopital Henri Mondor Creteil France
- INSERM IMRB Univ Paris Est Creteil Creteil France
| | - Vincent Audard
- French Referral Centre for Cardiac Amyloidosis Cardiogen Network GRC Amyloid Research Institute Henri Mondor Hospital Creteil France
- Service de Néphrologie et Transplantation AP‐HP, Hopital Henri Mondor Creteil France
| | - François Lemonnier
- French Referral Centre for Cardiac Amyloidosis Cardiogen Network GRC Amyloid Research Institute Henri Mondor Hospital Creteil France
- Unité Hémopathies Lymphoïdes AP‐HP, Hopital Henri Mondor Creteil France
| | - Fabien Le Bras
- French Referral Centre for Cardiac Amyloidosis Cardiogen Network GRC Amyloid Research Institute Henri Mondor Hospital Creteil France
- Unité Hémopathies Lymphoïdes AP‐HP, Hopital Henri Mondor Creteil France
| | - Karim Belhadj
- French Referral Centre for Cardiac Amyloidosis Cardiogen Network GRC Amyloid Research Institute Henri Mondor Hospital Creteil France
- Unité Hémopathies Lymphoïdes AP‐HP, Hopital Henri Mondor Creteil France
| | - Anissa Moktefi
- French Referral Centre for Cardiac Amyloidosis Cardiogen Network GRC Amyloid Research Institute Henri Mondor Hospital Creteil France
- Département de Pathologie AP‐HP, Hopital Henri Mondor Creteil France
| | - Elsa Poullot
- French Referral Centre for Cardiac Amyloidosis Cardiogen Network GRC Amyloid Research Institute Henri Mondor Hospital Creteil France
- Département de Pathologie AP‐HP, Hopital Henri Mondor Creteil France
| | - Khalil El Karoui
- French Referral Centre for Cardiac Amyloidosis Cardiogen Network GRC Amyloid Research Institute Henri Mondor Hospital Creteil France
- Service de Néphrologie et Transplantation AP‐HP, Hopital Henri Mondor Creteil France
| | - Jehan Dupuis
- French Referral Centre for Cardiac Amyloidosis Cardiogen Network GRC Amyloid Research Institute Henri Mondor Hospital Creteil France
- Unité Hémopathies Lymphoïdes AP‐HP, Hopital Henri Mondor Creteil France
| | - Alizée Maarek
- French Referral Centre for Cardiac Amyloidosis Cardiogen Network GRC Amyloid Research Institute Henri Mondor Hospital Creteil France
- Unité Hémopathies Lymphoïdes AP‐HP, Hopital Henri Mondor Creteil France
| | - Louise Roulin
- French Referral Centre for Cardiac Amyloidosis Cardiogen Network GRC Amyloid Research Institute Henri Mondor Hospital Creteil France
- Unité Hémopathies Lymphoïdes AP‐HP, Hopital Henri Mondor Creteil France
| | - Marie‐Hélène Delfau‐Larue
- Département d'Hématologie‐Immunologie AP‐HP, Hopital Henri Mondor Creteil France
- INSERM IMRB Univ Paris Est Creteil Creteil France
| | - Silvia Oghina
- French Referral Centre for Cardiac Amyloidosis Cardiogen Network GRC Amyloid Research Institute Henri Mondor Hospital Creteil France
- Département de Cardiologie AP‐HP, Hopital Henri Mondor Creteil France
| | - Mounira Kharoubi
- French Referral Centre for Cardiac Amyloidosis Cardiogen Network GRC Amyloid Research Institute Henri Mondor Hospital Creteil France
- Département de Cardiologie AP‐HP, Hopital Henri Mondor Creteil France
| | - Mélanie Bézard
- French Referral Centre for Cardiac Amyloidosis Cardiogen Network GRC Amyloid Research Institute Henri Mondor Hospital Creteil France
- Département de Cardiologie AP‐HP, Hopital Henri Mondor Creteil France
| | - Amira Zaroui
- French Referral Centre for Cardiac Amyloidosis Cardiogen Network GRC Amyloid Research Institute Henri Mondor Hospital Creteil France
- Département de Cardiologie AP‐HP, Hopital Henri Mondor Creteil France
| | - Thibaud Damy
- French Referral Centre for Cardiac Amyloidosis Cardiogen Network GRC Amyloid Research Institute Henri Mondor Hospital Creteil France
- Département de Cardiologie AP‐HP, Hopital Henri Mondor Creteil France
- INSERM, IMRB, CEPiaA Univ Paris Est Creteil Creteil France
| | - Valérie Molinier‐Frenkel
- Département d'Hématologie‐Immunologie AP‐HP, Hopital Henri Mondor Creteil France
- INSERM IMRB Univ Paris Est Creteil Creteil France
- French Referral Centre for Cardiac Amyloidosis Cardiogen Network GRC Amyloid Research Institute Henri Mondor Hospital Creteil France
| |
Collapse
|
12
|
Serum Free Light-Chain Ratio at Diagnosis Is Associated with Early Renal Damage in Multiple Myeloma: A Case Series Real-World Study. Biomedicines 2022; 10:biomedicines10071657. [PMID: 35884962 PMCID: PMC9313319 DOI: 10.3390/biomedicines10071657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 06/29/2022] [Accepted: 07/08/2022] [Indexed: 11/17/2022] Open
Abstract
The serum free light-chain (FLC) ratio is a sensitive tool for the differential diagnosis of plasma cell disorders and is biomarker of multiple myeloma (MM) progression from premalignant conditions. Here, we investigate the potential role of FLC ratio at diagnosis in identifying early renal damage in MM patients and other correlations with clinical, laboratory, and molecular findings. A total of 34 MM patients who had undergone autologous stem cell transplantation were included in this retrospective case series study, and FLC quantification was performed with nephelometric assays. In our study, sFLC ratio was significantly associated with light-chain MM and β-2 microglobulin levels, likely indicating a high disease burden at diagnosis, especially in patients without heavy chain M-protein at serum electrophoresis. Moreover, the sFLC ratio was inversely correlated with glomerular filtration rate, possibly identifying early renal damage in MM patients. Our preliminary results confirm the importance of early sFLC evaluation, especially in patients with the light-chain MM type and low disease burden, to minimize the risk of late renal failure.
Collapse
|
13
|
Natali P, Bedin R, Bernardi G, Corsini E, Cocco E, Schirru L, Crespi I, Lamonaca M, Sala A, Nicolò C, Di Filippo M, Villa A, Nociti V, De Michele T, Cavalla P, Caropreso P, Vitetta F, Cucinelli MR, Gastaldi M, Trenti T, Sola P, Ferraro D. Inter-Laboratory Concordance of Cerebrospinal Fluid and Serum Kappa Free Light Chain Measurements. Biomolecules 2022; 12:biom12050677. [PMID: 35625604 PMCID: PMC9138559 DOI: 10.3390/biom12050677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/30/2022] [Accepted: 05/04/2022] [Indexed: 11/16/2022] Open
Abstract
The kappa index (K-Index), calculated by dividing the cerebrospinal fluid (CSF)/serum kappa free light chain (KFLC) ratio by the CSF/serum albumin ratio, is gaining increasing interest as a marker of intrathecal immunoglobulin synthesis. However, data on inter-laboratory agreement of these measures is lacking. The aim was to assess the concordance of CSF and serum KFLC measurements, and of K-index values, across different laboratories. KFLC and albumin of 15 paired CSF and serum samples were analyzed by eight participating laboratories. Four centers used Binding Site instruments and assays (B), three used Siemens instruments and assays (S), and one center used a Siemens instrument with a Binding Site assay (mixed). Absolute individual agreement was calculated using a two-way mixed effects intraclass correlation coefficient (ICC). Cohen’s kappa coefficient (k) was used to measure agreement on positive (≥5.8) K-index values. There was an excellent agreement in CSF KFLC measurements across all laboratories (ICC (95% confidence interval): 0.93 (0.87–0.97)) and of serum KFLC across B and S laboratories (ICC: 0.91 (0.73–0.97)), while ICC decreased (to 0.81 (0.53–0.93)) when including the mixed laboratory in the analysis. Concordance for a positive K-Index was substantial across all laboratories (k = 0.77) and within S laboratories (k = 0.71), and very good (k = 0.89) within B laboratories, meaning that patients rarely get discordant results on K-index positivity notwithstanding the testing in different laboratories and the use of different platforms/assays.
Collapse
Affiliation(s)
- Patrizia Natali
- Department of Laboratory Medicine, Azienda Ospedaliero-Universitaria and Azienda Unità Sanitaria Locale, 41126 Modena, Italy; (P.N.); (M.R.C.); (T.T.)
| | - Roberta Bedin
- Department of Biomedical, Metabolic and Neurosciences, University of Modena and Reggio Emilia, 41126 Modena, Italy;
| | - Gaetano Bernardi
- Laboratory Medicine Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy; (G.B.); (E.C.)
| | - Elena Corsini
- Laboratory Medicine Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy; (G.B.); (E.C.)
| | - Eleonora Cocco
- Multiple Sclerosis Center, ATS Sardegna/University of Cagliari, 09047 Cagliari, Italy; (E.C.); (L.S.)
| | - Lucia Schirru
- Multiple Sclerosis Center, ATS Sardegna/University of Cagliari, 09047 Cagliari, Italy; (E.C.); (L.S.)
| | - Ilaria Crespi
- Clinical Biochemistry Laboratory, Azienda Ospedaliero Universitaria Maggiore della Carità of Novara, 28100 Novara, Italy; (I.C.); (M.L.)
| | - Marta Lamonaca
- Clinical Biochemistry Laboratory, Azienda Ospedaliero Universitaria Maggiore della Carità of Novara, 28100 Novara, Italy; (I.C.); (M.L.)
| | - Arianna Sala
- Neurology Unit, CReSM, Azienda Ospedaliero Universitaria San Luigi Gonzaga, 10043 Orbassano, Italy;
| | - Cinzia Nicolò
- Clinical Chemistry and Microbiology Laboratory, Azienda Ospedaliero Universitaria San Luigi Gonzaga, 10043 Orbassano, Italy;
| | | | - Alfredo Villa
- Clinical Pathology and Haematology Laboratory, Azienda Ospedaliera of Perugia, 06132 Perugia, Italy;
| | - Viviana Nociti
- Multiple Sclerosis Center, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Catholic University, 00168 Rome, Italy;
| | - Teresa De Michele
- Clinical Chemistry, Biochemistry and Molecular Biology Laboratory, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy;
| | - Paola Cavalla
- Multiple Sclerosis Center, Department of Neurosciences and Mental Health, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza of Torino, 10126 Torino, Italy;
| | - Paola Caropreso
- Clinical Biochemistry Laboratory, Department of Laboratory Medicine, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza of Torino, 10126 Torino, Italy;
| | - Francesca Vitetta
- Neurology Unit, Azienda Ospedaliero-Universitaria of Modena, 41126 Modena, Italy; (F.V.); (P.S.)
| | - Maria Rosaria Cucinelli
- Department of Laboratory Medicine, Azienda Ospedaliero-Universitaria and Azienda Unità Sanitaria Locale, 41126 Modena, Italy; (P.N.); (M.R.C.); (T.T.)
| | - Matteo Gastaldi
- Neuroimmunology Laboratory, IRCCS Mondino Foundation, 27100 Pavia, Italy;
| | - Tommaso Trenti
- Department of Laboratory Medicine, Azienda Ospedaliero-Universitaria and Azienda Unità Sanitaria Locale, 41126 Modena, Italy; (P.N.); (M.R.C.); (T.T.)
| | - Patrizia Sola
- Neurology Unit, Azienda Ospedaliero-Universitaria of Modena, 41126 Modena, Italy; (F.V.); (P.S.)
| | - Diana Ferraro
- Department of Biomedical, Metabolic and Neurosciences, University of Modena and Reggio Emilia, 41126 Modena, Italy;
- Neurology Unit, Azienda Ospedaliero-Universitaria of Modena, 41126 Modena, Italy; (F.V.); (P.S.)
- Correspondence: ; Tel.: +39-059-396-1678
| | | |
Collapse
|
14
|
Hopson MB, Bhutani D, Sarkaria S, Maurer MS, Griffin JM, Mapara M, Lentzsch S, Chakraborty R. Impact of light chain isotype on clinical features and outcomes in systemic AL amyloidosis. Leuk Lymphoma 2022; 63:2109-2113. [DOI: 10.1080/10428194.2022.2060502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
| | - Divaya Bhutani
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY, USA
| | - Shawn Sarkaria
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY, USA
| | | | - Jan M. Griffin
- Irving Medical Center, Columbia University, New York, NY, USA
| | - Markus Mapara
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY, USA
| | - Suzanne Lentzsch
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY, USA
| | | |
Collapse
|
15
|
Bujarski S, Sutanto C, Spektor TM, To J, Swift RA, Green T, Eades BR, Emamy-Sadr M, Souther E, Berenson JR. Use of serum B-cell maturation antigen levels to predict outcomes for myeloma patients treated with ruxolitinib, lenalidomide and methylprednisolone. Hematol Oncol 2022; 40:243-248. [PMID: 34982491 DOI: 10.1002/hon.2961] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 12/28/2021] [Accepted: 12/30/2021] [Indexed: 01/14/2023]
Abstract
Previous retrospective studies have shown that serum B-cell maturation antigen (sBCMA) levels predict outcomes among patients with multiple myeloma (MM) undergoing new treatments. Specifically, baseline levels and changes during treatment of this protein predict both progression free survival (PFS) and overall survival. However, prospective studies are lacking evaluating sBCMA for determining outcomes among MM patients undergoing new treatments. Thus, we evaluated whether its baseline levels and changes during treatment in the amount of this serum marker predict outcomes among 38 relapsed/refractory MM patients treated with ruxolitinib, lenalidomide and methylprednisolone in a phase 1 trial. Patients with baseline sBCMA levels in the lowest three quartiles had longer PFS (median PFS 136 vs. 28 days; p < 0.0001). This was also shown for patients with baseline levels below the median (median PFS 140 vs. 77 days; p = 0.0225). PFS was shorter for patients whose sBCMA levels increased ≥25% through their first cycle (median PFS: 50 vs. 134 days, p = 0.0022), second cycle (median PFS: 50 vs. 141 days, p = 0.0273), and during the first three cycles of study treatment (median PFS: 50 vs. 220 days, p < 0.0001). No patient whose sBCMA increased ≥25% during cycle 1 responded whereas the majority (58%) of patients whose level increased <25% responded. This is the first prospective study to determine whether sBCMA levels predict outcomes for MM patients undergoing a non-BCMA directed treatment regimen and demonstrates that baseline levels and its changes during treatment predict PFS and the likelihood of responding to their treatment. These results add to the growing literature suggesting that this serum marker will be useful for determining outcomes for patients undergoing treatment for MM.
Collapse
Affiliation(s)
- Sean Bujarski
- James R. Berenson, MD, Inc., West Hollywood, California, USA
| | | | | | - Jennifer To
- Oncotherapeutics, West Hollywood, California, USA
| | - Regina A Swift
- James R. Berenson, MD, Inc., West Hollywood, California, USA
| | - Tracy Green
- James R. Berenson, MD, Inc., West Hollywood, California, USA
| | | | | | | | - James R Berenson
- James R. Berenson, MD, Inc., West Hollywood, California, USA.,OncoTracker, West Hollywood, California, USA.,Oncotherapeutics, West Hollywood, California, USA.,Institute for Myeloma and Bone Cancer Research, West Hollywood, California, USA
| |
Collapse
|
16
|
Markovic U, Romano A, Bellofiore C, Condorelli A, Garibaldi B, Bulla A, Duminuco A, Del Fabro V, Di Raimondo F, Conticello C. Role of Serum Free Light Chain Assay in Relapsed/Refractory Multiple Myeloma. A Real-Life Unicentric Retrospective Study. Cancers (Basel) 2021; 13:cancers13236017. [PMID: 34885127 PMCID: PMC8656731 DOI: 10.3390/cancers13236017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 11/24/2021] [Accepted: 11/27/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND In the era of novel drugs a growing number of multiple myeloma (MM) patients are treated until disease progression. Serum free light chain (sFLC) assay is recommended for disease monitoring in oligo-secretory and micromolecular MM. METHODS In this real-life survey, a total of 130 relapsed/refractory MM patients treated at our center with at least three lines were investigated as a retrospective cohort. RESULTS The median age at diagnosis was 64 years and more than half of patients were male. A total of 24 patients (18%) had oligo-secretory/micromolecular disease at diagnosis. More than 20% of 106 normo-secretory patients had oligo-secretory/micromolecular escape. In order to evaluate potential role of sFLC assay before ("pre") and after ("post") every treatment line, involved serum free light chain values (iFLC) less than 138 mg/mL and serum free light chain ratios (FLCr) <25 were identified by using ROC curve analysis. The analysis of the entire cohort throughout four treatment lines demonstrated a statistically significant negative impact on progression-free survival (PFS) for both involved pre-sFLC and its ratio (respectively p = 0.0086 and p = 0.0065). Furthermore, both post-iFLC and post-FLCr greater than the pre-established values had a negative impact on PFS of the study cohort; respectively, p = 0.014 and p = 0.0079. Odds ratio analysis evidenced that patients with both involved post-sFLC greater than 138 mg/mL and post-FLCr above 25 at disease relapse had a higher probability of having clinical relapse (respectively p = 0.026 and p = 0.006). CONCLUSIONS Alterations of sFLC values, namely iFLC and FLCr, both prior to treatment initiation and in the course of therapy at every treatment line, could be of aid in relapse evaluation and treatment outcome. We therefore suggest close periodical monitoring of sFLC assay, independently from secretory status.
Collapse
Affiliation(s)
- Uros Markovic
- Division of Hematology, Azienda Policlinico-OVE, University of Catania, 95124 Catania, Italy; (A.R.); (C.B.); (A.C.); (B.G.); (A.B.); (A.D.); (V.D.F.); (F.D.R.); (C.C.)
- Oncohematology and BMT Unit, Mediterranean Institute of Oncology, 95029 Viagrande, Italy
- Correspondence:
| | - Alessandra Romano
- Division of Hematology, Azienda Policlinico-OVE, University of Catania, 95124 Catania, Italy; (A.R.); (C.B.); (A.C.); (B.G.); (A.B.); (A.D.); (V.D.F.); (F.D.R.); (C.C.)
- Postgraduate School of Hematology, University of Catania, 95124 Catania, Italy
| | - Claudia Bellofiore
- Division of Hematology, Azienda Policlinico-OVE, University of Catania, 95124 Catania, Italy; (A.R.); (C.B.); (A.C.); (B.G.); (A.B.); (A.D.); (V.D.F.); (F.D.R.); (C.C.)
- Postgraduate School of Hematology, University of Catania, 95124 Catania, Italy
| | - Annalisa Condorelli
- Division of Hematology, Azienda Policlinico-OVE, University of Catania, 95124 Catania, Italy; (A.R.); (C.B.); (A.C.); (B.G.); (A.B.); (A.D.); (V.D.F.); (F.D.R.); (C.C.)
- Postgraduate School of Hematology, University of Catania, 95124 Catania, Italy
| | - Bruno Garibaldi
- Division of Hematology, Azienda Policlinico-OVE, University of Catania, 95124 Catania, Italy; (A.R.); (C.B.); (A.C.); (B.G.); (A.B.); (A.D.); (V.D.F.); (F.D.R.); (C.C.)
- Postgraduate School of Hematology, University of Catania, 95124 Catania, Italy
| | - Anna Bulla
- Division of Hematology, Azienda Policlinico-OVE, University of Catania, 95124 Catania, Italy; (A.R.); (C.B.); (A.C.); (B.G.); (A.B.); (A.D.); (V.D.F.); (F.D.R.); (C.C.)
| | - Andrea Duminuco
- Division of Hematology, Azienda Policlinico-OVE, University of Catania, 95124 Catania, Italy; (A.R.); (C.B.); (A.C.); (B.G.); (A.B.); (A.D.); (V.D.F.); (F.D.R.); (C.C.)
- Postgraduate School of Hematology, University of Catania, 95124 Catania, Italy
| | - Vittorio Del Fabro
- Division of Hematology, Azienda Policlinico-OVE, University of Catania, 95124 Catania, Italy; (A.R.); (C.B.); (A.C.); (B.G.); (A.B.); (A.D.); (V.D.F.); (F.D.R.); (C.C.)
| | - Francesco Di Raimondo
- Division of Hematology, Azienda Policlinico-OVE, University of Catania, 95124 Catania, Italy; (A.R.); (C.B.); (A.C.); (B.G.); (A.B.); (A.D.); (V.D.F.); (F.D.R.); (C.C.)
- Postgraduate School of Hematology, University of Catania, 95124 Catania, Italy
| | - Concetta Conticello
- Division of Hematology, Azienda Policlinico-OVE, University of Catania, 95124 Catania, Italy; (A.R.); (C.B.); (A.C.); (B.G.); (A.B.); (A.D.); (V.D.F.); (F.D.R.); (C.C.)
| |
Collapse
|
17
|
Daves M, Piccin A, Roccaforte V, Lippi G. Comparison of Freelite and N-Latex serum free light chain assays: a critical review. Biochem Med (Zagreb) 2021; 31:030701. [PMID: 34393594 PMCID: PMC8340501 DOI: 10.11613/bm.2021.030701] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 06/12/2021] [Indexed: 11/07/2022] Open
Abstract
Introduction The measurement of serum free light chain (FLC) represents a fundamental aspect on the assessment of patients with monoclonal gammopathies (MG). Different analytical methods for FLC have become available with the possibility to obtain different value with a substantial impact on the assessment of patients with MG. This study aimed to evaluate FLC results obtained with two different assays and how the difference value obtained can impact in the patient’s assessment. Materials and methods Ninety-three patient serum samples that underwent analysis for FLC with two different methods, Serum Freelite (The Binding Site, Birmingham, UK) and N-Latex FLC (Siemens, Marburg, Germany), were included in this retrospective study. Statistical analysis was performed to evaluate correlation, difference, and the grade of concordance between the results obtained with the two methods. Results Significant statistical differences between the results obtained from the two methods were found (P < 0.05). A good correlation was found (0.99 for κ FLC, 0.95 for λ FLC, and 0.94 for the κ/λ ratio, respectively). We found a weighted kappa value of 0.65 for κ/λ ratio, 0.65 for λ FLC and 0.90 for κ FLC. A positive bias found with the Bland-Altman plot mirrors overestimation of κ FLC and κ/λ ratio with Freelite compared to N-Latex, whilst a negative bias underscores underestimation of λ FLC by Freelite compared to N-Latex. Conclusion Although in general the concordance between Freelite and N-Latex appears satisfactory, several discrepancies could be evidenced and consequently the two assays are not interchangeable.
Collapse
Affiliation(s)
- Massimo Daves
- Clinical Biochemical Laboratory, Hospital of Bolzano, Bolzano, Italy
| | - Andrea Piccin
- Northern Ireland Blood Transfusion Service (NIBTS), Belfast, United Kingdom.,Department of Internal Medicine V, University of Innsbruck, Innsbruck, Austria
| | | | - Giuseppe Lippi
- Section of Clinical Biochemistry, Verona University of Verona, Verona, Italy
| |
Collapse
|
18
|
Fager Ferrari M, Lemonakis K, Förnvik Jonsson M. A rare case of IgE kappa monoclonal gammopathy of undetermined significance identified in a Swedish female. Scandinavian Journal of Clinical and Laboratory Investigation 2021; 81:385-388. [PMID: 34097568 DOI: 10.1080/00365513.2021.1929443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Monoclonal gammopathies involving immunoglobulin E (IgE) is a very rare phenomenon, with less than 70 cases being previously described in the literature. The IgE monoclonal gammopathies include malignant plasma cell disorders such as IgE multiple myeloma (MM), as well as the associated premalignant condition IgE monoclonal gammopathy of undetermined significance (MGUS). We report a case of a 41-year-old woman presenting with an IgE kappa monoclonal protein following routine laboratory testing. Serum protein electrophoresis (SPEP) initially showed a monoclonal protein in the beta-2 fraction, at an estimated concentration of <4 g/L. Subsequent serum immunofixation electrophoresis (SIFE) including antisera to Ig heavy chains delta and epsilon confirmed the presence of an IgE kappa monoclonal protein. Analysis of serum free light chains (FLCs) showed increased levels of kappa FLC, resulting in an abnormally elevated kappa/lambda FLC ratio. No Bence-Jones proteinuria was present. Bone marrow aspiration showed 6% plasma cells, and no sign of myeloma-associated end-organ damage was evident. Consequently, the patient was diagnosed with IgE kappa MGUS. In the present report, the clinical characteristics of the patient are compared to previous descriptions of IgE monoclonal gammopathy. The report further emphasizes the importance of considering the presence of monoclonal IgD or IgE when SIFE shows a clear band positive for a light chain but is negative for Ig heavy chains gamma, alpha and mu.
Collapse
|
19
|
Bujarski S, Udd K, Soof C, Chen H, Spektor TM, Safaie T, Li M, Stern J, Wang C, Xu N, Emamy-Sadr M, Swift R, Rahbari A, Patil S, Souther E, Regidor B, Sutanto C, Berenson JR. Baseline and Changes in Serum B-Cell Maturation Antigen Levels Rapidly Indicate Changes in Clinical Status Among Patients with Relapsed/Refractory Multiple Myeloma Starting New Therapy. Target Oncol 2021; 16:503-515. [PMID: 34097243 DOI: 10.1007/s11523-021-00821-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND B-cell maturation antigen (BCMA) is expressed on malignant plasma cells from patients with multiple myeloma (MM). These patients have higher levels of serum (s)BCMA than healthy subjects, and levels correlate with disease status. The half-life of sBCMA is only 24-36 h, and levels are independent of renal function. OBJECTIVE We determined whether baseline sBCMA values, a ≥ 25% increase, and a ≥ 50% decrease during treatment predicted progression-free survival (PFS) and overall survival (OS) among 81 patients with relapsed/refractory MM (RRMM) starting new treatments. METHODS Serum was obtained on day 22 of each patient's 28-day cycle of new therapy. Kaplan-Meier survival analysis and log-rank comparison tests were used to determine the effect of baseline sBCMA. The effect of percentage change in sBCMA was investigated using time-dependent Cox proportional hazard models. RESULTS Patients with baseline sBCMA levels above the median had a shorter PFS (p = 0.0077), and those in the highest quartile had a shorter PFS (p = 0.0012) and OS (p = 0.0022). A ≥ 25% increase at week 4, week 8, and anytime through week 12 predicted a shorter PFS (p = 0.0011, p = 0.0005, and p < 0.0001, respectively). A ≥ 50% decrease at week 4, week 8, and anytime through week 12 predicted a longer PFS (p = 0.0045, p = 0.029, p = 0.0055, respectively). A ≥ 25% increase in sBCMA occurred before progression according to International Myeloma Working Group criteria in 67.5% of patients. CONCLUSIONS Our results indicate the potential for the use of sBCMA as a new biomarker for monitoring patients with RRMM.
Collapse
Affiliation(s)
- Sean Bujarski
- Institute for Myeloma and Bone Cancer Research, 9201 W. Sunset Blvd., Ste. 300, West Hollywood, CA, 90069, USA
- James R Berenson MD, Inc., West Hollywood, CA, USA
| | - Kyle Udd
- Institute for Myeloma and Bone Cancer Research, 9201 W. Sunset Blvd., Ste. 300, West Hollywood, CA, 90069, USA
- James R Berenson MD, Inc., West Hollywood, CA, USA
| | | | - Haiming Chen
- Institute for Myeloma and Bone Cancer Research, 9201 W. Sunset Blvd., Ste. 300, West Hollywood, CA, 90069, USA
| | | | | | - Mingjie Li
- Institute for Myeloma and Bone Cancer Research, 9201 W. Sunset Blvd., Ste. 300, West Hollywood, CA, 90069, USA
| | - Joshua Stern
- Institute for Myeloma and Bone Cancer Research, 9201 W. Sunset Blvd., Ste. 300, West Hollywood, CA, 90069, USA
| | - Cathy Wang
- Institute for Myeloma and Bone Cancer Research, 9201 W. Sunset Blvd., Ste. 300, West Hollywood, CA, 90069, USA
| | - Ning Xu
- Institute for Myeloma and Bone Cancer Research, 9201 W. Sunset Blvd., Ste. 300, West Hollywood, CA, 90069, USA
| | | | - Regina Swift
- James R Berenson MD, Inc., West Hollywood, CA, USA
| | - Ashkon Rahbari
- Institute for Myeloma and Bone Cancer Research, 9201 W. Sunset Blvd., Ste. 300, West Hollywood, CA, 90069, USA
| | - Saurabh Patil
- Institute for Myeloma and Bone Cancer Research, 9201 W. Sunset Blvd., Ste. 300, West Hollywood, CA, 90069, USA
| | | | | | | | - James R Berenson
- Institute for Myeloma and Bone Cancer Research, 9201 W. Sunset Blvd., Ste. 300, West Hollywood, CA, 90069, USA.
- James R Berenson MD, Inc., West Hollywood, CA, USA.
- ONCOtherapuetics, West Hollywood, CA, USA.
- ONCOtracker, West Hollywood, CA, USA.
| |
Collapse
|
20
|
Sarto C, Intra J, Fania C, Brivio R, Brambilla P, Leoni V. Monoclonal free light chain detection and quantification: Performances and limits of available laboratory assays. Clin Biochem 2021; 95:28-33. [PMID: 33991536 DOI: 10.1016/j.clinbiochem.2021.05.006] [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: 02/20/2021] [Revised: 04/25/2021] [Accepted: 05/10/2021] [Indexed: 11/19/2022]
Abstract
The detection and quantification of immunoglobulin free light chains in serum and urine is recommended for the diagnosis and monitoring of monoclonal gammopathies according to the guidelines of the International Myeloma Working Group (IMWG). Several tests are currently available in the clinical laboratory to detect and quantify free light chains but although quality, efficiency, and effectiveness have been improved, the results are still variable and poorly harmonized and standardized. The present review article wants to analyze these aspects, with a keen eye on techniques, such as mass spectrometry, that could replace in the practical clinical laboratory the current methods including Bence-Jones protein assay and free light chain immunoassays.
Collapse
Affiliation(s)
- C Sarto
- Department of Laboratory Medicine, University of Milano-Bicocca, Azienda Socio Sanitaria Territoriale della Brianza ASST-Brianza, Desio Hospital, via Mazzini 1, 20833 Desio, (MB), Italy
| | - J Intra
- Clinical Chemistry Laboratory, University of Milano-Bicocca, Azienda Socio Sanitaria Territoriale di Monza ASST-Monza, St Gerardo Hospital, via Pergolesi 33, 20900 Monza, (MB), Italy.
| | - C Fania
- Clinical Chemistry Unit, "Maggiore della Carità" University Hospital, 28100 Novara, Italy
| | - R Brivio
- Clinical Chemistry Laboratory, University of Milano-Bicocca, Azienda Socio Sanitaria Territoriale di Monza ASST-Monza, St Gerardo Hospital, via Pergolesi 33, 20900 Monza, (MB), Italy
| | - P Brambilla
- Department of Laboratory Medicine, University of Milano-Bicocca, Azienda Socio Sanitaria Territoriale della Brianza ASST-Brianza, Desio Hospital, via Mazzini 1, 20833 Desio, (MB), Italy
| | - V Leoni
- Department of Laboratory Medicine, University of Milano-Bicocca, Azienda Socio Sanitaria Territoriale della Brianza ASST-Brianza, Desio Hospital, via Mazzini 1, 20833 Desio, (MB), Italy
| |
Collapse
|
21
|
Kwapisz D. Serum free light chains in solid organ transplant recipients. Clin Transplant 2021; 35:e14286. [PMID: 33715217 DOI: 10.1111/ctr.14286] [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: 12/02/2020] [Revised: 02/28/2021] [Accepted: 03/08/2021] [Indexed: 11/30/2022]
Abstract
Immunoglobulin is built by a pair of identical heavy and a pair of identical light chains. Light chains are produced in excess compared to heavy chains. Free light chains (FLCs) are those which are not combined with heavy chains. Currently, numerous assays are available for the measurement of serum FLCs (sFLCs). These assays cannot be used interchangeably, and renal function should be taken into account in interpreting test results. Levels of kappa and lambda sFLCs are usually used to diagnose and monitor plasma cell dyscrasias. However, the clinical relevance of sFLCs is being investigated in patients with a variety of diseases, including patients after transplantation. There are contradictory results regarding the usefulness of sFLCs in the prediction of post-transplant lymphoproliferative disorder (PTLD). However, it seems that sFLCs may be helpful in the prediction of early-onset PTLD. Some studies have shown that low levels of sFLCs are associated with a higher risk of infection in patients after transplantation. This review summarizes and highlights recent advances in the utility of sFLCs in the prediction of PTLD and infection, and inflammation assessment in patients after solid organ transplantation. Moreover, the influence of immunosuppressive treatment on sFLCs levels is described briefly.
Collapse
Affiliation(s)
- Dorota Kwapisz
- Department of Immunology, Transplantology and Internal Diseases, University Clinical Center of the Medical University of Warsaw, Warsaw, Poland
| |
Collapse
|
22
|
Morales-García LJ, Pacheco-Delgado MS. Serum free light chain reference intervals in an Optilite and their influence on clinical guidelines. Clin Biochem 2021; 92:54-60. [PMID: 33662349 DOI: 10.1016/j.clinbiochem.2021.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 01/26/2021] [Accepted: 02/16/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Serum free light chain (FLC) analysis has been incorporated into the International Myeloma Working Group guidelines for the diagnosis and management of all monoclonal gammopathies. These recommendations were solely based on a single assay method (Freelite assay) and instrument. Here, we establish new reference intervals (RIs) for kappa and lambda FLC and the kappa-lambda difference and sum and a new diagnostic range for kappa/lambda FLC ratio (K/L-FLC) in an Optilite turbidimeter (The Binding Site) with the Freelite assay. METHODS To establish new RIs, the CLSI EP28-A3C protocol was applied to 249 sample blood donors from Fuenlabrada, Spain, and the central 95% and total range were estimated. Samples from patients with polyclonal hypo- and hypergammaglobulinemia were used for the evaluation of K/L-FLC as a monoclonal proliferation index. RESULTS The new RIs and the new K/L-FLC diagnostic range for the Optilite (0.65-2.56 mg/L) are very different from those in on the guidelines (0.26-1.65 mg/L). We propose new RIs for the K - L difference and the K + L sum. Diagnostic range validation as a monoclonal proliferation index with samples with hypo- and hypergammaglobulinemia confirms this new range. CONCLUSIONS In this study, we present the FLC RI for Freelite reagents measured on an Optilite turbidimeter. These ranges are different from those provided by the manufacturer and from those used in most studies in the literature, which may lead to patient misclassification. Manufacturers and clinical laboratories must strive to provide RIs for the technology they are using and for their population.
Collapse
Affiliation(s)
- Luis J Morales-García
- Department of Clinical Laboratory, Hospital Universitario de Fuenlabrada, Camino del Molino 2, Fuenlabrada, Madrid 28942, Spain.
| | - María S Pacheco-Delgado
- Department of Clinical Laboratory, Hospital Universitario de Fuenlabrada, Camino del Molino 2, Fuenlabrada, Madrid 28942, Spain.
| |
Collapse
|
23
|
Caponi L, Koni E, Romiti N, Paolicchi A, Franzini M. Free light chain UV quantification compared with immunochemical measurement: How dimers and monomers may influence the results. Clin Chim Acta 2020; 510:278-284. [DOI: 10.1016/j.cca.2020.07.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 07/11/2020] [Indexed: 11/28/2022]
|