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Zeman D, Štork M, Švancarová L, Borský M, Pospíšilová M, Adam Z, Beňovská M, Pour L. Isoelectric focusing followed by affinity immunoblotting to detect monoclonal free light chains in monoclonal gammopathies: Comparison with immunofixation electrophoresis and free light chain ratio. Ann Clin Biochem 2024:45632231221439. [PMID: 38073192 DOI: 10.1177/00045632231221439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND Isoelectric focusing (IEF) is a method with an exquisite resolution, and coupled with affinity immunoblotting (AIB), it can provide superior sensitivity to detect monoclonal free light chains (FLC). METHODS We tested the hypothesis that IEF/AIB is more sensitive and specific for monoclonal FLC detection in serum and urine samples than conventional methods, that is, electrophoresis (ELP), immunofixation (IF) and serum FLC ratio assessment. Investigation included 107 samples of 68 patients, among which 21 multiple myeloma patients were recently tested for minimal residual disease and 18 patients with AL amyloidosis. RESULTS Monoclonal FLC were detected by IEF/AIB in 37% of serum samples negative for monoclonal FLC on ELP/IF. As for urine samples, significant advantage of the IEF/AIB over ELP/IF was not demonstrated. Considering both serum and urine results, IEF/AIB definitely revealed monoclonal FLC in 20/83 (24%) of ELP/IF-negative samples. FLC ratio was abnormally high (>1.65) in all 11 patients definitely positive for monoclonal FLC kappa by IEF/AIB but also in 16/47 (34%) IEF/AIB-negative samples. Abnormally low values (<0.26) were found only in 10/28 samples (36%) positive for monoclonal FLC lambda. Appropriate use of renal FLC ratio reference range reduced the number of presumably false positives (6/47, i.e. 13%) but not false negatives (17/28, i.e. 61%). CONCLUSIONS The IEF/AIB method is more sensitive than IF and might be used in patients with negative IF results before deciding whether to proceed to minimal residual disease testing.
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Affiliation(s)
- David Zeman
- Department of Laboratory Medicine, Division of Clinical Biochemistry, University Hospital Brno, Brno, Czech Republic
- Department of Laboratory Methods, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Martin Štork
- Department of Internal Medicine, Haematology and Oncology, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Lenka Švancarová
- Department of Laboratory Methods, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Marek Borský
- Department of Internal Medicine, Haematology and Oncology, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Michaela Pospíšilová
- Department of Laboratory Medicine, Division of Clinical Biochemistry, University Hospital Brno, Brno, Czech Republic
- Department of Laboratory Methods, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Zdeněk Adam
- Department of Internal Medicine, Haematology and Oncology, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Miroslava Beňovská
- Department of Laboratory Medicine, Division of Clinical Biochemistry, University Hospital Brno, Brno, Czech Republic
- Department of Laboratory Methods, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Luděk Pour
- Department of Internal Medicine, Haematology and Oncology, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
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Karaszewski K, Jasiński M, Waszczuk-Gajda A, Rodziewicz-Lurzyńska A, Ciepiela O, Jędrzejczak WW. Oligoclonal gammopathy: An analysis of 253 cases. ADV CLIN EXP MED 2024; 33:127-134. [PMID: 37341173 DOI: 10.17219/acem/166297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 04/16/2023] [Accepted: 05/18/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND Oligoclonal gammopathy (OG) is a rare disorder of the lymphoid system that is characterized by the presence of at least 2 distinct monoclonal proteins in a patient's serum or urine. The biological and clinical characteristics of this disease are as yet poorly understood. OBJECTIVES The study aimed to assess whether there are significant differences between patients with OG regarding the developmental history (i.e., OG diagnosed at the first presentation compared to OG that has developed in patients with an original monoclonal gammopathy) and the number of monoclonal proteins (2 compared to 3). Moreover, we attempted to determine when secondary oligoclonality develops following the original diagnosis of monoclonal gammopathy. MATERIAL AND METHODS Patients were analyzed with regard to their age at diagnosis, sex, serum monoclonal proteins, and underlying hematological disorders. Multiple myeloma (MM) patients were additionally evaluated for their Durie-Salmon stage and cytogenetic alterations. RESULTS Patients with triclonal gammopathy (TG: n = 29) did not differ significantly from patients with biclonal gammopathy (BG: n = 223) (p = 0.81) in terms of age at diagnosis and the dominant diagnosis (MM was the most common diagnosis (65.0% and 64.7%, respectively)). In both cohorts, myeloma patients were mainly classified to the Durie-Salmon stage III. In the TG cohort, there was a higher proportion of males (69.0%) than among patients with BG (52.5%). Oligoclonality developed at various times after diagnosis (up to 80 months in the investigated cohort). However, the occurrence of new cases was higher during the initial 30-month period following the diagnosis of monoclonal gammopathy. CONCLUSIONS There are only small differences between patients with primary compared to secondary OG, between BG and TG, and most patients have a combination of IgGκ+IgGλ. Oligoclonality could develop at any time after the diagnosis of monoclonal gammopathy, but it happens more frequently during the first 30 months, with advanced myeloma being the most prevalent underlying disorder.
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Affiliation(s)
- Kajetan Karaszewski
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, Poland
| | - Marcin Jasiński
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, Poland
- Doctoral School, Medical University of Warsaw, Poland
| | - Anna Waszczuk-Gajda
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, Poland
| | | | - Olga Ciepiela
- Department of Laboratory Medicine, Medical University of Warsaw, Poland
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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4
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Shah SK, Hagrass HA. Evusheld, a SARS-CoV-2 spike protein-directed attachment inhibitor, appears in serum protein electrophoresis and immunofixation: a case study. Lab Med 2023; 54:e201-e203. [PMID: 37707512 DOI: 10.1093/labmed/lmad085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023] Open
Abstract
Serum protein electrophoresis (SPE) and immunofixation (IFE) assays are commonly used to diagnose and monitor patients with multiple myeloma (MM). Identifying analytical interferences in SPE and IFE caused by therapeutic monoclonal antibodies (tmAbs) can be challenging. Here we report the case of a 72-year-old male with a long history of relapsed immunoglobulin (Ig)G kappa MM. A follow-up SPE showed the original peak plus 2 additional cathode peaks. Immunofixation was ordered as a reflex test to investigate the new peaks that showed initial patient monoclonal IgG kappa in addition to 2 restricted bands of the IgG kappa type. Therapeutic monoclonal antibody interference was suspected and the patient's chart was reviewed. The patient was not on any antimyeloma monoclonal antibody therapy. However, preexposure prophylaxis therapeutic monoclonal antibodies tixagevimab plus cilgavimab (Evusheld) for severe acute SARS-CoV-2 was administered approximately 45 minutes before sample collection, which led to the identifiable spikes and correlated bands. After 2 days, the IgG kappa bands disappeared, confirming this therapy's effect on SPE and IFE. Therefore, clinical pathologists should be aware of when providers prescribe new monoclonal antibody therapy and become familiar with the position of commonly prescribed (tmAbs) therapies at their institutions.
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Affiliation(s)
- Sumit K Shah
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR, US
| | - Hoda A Hagrass
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR, US
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5
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Jerbi A, Hachicha H, Charfi A, Kallel F, Feki S, Ben Ayed M, Ayadi F, Akrout R, Frikha F, Amouri A, Kammoun K, Mdhaffar M, Ben Hmida M, Tahri N, Bahloul Z, Baklouti S, Elloumi M, Masmoudi H. Biclonal Gammopathies in South Tunisia: Clinical and Biological Characteristics. Lab Med 2023; 54:464-468. [PMID: 36799924 DOI: 10.1093/labmed/lmac153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023] Open
Abstract
OBJECTIVE Biclonal gammopathies (BGs) are rare situations characterized by the production of 2 monoclonal proteins. There are no available data on BGs in North Africa. We aimed to estimate the prevalence of BGs in our population and describe their clinical and laboratory features. METHODS We conducted a 31-year retrospective study including patients with persistent double monoclonal bands based on the results of immunofixation/immunoelectrophoresis. RESULTS A total of 35 patients with available clinical data (sex ratio, M/F = 1.53; mean age, 70 ± 10.87 years [range, 45-90 years]) were included. The main associated conditions were multiple myeloma (MM) (40%), BG of undetermined significance (BGUS) (34%), and lymphoproliferative diseases (23%). Only one-third of the patients had 2 monoclonal spikes on serum protein electrophoresis. The most common paraprotein combinations were immunoglobulin (Ig)G-IgG (25%) and IgG-IgA (23%) with different light chains in one-half of the cases. The mean follow-up was 25.6 months (median, 12 months). No BGUS evolved into a malignant disease. CONCLUSION BGs are rare in clinical laboratory routine but must be accurately identified by the pathologist. Our cohort is characterized by a high prevalence of BGUS compared with MM.
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Affiliation(s)
- Ameni Jerbi
- Immunology Department, Habib Bourguiba, University Hospital, University of Sfax, Sfax, Tunisia
| | - Hend Hachicha
- Immunology Department, Habib Bourguiba, University Hospital, University of Sfax, Sfax, Tunisia
| | - Aida Charfi
- Histocompatibility Department, Hedi Chaker University Hospital, University of Sfax, Sfax, Tunisia
| | - Faten Kallel
- Hematology Department, Hedi Chaker University Hospital, University of Sfax, Sfax, Tunisia
| | - Sawsan Feki
- Immunology Department, Habib Bourguiba, University Hospital, University of Sfax, Sfax, Tunisia
| | - Mourad Ben Ayed
- Immunology Department, Habib Bourguiba, University Hospital, University of Sfax, Sfax, Tunisia
| | - Faten Ayadi
- Immunology Department, Habib Bourguiba, University Hospital, University of Sfax, Sfax, Tunisia
| | - Rim Akrout
- Rheumatology Department, Hedi Chaker University Hospital, University of Sfax, Sfax, Tunisia
| | - Faten Frikha
- Internal Medicine Department, Hedi Chaker University Hospital, University of Sfax, Sfax, Tunisia
| | - Ali Amouri
- Gastro-enterology Department, Hedi Chaker University Hospital, University of Sfax, Sfax, Tunisia
| | - Khaoula Kammoun
- Nephrology Department, Hedi Chaker University Hospital, University of Sfax, Sfax, Tunisia
| | - Moez Mdhaffar
- Hematology Department, Hedi Chaker University Hospital, University of Sfax, Sfax, Tunisia
| | - Mohamed Ben Hmida
- Nephrology Department, Hedi Chaker University Hospital, University of Sfax, Sfax, Tunisia
| | - Nabil Tahri
- Gastro-enterology Department, Hedi Chaker University Hospital, University of Sfax, Sfax, Tunisia
| | - Zouheir Bahloul
- Internal Medicine Department, Hedi Chaker University Hospital, University of Sfax, Sfax, Tunisia
| | - Sofien Baklouti
- Rheumatology Department, Hedi Chaker University Hospital, University of Sfax, Sfax, Tunisia
| | - Moez Elloumi
- Hematology Department, Hedi Chaker University Hospital, University of Sfax, Sfax, Tunisia
| | - Hatem Masmoudi
- Immunology Department, Habib Bourguiba, University Hospital, University of Sfax, Sfax, Tunisia
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Hayes AM, Kastl B, Perry E, Moore AR, Springer NL. Multiple myeloma presenting as blepharitis in a horse. Vet Clin Pathol 2023; 52:514-520. [PMID: 37248209 DOI: 10.1111/vcp.13227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 11/21/2022] [Accepted: 12/07/2022] [Indexed: 05/31/2023]
Abstract
Myeloma-related disorders, including multiple myeloma, extramedullary plasmacytoma, and solid osseous plasmacytoma, are rare in horses. Clinical complaints for myeloma-related disorders are nonspecific, and when present, M-protein location is more variable on protein electrophoresis in horses relative to dogs and cats. Here, we describe a case of a 15-year-old Thoroughbred mare who presented with recurrent blepharitis. Marked hyperglobulinemia was an incidental finding on routine hematologic and biochemical testing. Bone marrow aspiration consisted of >30% plasma cells, and serum protein electrophoresis demonstrated a monoclonal gammopathy in the alpha 2 fraction leading to a diagnosis of multiple myeloma. Immunofixation and radial immunodiffusion confirmed the presence of an IgG M-protein. Based on a restricted peak in the alpha 2 location, the specific M-protein is suspected to be IgG(T), an IgG isotype unique to horses. M-protein migration in horses is variable relative to dogs and cats, yet immunofixation can still be used to identify equine IgG M-protein isotypes. The unique clinical presentation in this case also serves as a reminder to consider neoplasia in horses with unusual or nonspecific clinical signs.
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Affiliation(s)
- Allison M Hayes
- Department of Diagnostic Medicine/Pathobiology, Kansas State University, Manhattan, Kansas, USA
| | - Brandy Kastl
- Department of Diagnostic Medicine/Pathobiology, Kansas State University, Manhattan, Kansas, USA
| | | | - A Russell Moore
- Department of Microbiology, Immunology, and Pathology, Colorado State University, Fort Collins, Colorado, USA
| | - Nora L Springer
- Department of Diagnostic Medicine/Pathobiology, Kansas State University, Manhattan, Kansas, USA
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Guerlin M, Mourou K, Martini V, Soetart N, Comazzi S, Trumel C, Granat F. Waldenström's Macroglobulinemia in a Normoproteinemic Dog with Atypical Bimorphic Plasmacytoid Differentiation and Monoclonal Gammopathy. Vet Sci 2023; 10:vetsci10050355. [PMID: 37235438 DOI: 10.3390/vetsci10050355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/02/2023] [Accepted: 05/10/2023] [Indexed: 05/28/2023] Open
Abstract
A 2-year-old neutered female Small Munsterlander dog was presented for an insect bite. Physical examination revealed a poor body condition, a peripheral lymphadenomegaly, and suspected splenomegaly. A complete blood count (Sysmex XN-V) revealed marked leukocytosis with lymphocytosis and abnormal dot plots. An abnormal monomorphic lymphoid population and marked rouleaux formation were noted on the blood smear. Lymph node aspirates contained an atypical bimorphic population of lymphocytes, either with a plasmacytoid or a blastic appearance. This double population was also found in the spleen, liver, bone marrow, tonsils, and other tissues. Peripheral blood and lymph node clonality assays revealed clonal BCR gene rearrangement. Flow cytometry revealed a mixed population of small-sized B-cells (CD79a+ CD21+ MHCII+) and medium-sized B-cells (CD79a+ CD21- MHCII-) in lymph nodes and a dominant population of small-sized mature B-cells (CD21+ MHCII+) in peripheral blood. Though normoproteinemic, serum protein electrophoresis revealed an increased α2-globulin fraction with an atypical restricted peak, identified as monoclonal IgM by immunofixation. Urine protein immunofixation revealed a Bence-Jones proteinuria. A diagnosis of Waldenström's macroglobulinemia was made. Chemotherapy was initiated, but the dog was euthanized 12 months after the initial presentation due to marked clinical degradation.
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Affiliation(s)
- Maud Guerlin
- Département des Sciences Cliniques des Animaux de Compagnie et de Sport, Université de Toulouse, ENVT, 31000 Toulouse, France
- CREFRE, Université de Toulouse, INSERM, ENVT, UPS, 31000 Toulouse, France
| | - Kévin Mourou
- Département des Animaux de Compagnie, Université de Lyon, VetAgro Sup, Marcy L'Etoile, 69007 Lyon, France
| | - Valeria Martini
- Department of Veterinary Medicine and Animal Sciences, University of Milan, Via dell'Università 6, 26900 Lodi, Italy
| | - Nicolas Soetart
- LabOniris-Department of Biology, Pathology and Food Science, Oniris-Nantes Atlantic National College of Veterinary Medicine, Food Science and Engineering, 44300 Nantes, France
| | - Stefano Comazzi
- Department of Veterinary Medicine and Animal Sciences, University of Milan, Via dell'Università 6, 26900 Lodi, Italy
| | - Catherine Trumel
- Département des Sciences Cliniques des Animaux de Compagnie et de Sport, Université de Toulouse, ENVT, 31000 Toulouse, France
- CREFRE, Université de Toulouse, INSERM, ENVT, UPS, 31000 Toulouse, France
| | - Fanny Granat
- Département des Sciences Cliniques des Animaux de Compagnie et de Sport, Université de Toulouse, ENVT, 31000 Toulouse, France
- CRCT, Université de Toulouse, INSERM, UMR 1037, ENVT, 31000 Toulouse, France
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Hughes KL, Rout ED, Avery PR, Pavuk AA, Avery AC, Moore AR. A series of heterogeneous lymphoproliferative diseases with CD3 and MUM1 co-expressed in cats and dogs. J Vet Diagn Invest 2023; 35:22-33. [PMID: 36424869 PMCID: PMC9751460 DOI: 10.1177/10406387221139799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Lymphoma diagnosis in dogs and cats is continually evolving as new subtypes and human correlates are being recognized. In humans, T-cell lymphomas with MUM1 expressed and plasma cell neoplasia or B-cell lymphomas with CD3 expressed aberrantly are reported only rarely. We report here a case series of tumors in dogs and cats with CD3 and MUM1 co-expressed as determined by immunocytochemistry or immunohistochemistry. Lineage was assigned for these tumors by 3 board-certified pathologists and a veterinary immunologist based on review of clinical and cellular features and the results of ancillary testing including PCR for antigen receptor rearrangements, flow cytometry, and serum protein electrophoresis with immunofixation. In cats, 7 of 7 tumors, and in dogs, 3 of 6 tumors with CD3 and MUM1 co-expressed had clonal rearrangement of the immunoglobulin gene or serum monoclonal immunoglobulin, consistent with a diagnosis of a plasma cell neoplasia or myeloma-related disorder with CD3 expressed aberrantly. Disease was often disseminated; notably, 3 of 7 feline cases had cutaneous and/or subcutaneous involvement in the tarsal area. In dogs, 3 of 6 cases had a clonal T-cell receptor gamma result and no clonal immunoglobulin gene rearrangement and were diagnosed as a T-cell tumor with MUM1 expressed. The use of multiple testing modalities in our series of tumors with plasma-cell and T-cell antigens in dogs and cats aided in the comprehensive identification of the lymphoproliferative disease subtype.
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Affiliation(s)
- Kelly L. Hughes
- Department of Microbiology, Immunology, Pathology, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, CO, USA
| | - Emily D. Rout
- Department of Microbiology, Immunology, Pathology, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, CO, USA
| | - Paul R. Avery
- Department of Microbiology, Immunology, Pathology, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, CO, USA
| | | | - Anne C. Avery
- Department of Microbiology, Immunology, Pathology, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, CO, USA
| | - A Russell Moore
- Department of Microbiology, Immunology, Pathology, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, CO, USA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Willrich MAV. Commentary on Significance of Monoclonal Band in Cerebral Spinal Fluid. Clin Chem 2022; 68:281. [PMID: 35104858 DOI: 10.1093/clinchem/hvab255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 08/10/2021] [Indexed: 11/14/2022]
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Khan NAJ, Nellhaus E, Griswold D, Jamil MO. First Case of Nodular Localized Primary Cutaneous Amyloidosis Treated With Bortezomib and Dexamethasone. J Investig Med High Impact Case Rep 2021; 9:23247096211058488. [PMID: 34894809 PMCID: PMC8672373 DOI: 10.1177/23247096211058488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Nodular localized cutaneous amyloidosis is a rare form of cutaneous amyloidosis and is characterized by an extracellular deposition of insoluble amyloid fibrils which are either primarily cutaneous or a manifestation of an underlying systemic amyloidosis. Biopsy of the lesion is mandatory for the diagnosis, and histopathology shows diffuse amyloid deposits with plasmacytic infiltration. Apple-green birefringence characteristic of amyloidosis is observed when stained with Congo red and viewed under polarized light. Amyloid subtyping is done with laser microdissection followed by mass spectrometry. Majority of these lesions do not require any treatment but surgical excision, shave excision, laser therapy, and radiotherapy can be considered for symptomatic nodular localized primary cutaneous amyloidosis (NLPCA). We present a case of recurrent NLPCA in a 64-year-old woman who was treated with bortezomib and dexamethasone after failing several local therapies with excellent response.
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Affiliation(s)
| | - Emma Nellhaus
- Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, USA
| | - Doreen Griswold
- Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, USA
| | - Muhammad Omer Jamil
- Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, USA
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Thoren KL, McCash SI, Murata K. Immunotyping Provides Equivalent Results to Immunofixation in a Population with a High Prevalence of Monoclonal Gammopathies. J Appl Lab Med 2021; 6:1551-1560. [PMID: 34329441 DOI: 10.1093/jalm/jfab067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 05/25/2021] [Indexed: 11/14/2022]
Abstract
BACKGROUND Serum immunofixation (IF) is a common laboratory test used to diagnose and monitor patients with monoclonal gammopathies. Similarly, immunotyping (IT) by capillary electrophoresis can confirm the presence of a monoclonal protein (M-protein) and determine its isotype. The goal of this study was to compare the ability of IT and IF to detect M-proteins. METHODS IT and IF results for 1000 waste clinical serum samples were obtained. All results were interpreted blindly by reviewers who were experienced in each technique. Results were compared by band. Results were also compared to patient history to determine if the original clone was present. We determined the sensitivity of IT and IF alone and in combination with additional tests. Finally, we evaluated the impact of reviewer training on the sensitivity of IT. RESULTS IT and IF were concordant in 721/773 (93%) samples with a history of an intact M-protein and in 143/172 (83%) samples with a history of a free light chain (FLC) M-protein. IF was significantly more sensitive than IT for the detection of FLC M-proteins (P < 0.0001). However, IF was not more sensitive than IT for detection of intact M-proteins (P = 0.1272) or when each test was combined with the FLC ratio or urine immunofixation (P = 0.2812 and P = 0.6171, respectively). Finally, after training, inexperienced reviewers improved their IT sensitivity by 19%. CONCLUSION IT provides equivalent results to IF for the detection of monoclonal proteins. Training and experience are critical to the accurate interpretation of IT.
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Affiliation(s)
- Katie L Thoren
- Clinical Chemistry Service, Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Samuel I McCash
- 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
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Mellors PW, Kohlhagen MC, Dasari S, Willrich MAV, Gertz MA, Kumar SK, Lacy MQ, Murray DL, Dispenzieri A. Belantamab mafodotin detection by MASS-FIX and immunofixation. Clin Chem Lab Med 2021; 59:e430-e433. [PMID: 34114387 DOI: 10.1515/cclm-2021-0326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 05/28/2021] [Indexed: 11/15/2022]
Affiliation(s)
| | - Mindy C Kohlhagen
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Surendra Dasari
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Maria A V Willrich
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Morie A Gertz
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Shaji K Kumar
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Martha Q Lacy
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - David L Murray
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Angela Dispenzieri
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
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14
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Turner KA, Frinack JL, Ettore MW, Tate JR, Graziani MS, Jacobs JFM, Booth RA, McCudden CR, Keren DF, Delgado JC, Zemtsovskaja G, Fullinfaw RO, Caldini A, de Malmanche T, Katakouzinos K, Burke M, Palladini G, Altinier S, Zaninotto M, Righetti G, Melki MT, Bell S, Willrich MAV. An international multi-center serum protein electrophoresis accuracy and M-protein isotyping study. Part I: factors impacting limit of quantitation of serum protein electrophoresis. Clin Chem Lab Med 2021; 58:533-546. [PMID: 31940284 DOI: 10.1515/cclm-2019-1104] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 12/02/2019] [Indexed: 11/15/2022]
Abstract
Background Serum protein electrophoresis (SPEP) is used to quantify the serum monoclonal component or M-protein, for diagnosis and monitoring of monoclonal gammopathies. Significant imprecision and inaccuracy pose challenges in reporting small M-proteins. Using therapeutic monoclonal antibody-spiked sera and a pooled beta-migrating M-protein, we aimed to assess SPEP limitations and variability across 16 laboratories in three continents. Methods Sera with normal, hypo- or hypergammaglobulinemia were spiked with daratumumab, Dara (cathodal migrating), or elotuzumab, Elo (central-gamma migrating), with concentrations from 0.125 to 10 g/L (n = 62) along with a beta-migrating sample (n = 9). Provided with total protein (reverse biuret, Siemens), laboratories blindly analyzed samples according to their SPEP and immunofixation (IFE) or immunosubtraction (ISUB) standard operating procedures. Sixteen laboratories reported the perpendicular drop (PD) method of gating the M-protein, while 10 used tangent skimming (TS). A mean percent recovery range of 80%-120% was set as acceptable. The inter-laboratory %CV was calculated. Results Gamma globulin background, migration pattern and concentration all affect the precision and accuracy of quantifying M-proteins by SPEP. As the background increases, imprecision increases and accuracy decreases leading to overestimation of M-protein quantitation especially evident in hypergamma samples, and more prominent with PD. Cathodal migrating M-proteins were associated with less imprecision and higher accuracy compared to central-gamma migrating M-proteins, which is attributed to the increased gamma background contribution in M-proteins migrating in the middle of the gamma fraction. There is greater imprecision and loss of accuracy at lower M-protein concentrations. Conclusions This study suggests that quantifying exceedingly low concentrations of M-proteins, although possible, may not yield adequate accuracy and precision between laboratories.
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Affiliation(s)
- Katherine A Turner
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Jody L Frinack
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Michael W Ettore
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Jillian R Tate
- Department of Chemical Pathology, Pathology Queensland, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | | | - Joannes F M Jacobs
- Department of Laboratory Medicine, Radboud University Medical Center, Laboratory Medical Immunology, Nijmegen, the Netherlands
| | - Ronald A Booth
- Department of Pathology and Laboratory Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Christopher R McCudden
- Department of Pathology and Laboratory Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | | | - Julio C Delgado
- ARUP Laboratories, Department of Pathology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Galina Zemtsovskaja
- Clinical Chemistry Laboratory, North Estonia Medical Centre, Tallinn, Estonia
| | - Robert O Fullinfaw
- Department of Chemical Pathology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Anna Caldini
- General Laboratory, Careggi University Hospital, Florence, Italy
| | - Theo de Malmanche
- NSW Health Pathology, Immunology Department, John Hunter Hospital, New Lambton Heights, NSW, Australia
| | - Katina Katakouzinos
- Immunopathology Department, Royal Prince Alfred Hospital, Missenden Rd, Camperdown, NSW, Australia
| | - Matthew Burke
- Department of Chemical Pathology, Pathology Queensland, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Giovanni Palladini
- Amyloidosis Research and Treatment Center, Foundation IRCCS Policlinico San Matteo, and Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Sara Altinier
- Laboratory Medicine of the University Hospital of Padova, Padova, Italy
| | - Martina Zaninotto
- Laboratory Medicine of the University Hospital of Padova, Padova, Italy
| | | | | | | | - Maria Alice Vieira Willrich
- Division of Clinical Biochemistry and Immunology, Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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15
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Jacobs JFM, Turner KA, Graziani MS, Frinack JL, Ettore MW, Tate JR, Booth RA, McCudden CR, Keren DF, Delgado JC, Zemtsovskaja G, Fullinfaw RO, Caldini A, de Malmanche T, Katakouzinos K, Burke M, Palladini G, Altinier S, Zaninotto M, Righetti G, Melki MT, Bell S, Willrich MAV. An international multi-center serum protein electrophoresis accuracy and M-protein isotyping study. Part II: limit of detection and follow-up of patients with small M-proteins. Clin Chem Lab Med 2021; 58:547-559. [PMID: 31940285 DOI: 10.1515/cclm-2019-1105] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 12/17/2019] [Indexed: 11/15/2022]
Abstract
Background Electrophoretic methods to detect, characterize and quantify M-proteins play an important role in the management of patients with monoclonal gammopathies (MGs). Significant uncertainty in the quantification and limit of detection (LOD) is documented when M-proteins are <10 g/L. Using spiked sera, we aimed to assess the variability in intact M-protein quantification and LOD across 16 laboratories. Methods Sera with normal, hypo- or hyper-gammaglobulinemia were spiked with daratumumab or elotuzumab, with concentrations from 0.125 to 10 g/L (n = 62) along with a beta-migrating sample (n = 9). Laboratories blindly analyzed samples according to their serum protein electrophoresis (SPEP)/isotyping standard operating procedures. LOD and intra-laboratory percent coefficient of variation (%CV) were calculated and further specified with regard to the method (gel/capillary electrophoresis [CZE]), gating strategy (perpendicular drop [PD]/tangent skimming [TS]), isotyping (immunofixation/immunosubtraction [ISUB]) and manufacturer (Helena/Sebia). Results All M-proteins ≥1 g/L were detected by SPEP. With isotyping the LOD was moderately more sensitive than with SPEP. The intensity of polyclonal background had the biggest negative impact on LOD. Independent of the method used, the intra-laboratory imprecision of M-protein quantification was small (mean CV = 5.0%). Low M-protein concentration and high polyclonal background had the strongest negative impact on intra-laboratory precision. All laboratories were able to follow trend of M-protein concentrations down to 1 g/L. Conclusions In this study, we describe a large variation in the reported LOD for both SPEP and isotyping; overall LOD is most affected by the polyclonal immunoglobulin background. Satisfactory intra-laboratory precision was demonstrated. This indicates that the quantification of small M-proteins to monitor patients over time is appropriate, when subsequent testing is performed within the same laboratory.
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Affiliation(s)
- Joannes F M Jacobs
- Laboratory Medical Immunology, Department of Laboratory Medicine, Radboud University Medical Center, Geert Grooteplein 10, 6525 GA Nijmegen, The Netherlands
| | - Katherine A Turner
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | | | - Jody L Frinack
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Michael W Ettore
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Jillian R Tate
- Department of Chemical Pathology, Pathology Queensland, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Ronald A Booth
- Department of Pathology and Laboratory Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Christopher R McCudden
- Department of Pathology and Laboratory Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - David F Keren
- Department of Pathology, The University of Michigan, Ann Arbor, MI, USA
| | - Julio C Delgado
- ARUP Laboratories, Department of Pathology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Galina Zemtsovskaja
- Clinical Chemistry Laboratory, North Estonia Medical Centre, Tallinn, Estonia
| | - Robert O Fullinfaw
- Department of Chemical Pathology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Anna Caldini
- General Laboratory, Careggi University Hospital, Florence, Italy
| | - Theo de Malmanche
- NSW Health Pathology, Immunology Department, John Hunter Hospital, New Lambton Heights NSW, Australia
| | - Katina Katakouzinos
- Immunopathology Department, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Matthew Burke
- Department of Chemical Pathology, Pathology Queensland, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Giovanni Palladini
- Amyloidosis Research and Treatment Center, Foundation IRCCS Policlinico San Matteo, and Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Sara Altinier
- Laboratory Medicine of the University Hospital of Padova, Padova, Italy
| | - Martina Zaninotto
- Laboratory Medicine of the University Hospital of Padova, Padova, Italy
| | | | | | | | - Maria Alice Vieira Willrich
- Division of Clinical Biochemistry and Immunology, Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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16
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Brown JE, Russell EB, Moore AR, Oscos-Snowball A, Stent A, Courtman NF. Hypoglobulinemia in a dog with disseminated plasma cell neoplasia: Case report and review of the diagnostic criteria. Vet Clin Pathol 2021; 50:227-235. [PMID: 33913178 DOI: 10.1111/vcp.12948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/13/2020] [Accepted: 09/03/2020] [Indexed: 01/01/2023]
Abstract
This is the first reported case of hypoglobulinemia in a dog with disseminated plasma cell neoplasia. A 6-year-old male intact Rottweiler was referred to the U-Vet Animal Hospital (Werribee, Vic, Australia) for weight loss, hyporexia, lethargy, vomiting, and soft stools. Examination of a buffy coat preparation and splenic and liver aspirates revealed a monomorphic population of plasmacytoid cells, and the same cells comprised approximately 90% of bone marrow samples submitted for cytologic and histologic evaluation. Biochemistry revealed a hypoglobulinemia, and the presence of an M-protein was not supported by serum and urine protein electrophoresis or serum immunofixation. Immunohistochemistry demonstrated strong nuclear labeling for MUM-1.
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Affiliation(s)
- Juliet E Brown
- U-Vet Werribee Animal Hospital and Faculty of Veterinary and Agricultural Science, University of Melbourne, Werribee, Vic., Australia
| | - Elise B Russell
- U-Vet Werribee Animal Hospital and Faculty of Veterinary and Agricultural Science, University of Melbourne, Werribee, Vic., Australia
| | - A Russell Moore
- Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, CO, USA
| | - Astrid Oscos-Snowball
- U-Vet Werribee Animal Hospital and Faculty of Veterinary and Agricultural Science, University of Melbourne, Werribee, Vic., Australia
| | - Andrew Stent
- U-Vet Werribee Animal Hospital and Faculty of Veterinary and Agricultural Science, University of Melbourne, Werribee, Vic., Australia
| | - Natalie F Courtman
- U-Vet Werribee Animal Hospital and Faculty of Veterinary and Agricultural Science, University of Melbourne, Werribee, Vic., Australia
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17
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Moore AR, Harris A, Jeffries C, Avery PR, Vickery K. Retrospective evaluation of the use of the International Myeloma Working Group response criteria in dogs with secretory multiple myeloma. J Vet Intern Med 2020; 35:442-450. [PMID: 33215766 PMCID: PMC7848390 DOI: 10.1111/jvim.15967] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 10/24/2020] [Accepted: 11/05/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Current recommendations for monitoring disease progression and response to treatment in humans with multiple myeloma include evaluation of serum paraprotein (M-protein) concentration. Densitometry, species-specific radial immunodiffusion (RID) and ELISA methods can be used to quantify M-proteins. OBJECTIVE Retrospectively evaluate use of the International Myeloma Working Group (IMWG) response criteria for humans in dogs with multiple myeloma. ANIMALS Sixteen dogs with a diagnosis of multiple myeloma, M-protein documented by serum protein electrophoresis (SPE) and immunofixation (IF) in an initial sample and subsequent electrophoretic evaluation of serial samples. METHODS Retrospectively, densitometric M-proteins, RID and globulins were measured and characterized according to IMWG criteria. Available clinical history was reviewed. Overall survival time (OST) was calculated from initial electrophoretic evaluation to death or last contact. RESULTS All cases received some form of nonstandardized chemotherapy. Complete response (CR), a lack of detectable M-protein by SPE and IF, was documented in 1 case. Median survival was longer for dogs that attained ≥90% densitometric M-protein reduction (630 days) than for those that did not attain at least 50% reduction in densitometric M-protein (284 days; log rank P = .006). Five dogs were defined as having progressive disease (M-protein increase of >25% and at least 0.5 g/dL from nadir), which correlated with concurrent or subsequent clinical deterioration. Response criteria categorized by serum globulins or RID was not correlated with OST or clinical findings. CONCLUSIONS AND CLINICAL IMPORTANCE Densitometric M-protein characterized using IMWG response criteria correlated with OST and clinical findings. Densitometric M-protein detection should be used to monitor dogs with multiple myeloma.
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Affiliation(s)
- A Russell Moore
- Department of Microbiology, Immunology and Pathology, Colorado State University, Ft. Collins, Colorado, USA
| | - Adam Harris
- Department of Microbiology, Immunology and Pathology, Colorado State University, Ft. Collins, Colorado, USA
| | - Christina Jeffries
- Department of Microbiology, Immunology and Pathology, Colorado State University, Ft. Collins, Colorado, USA
| | - Paul R Avery
- Department of Microbiology, Immunology and Pathology, Colorado State University, Ft. Collins, Colorado, USA
| | - Kate Vickery
- Department of Clinical Sciences, Colorado State University, Ft. Collins, Colorado, USA
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18
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Janicki P, Niemczyk STANIS. Non-secretory multiple myeloma in a patient with chronic kidney disease. Pol Merkur Lekarski 2020; 48:344-345. [PMID: 33130796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
UNLABELLED Multiple myeloma (MM) ) is a malignant plasma cell disorder from the group of monoclonal gammopathies. One of the most frequent diagnostic findings is the M-spike in serum protein electrophoresis (SPEP), which is notably absent in a rare non-secretory subtype of this disease. A CASE REPORT A case report describes a 55-year old woman with a history of chronic kidney disease (CKD) in stage 3, proteinuria, asthma and Graves' disease. She presented for a diagnosis of proteinuria (of 2,2 g/24 h). Her SPEP was normal, and she underwent a kidney biopsy, which showed mild glomerulal abnormalities. She returned to the clinic after 5 years with progression of CKD (between hospitalizations creatinine rose from 1,27 mg/dl to 2,8) and proteinuria (2,7 g/24 h). She had normocytic anemia, normocalcemia and normal ESR. The SPEP showed no suspicious findings, but suspecting multiple myeloma, immunofixation was performed. It showed excessive levels of kappa FLC in serum and urine. A bone marrow biopsy showed plasmocytes characteristic for MM in both number and phenotype. No osteolytic lesions were shown in diagnostic imaging, and beta-2-microglobulin was elevated to 6,5 μg. Thus, the patient was diagnosed with ISS stage 3 multiple myeloma and referred to a hematology clinic for treatment. CONCLUSIONS The diagnosis of atypical cases of multiple myeloma may pose a difficulty to clinicians. Knowledge of diagnostic tests is required to introduce proper treatment.
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Affiliation(s)
- Piotr Janicki
- Department of Internal Disease, Nephrology and Dialysotherapy, Military Institute of Medicine, Warsaw, Poland
| | - STANISłAW Niemczyk
- Department of Internal Disease, Nephrology and Dialysotherapy, Military Institute of Medicine, Warsaw, Poland
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19
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Tokunaga T, Hashimoto H, Yoshida Y, Sugimoto T, Mokuda S, Kosaka Y, Shimizu R, Hirata S, Kumagai T, Komoto K, Wada H, Sugiyama E. Immunoglobulin D-kappa multiple myeloma in a patient with rheumatoid arthritis: a case report and review of the literature. Mod Rheumatol Case Rep 2020; 5:22-28. [PMID: 32985955 DOI: 10.1080/24725625.2020.1826651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
A 77-year-old Japanese woman with a 21-year history of seropositive, erosive rheumatoid arthritis (RA) and a 10-year history of methotrexate (MTX) therapy was admitted with malaise and mild consciousness disturbance. Laboratory data showed hypercalcemia, acute kidney injury, normocytic anaemia, and thrombocytopenia. As we first assumed drug-induced toxicity by MTX and eldecalcitol, both were discontinued and leucovorin rescue therapy and calcitonin were administered. However, her condition continued to worsen. Serum protein electrophoresis showed only a small M-peak, immunoelectrophoresis of both the serum and urine demonstrated Bence-Jones kappa (κ) type monoclonal protein without immunoglobulin heavy chain, and bone marrow examination revealed proliferation of plasma cells. We diagnosed her with Bence-Jones κ type multiple myeloma (MM) and transferred her to the department of haematology of a higher order medical institution. Conclusively, the diagnosis of immunoglobulin (Ig) D-κ type MM, a rare variant of this disorder, was determined in accordance with serum immunofixation. Several previous studies have suggested that pre-existing RA is a risk factor for MM. Although IgD MM is characterised by its clinical severity and poor prognosis compared to other subtypes, it is often misdiagnosed or mistaken as light chain type MM, as in the present case, because of the low level of IgD M-protein, resulting in delayed diagnosis. Physicians must take MM into consideration as a differential diagnosis when inactive RA patients present with inexplicable elevated calcium, renal failure, anaemia, and bone lesion symptoms and should be aware of IgD MM to establish the correct diagnosis promptly.
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Affiliation(s)
- Tadahiro Tokunaga
- Department of Internal Medicine and Rheumatology, Health Insurance Society of Hitachi Zosen, Innoshima General Hospital, Hiroshima, Japan.,Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Hiroo Hashimoto
- Department of Internal Medicine and Rheumatology, Health Insurance Society of Hitachi Zosen, Innoshima General Hospital, Hiroshima, Japan
| | - Yusuke Yoshida
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Tomohiro Sugimoto
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Sho Mokuda
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Yoko Kosaka
- Division of Hematology, Department of Medicine, Kawasaki Medical School, Okayama, Japan
| | - Risa Shimizu
- Division of Hematology, Department of Medicine, Kawasaki Medical School, Okayama, Japan
| | - Shintaro Hirata
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Tomoyo Kumagai
- Department of Clinical Laboratory, Health Insurance Society of Hitachi Zosen, Innoshima General Hospital, Hiroshima, Japan
| | - Kiichi Komoto
- Department of Internal Medicine and Rheumatology, Health Insurance Society of Hitachi Zosen, Innoshima General Hospital, Hiroshima, Japan
| | - Hideho Wada
- Division of Hematology, Department of Medicine, Kawasaki Medical School, Okayama, Japan
| | - Eiji Sugiyama
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
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20
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Strobel SL, Lunsford KL. Enhancing the Role of the Medical Technologist in Serum Protein Electrophoresis Interpretation: A Pattern Recognition Approach to Identifying Obvious and Potentially Significant Subtle Alterations. Ann Clin Lab Sci 2020; 50:670-673. [PMID: 33067214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Medical technologists who perform serum protein electrophoresis can provide valuable input and assistance in the interpretation of the electrophoretic pattern. Recognition of common alterations in conjunction with the utilization of standardized interpretation comments expedites the final interpretation performed by the clinical pathologist. Improved understanding of the clinical utility of the electrophoretic interpretation enhances the role and satisfaction of the medical technologists.
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Affiliation(s)
- Stephen L Strobel
- Department of Pathology, Bon Secours Mercy Health - St. Vincent Hospital, Toledo, OH, USA
| | - Kylie L Lunsford
- Department of Pathology, Bon Secours Mercy Health - St. Vincent Hospital, Toledo, OH, USA
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21
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Kohlhagen M, Dasari S, Willrich M, Hetrick M, Netzel B, Dispenzieri A, Murray DL. Automation and validation of a MALDI-TOF MS (Mass-Fix) replacement of immunofixation electrophoresis in the clinical lab. Clin Chem Lab Med 2020; 59:155-163. [PMID: 32745067 DOI: 10.1515/cclm-2020-0581] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 07/03/2020] [Indexed: 12/14/2022]
Abstract
Objectives A matrix assisted laser desorption ionization time of flight mass spectrometry (MALDI-TOF MS) method (Mass-Fix) as a replacement for gel-based immunofixation (IFE) has been recently described. To utilize Mass-Fix clinically, a validated automated method was required. Our aim was to automate the pre-analytical processing, improve positive specimen identification and ergonomics, reduce paper data storage and increase resource utilization without increasing turnaround time. Methods Serum samples were batched and loaded onto a liquid handler along with reagents and a barcoded sample plate. The pre-analytical steps included: (1) Plating immunopurification beads. (2) Adding 10 μl of serum. (3) Bead washing. (4) Eluting the immunoglobulins (Igs), and reducing to separate the heavy and light Ig chains. The resulting plate was transferred to a second low-volume liquid handler for MALDI plate spotting. MALDI-TOF mass spectra were collected. Integrated in-house developed software was utilized for sample tracking, driving data acquisition, data analysis, history tracking, and result reporting. A total of 1,029 residual serum samples were run using the automated system and results were compared to prior electrophoretic results. Results The automated Mass-Fix method was capable of meeting the validation requirements of concordance with IFE, limit of detection (LOD), sample stability and reproducibility with a low repeat rate. Automation and integrated software allowed a single user to process 320 samples in an 8 h shift. Software display facilitated identification of monoclonal proteins. Additionally, the process maintains positive specimen identification, reduces manual pipetting, allows for paper free tracking, and does not significantly impact turnaround time (TAT). Conclusions Mass-Fix is ready for implementation in a high-throughput clinical laboratory.
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Affiliation(s)
- Mindy Kohlhagen
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Surendra Dasari
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Maria Willrich
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - MeLea Hetrick
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Brian Netzel
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Angela Dispenzieri
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - David L Murray
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
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22
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Brivio R, Cappellani A, Carpenedo M, Minolfi V, Intra J, Romano R, Spinoni N, Brambilla P. IgE monoclonal gammopathy: The clinical relevance to perform the immunofixation using IgE antisera. Int J Lab Hematol 2020; 42:e237-e239. [PMID: 32662590 DOI: 10.1111/ijlh.13285] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/04/2020] [Accepted: 06/18/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Rinaldo Brivio
- Clinical Chemistry Laboratory, University of Milano-Bicocca, Azienda Socio Sanitaria Territoriale di Monza ASST-Monza, St Gerardo Hospital, Monza, Italy
| | - Adele Cappellani
- Clinical Chemistry Laboratory, University of Milano-Bicocca, Azienda Socio Sanitaria Territoriale di Monza ASST-Monza, St Gerardo Hospital, Monza, Italy
| | - Monica Carpenedo
- Department of Hematology and Transplantation, Azienda Socio Sanitaria Territoriale di Monza ASST-Monza, St Gerardo Hospital, Monza, Italy
| | - Vanna Minolfi
- Clinical Chemistry Laboratory, University of Milano-Bicocca, Azienda Socio Sanitaria Territoriale di Monza ASST-Monza, St Gerardo Hospital, Monza, Italy
| | - Jari Intra
- Clinical Chemistry Laboratory, University of Milano-Bicocca, Azienda Socio Sanitaria Territoriale di Monza ASST-Monza, St Gerardo Hospital, Monza, Italy
| | - Rita Romano
- Clinical Chemistry Laboratory, University of Milano-Bicocca, Azienda Socio Sanitaria Territoriale di Monza ASST-Monza, St Gerardo Hospital, Monza, Italy
| | - Nadia Spinoni
- Clinical Chemistry Laboratory, University of Milano-Bicocca, Azienda Socio Sanitaria Territoriale di Monza ASST-Monza, St Gerardo Hospital, Monza, Italy
| | - Paolo Brambilla
- Department of Laboratory Medicine, University of Milano-Bicocca, Azienda Socio Sanitaria Territoriale di Monza ASST-Monza, Desio Hospital, Desio, Italy
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23
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Vakili H, Koorse Germans S, Dong X, Kansagra A, Patel H, Muthukumar A, Hashim IA. 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:E219. [PMID: 32295157 DOI: 10.3390/diagnostics10040219] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [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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24
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Galakhoff N, Leven C, Eveillard JR, Tempescul A, Kerspern H, Aubron C, Buors C, Lippert É, Carré JL, Padelli M. A case of IgE myeloma transformed into IgE-producing plasma cell leukaemia. Biochem Med (Zagreb) 2019; 30:010801. [PMID: 31839726 PMCID: PMC6904968 DOI: 10.11613/bm.2020.010801] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 10/07/2019] [Indexed: 01/22/2023] Open
Abstract
This is a case report of a challenging diagnosis of IgE monoclonal gammopathy of undetermined significance, which transformed into myeloma, then transformed into IgE-producing plasma cell leukaemia in a 71-year-old male who was followed in Brest, France, from 2015 to 2019. The IgE-producing variant is the rarest sub-type of multiple myeloma, and plasma cell leukaemia is considered to be the rarest and the most aggressive of human monoclonal gammopathies. In November 2015, hypogammaglobulinemia was detected during a systematic check-up. A kappa light chain monoclonal gammopathy was first diagnosed due to an increase of the free kappa/lambda light chains ratio. No monoclonal immunoglobulin was detected by either serum protein electrophoresis (Capillarys 2, Sebia, Issy-les-Moulineaux, France) or immunofixation (Hydrasys 2, Sebia, Issy-les-Moulineaux, France). In June 2018, a blood smear led to the diagnosis of plasma cell leukaemia. A monoclonal peak was detected and identified as IgE-kappa. Analysis of an archival sample taken three years earlier, revealed the presence of a monoclonal IgE, which had been missed at diagnosis. Chemotherapy with bortezomib and dexamethasone was introduced. The patient survived 10 months after the diagnosis of leukaemia. This case shows that an abnormal free light chain ratio should be considered as a possible marker of IgE monoclonal gammopathy even in the absence of a solitary light chain revealed by immunofixation. In addition, the use of an undiluted serum may increase the sensitivity of the immunofixation for the detection of IgE monoclonal gammopathies compared to the 1:3 dilution recommended by the manufacturer.
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Affiliation(s)
- Nicolas Galakhoff
- Department of Biochemistry and Pharmaco-Toxicology, Brest University Hospital, Brest, France
| | - Cyril Leven
- Department of Biochemistry and Pharmaco-Toxicology, Brest University Hospital, Brest, France
| | | | - Adrian Tempescul
- Department of Haematology, Brest University Hospital, Brest, France
| | - Hélène Kerspern
- Department of Biochemistry and Pharmaco-Toxicology, Brest University Hospital, Brest, France
| | - Cécile Aubron
- Medical Intensive Care, Brest University Hospital, Brest, France
| | - Caroline Buors
- Laboratory of Haematology, Brest University Hospital, Brest, France
| | - Éric Lippert
- Laboratory of Haematology, Brest University Hospital, Brest, France.,Université de Brest, INSERM, EFS, UMR 1078, GGB, Brest, France
| | - Jean-Luc Carré
- Department of Biochemistry and Pharmaco-Toxicology, Brest University Hospital, Brest, France
| | - Maël Padelli
- Department of Biochemistry and Pharmaco-Toxicology, Martinique University Hospital, Fort-de-France, France
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25
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Colopy LJ, Shiu KB, Snyder LA, Avery AC, Rout ED, Moore AR. Immunoglobulin G4-related disease in a dog. J Vet Intern Med 2019; 33:2732-2738. [PMID: 31654456 PMCID: PMC6872619 DOI: 10.1111/jvim.15624] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 09/05/2019] [Indexed: 12/15/2022] Open
Abstract
Immunoglobulin G4-related disease (IgG4-RD), which affects many organ systems, has been recognized as a distinct clinical entity in human medicine for just over a decade but has not been previously identified in dogs. In humans, IgG4-RD is characterized by diffuse IgG4-positive lymphoplasmacytic infiltrates that commonly lead to increased serum concentrations of IgG4 and IgE, peripheral eosinophilia, tumorous swellings that often include the parotid salivary glands, obliterative phlebitis, and extensive fibrosis. Herein we describe the diagnosis, clinical progression, and successful treatment of IgG4-RD in an 8-year-old female spayed Husky mixed breed dog. Immunoglobulin G4-related disease should be considered as a differential diagnosis for dogs with vague clinical signs, lymphoplasmacytic swellings, restricted polyclonal gammopathy, eosinophilia or some combination of these findings.
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Affiliation(s)
- Lydia J Colopy
- Veterinary Emergency Service, Veterinary Specialty Center, Middleton, Wisconsin
| | - Kai-Biu Shiu
- Veterinary Emergency Service, Veterinary Specialty Center, Middleton, Wisconsin
| | - Laura A Snyder
- Veterinary Services, Marshfield Labs, Marshfield, Wisconsin
| | - Anne C Avery
- Department of Microbiology, Immunology, and Pathology, College of Veterinary Medicine and Biomedical Science, Colorado State University, Fort Collins, Colorado
| | - Emily D Rout
- Department of Microbiology, Immunology, and Pathology, College of Veterinary Medicine and Biomedical Science, Colorado State University, Fort Collins, Colorado
| | - A R Moore
- Department of Microbiology, Immunology, and Pathology, College of Veterinary Medicine and Biomedical Science, Colorado State University, Fort Collins, Colorado
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26
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Rachidi M, Lazarian G, Letestu R, Lusina D, Desbene C, Vidal V, Eclache V, Baran-Marszak F, Cymbalista F, Fleury C. [A primitive plasma cell leukemia with immunoglobulin (Ig) E]. Ann Biol Clin (Paris) 2019; 77:557-61. [PMID: 31512579 DOI: 10.1684/abc.2019.1476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We report here a case of primitive plasma cell leukemia with immunoglobulin (Ig) E. IgE myeloma is an exceptional variant of multiple myeloma, with a very poor prognosis. Its biological diagnosis requires specific analyzes in order to detect IgE gammopathy. Plasma cell leukemia (PCL) is also a very rare and very severe form of multiple myeloma. There are two variants: primitive PCL (pPCL) occurring de novo and secondary PCL (sPCL), evolution of a preexisting myeloma. Its diagnosis is essentially biological since it is defined by a blood plasmocytosis greater than 2 G/L or 20% of the leucocytes.
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27
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Gendron N, Flament H, Litvinova E, Ortuno S, Ajzenberg N, Faille D. The (Fab)ulous Destiny of Idarucizumab: Highlighting Its Interference with Urine Protein Immunofixation. TH Open 2019; 3:e306-e308. [PMID: 31535075 PMCID: PMC6746617 DOI: 10.1055/s-0039-1697642] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 08/05/2019] [Indexed: 10/27/2022] Open
Abstract
Idarucizumab is a humanized antigen binding fragment (Fab) of a recombinant anti-dabigatran monoclonal antibody (IgG1-kappa) that allows rapid and sustained reversal of dabigatran-induced anticoagulation in case of bleeding or urgent surgery. Herein, we report a very unusual case of dabigatran reversal by idarucizumab in a 79-year-old woman with acute kidney failure admitted to a hospital in a context of hemoptysis. Three repeated injections were necessary because of massive dabigatran overdose and high rebounds of dabigatran plasma concentration. Idarucizumab was found on urine immunofixation up to 6 days after the last injection where it reacted with anti-kappa light chain antibody, but not with anti-gamma heavy chain antibody. Physicians should be aware of the increased half-life of idarucizumab in this context of acute kidney impairment and of its interference with urine immunofixation because it could lead to false-positive results and misdiagnosis of a paraprotein.
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Affiliation(s)
- Nicolas Gendron
- Laboratoire d'Hématologie, Hôpital Bichat-Claude Bernard, AP-HP, Paris, France.,Université de Paris, INSERM, U1148, Paris, France
| | - Héloïse Flament
- Laboratoire d'Immunologie-Hématologie, Hôpital Bichat-Claude Bernard, AP-HP, Paris, France.,Université de Paris, INSERM, U1149, Paris, France
| | - Elena Litvinova
- Laboratoire d'Immunologie-Hématologie, Hôpital Bichat-Claude Bernard, AP-HP, Paris, France.,Université de Paris, INSERM, U1149, Paris, France
| | - Sofia Ortuno
- Service de Néphrologie, Hôpital Bichat-Claude Bernard, AP-HP, Paris, France
| | - Nadine Ajzenberg
- Laboratoire d'Hématologie, Hôpital Bichat-Claude Bernard, AP-HP, Paris, France.,Université de Paris, INSERM, U1148, Paris, France
| | - Dorothée Faille
- Laboratoire d'Hématologie, Hôpital Bichat-Claude Bernard, AP-HP, Paris, France.,Université de Paris, INSERM, U1148, Paris, France
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28
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Lalani A, Aziz K, Khan M, Zubair T, Ahmed SI. A Patient of Multiple Myeloma with Absent M-spike on Serum Protein Electrophoresis and Elevated Serum-Free Light Chains: A Case Report and Literature Review. Cureus 2019; 11:e5398. [PMID: 31620322 PMCID: PMC6793598 DOI: 10.7759/cureus.5398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Multiple myeloma is a neoplasm described as an abnormal growth of plasma cells that outnumbers the other normal hematopoietic cells inside the bone marrow. Patients are diagnosed at a median age of 66-77 years with 37% of those with age less than 65. Unexplained bone pain (most commonly in back and ribs), pathologic fractures, fatigue, and weight loss are common initial symptoms at presentation. Here, we report a rare presentation of multiple myeloma with normal serum protein electrophoresis but elevated serum-free light chains. The absence of monoclonal gammopathy on protein electrophoresis or normal immunofixation does not negate the diagnosis of multiple myeloma. Therefore, all the sub types of multiple myeloma need to be comprehensively studied to aid in reaching an accurate diagnosis.
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Affiliation(s)
- Areej Lalani
- Internal Medicine, Dow Medical College and Civil Hospital Karachi, Dow University of Health Sciences, Karachi, PAK
| | - Kashif Aziz
- Neurology, Jersey Neurosciences, New Jersey, USA
| | - Mehreen Khan
- Internal Medicine, George Washington University School of Medicine and Health Sciences, Washington DC, USA
| | - Tayyaba Zubair
- Internal Medicine, Desai Medical Center, Ellicott City, USA
| | - Syed Ijlal Ahmed
- Neurology, Liaquat National Hospital and Medical College, Karachi, PAK
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29
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Singh N, Agrawal N, Sekhri R, Mehta A, Kumar D, Vishwakarma G, Ahmed R, Bhurani D. Light chain myeloma: A brief report from India. INDIAN J PATHOL MICR 2019; 62:441-444. [PMID: 31361235 DOI: 10.4103/ijpm.ijpm_385_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Light chain myeloma (LCM) has a reported worldwide incidence of approximately 15%-20% among all multiple myeloma (MM) patients. Few western studies have shown strong correlation of LCM with anemia, higher International Staging System scores, proclivity to renal failure, elevated lactate dehydrogenase levels, raised serum-free light chain ratio, higher frequency of extramedullary plasmacytomas, and poorer overall survival, attributable probably to lack of differentiation and skeletal destruction. The primary aim of this retrospective observational study was to define the clinical and hematological characteristics as well as prognostic outcome of Indian LCM patients in comparison with the IgG and IgA subtypes. Patients were defined according to the International Myeloma Working Group diagnostic criteria 2016 and staged as per the International Staging System. Out of 104 patients of newly diagnosed MM in which results of serum immunofixation (IFE) were available, 65 were of IgG isotype (62.5%), 15 had IgA (14.4%), and 24 had light chain myelomas (LCMs) (23.1%). It was observed that LCM patients significantly correlated with hypercalcemia and higher serum-free light chain ratios, whereas IgA patients were strongly associated with anemia and lower serum albumin levels. However, no difference was found among the three subgroups in terms of serum lactate dehydrogenase levels, proclivity to renal failure, presence of lytic bone lesions, prognostic scoring, pretransplant chemosensitivity, and progession-free survival (1 year). Thus, it may be concluded that Indian LCM patients have significantly different clinico-hematological profile in comparison with other published studies worldwide. Also, their prognostic outcomes are not worse when compared with patients of other protein isotypes, probably due to standardized treatment regimens applied.
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Affiliation(s)
- Neha Singh
- Department of Pathology, Rajiv Gandhi Cancer Institute and Research Center, New Delhi, India
| | - Narendra Agrawal
- Department of Hemato-Oncology, Rajiv Gandhi Cancer Institute and Research Center, New Delhi, India
| | - Radhika Sekhri
- Department of Pathology, Rajiv Gandhi Cancer Institute and Research Center, New Delhi, India
| | - Anurag Mehta
- Department of Pathology, Rajiv Gandhi Cancer Institute and Research Center, New Delhi, India
| | - Dushyant Kumar
- Department of Molecular Pathology, Rajiv Gandhi Cancer Institute and Research Center, New Delhi, India
| | - Gayatri Vishwakarma
- Department of Research, Rajiv Gandhi Cancer Institute and Research Center, New Delhi, India
| | - Rayaz Ahmed
- Department of Hemato-Oncology, Rajiv Gandhi Cancer Institute and Research Center, New Delhi, India
| | - Dinesh Bhurani
- Department of Hemato-Oncology, Rajiv Gandhi Cancer Institute and Research Center, New Delhi, India
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30
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Mastroianni A, Panella R, Morelli D. Differential diagnosis between bone relapse of breast cancer and lambda light chain multiple myeloma: role of the clinical biochemist. Tumori 2019; 105:NP17-NP19. [PMID: 30799772 DOI: 10.1177/0300891619832521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE The integration of expertise between oncologist and clinical biochemist for the monitoring and diagnosis of plasma cell dyscrasia is crucial. In some cases, medical laboratory scientists can provide an original contribution using the appropriate techniques to arrive at a diagnosis. METHODS We report a case of 67-year-old woman who was admitted to our hospital for bone pain. Imaging studies showed multiple diffuse bone lytic lesions, and a laboratory screen revealed anemia and altered creatinemia; serum capillary zone electrophoresis confirmed a monoclonal peak in the γ-zone that had been known since 2011, typed as immunoglobulin G kappa by immunosubtraction electrophoresis. The patient had undergone surgery for breast cancer in 2013, and based on her clinical history, the oncologist suspected the presence of bone metastases from the breast cancer and opted for relative therapy. Immunosubtraction, however, showed a very small reduction in lambda free light chains in the beta zone, but it was difficult to establish if was a monoclonal component, and consequently additional tests were performed. DISCUSSION A monoclonal component composed of only lambda free light chains was evidenced. This result in association with multiple diffuse bone lytic lesions observed led us to suspect multiple myeloma and not bone metastases from the breast cancer. Based on these observations, we encouraged the oncologist to conduct an osteomedullary biopsy, allowing us to make a diagnosis of low-grade stage II lambda light chain multiple myeloma. CONCLUSION In this report, we show how the expertise of the clinical biochemist was instrumental in solving this case.
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Affiliation(s)
- Antonio Mastroianni
- Laboratory Medicine Unit-IRCCS Istituto Nazionale per lo Studio e la Cura dei Tumori, Milan, Italy
| | - Rossella Panella
- Laboratory Medicine Unit-IRCCS Istituto Nazionale per lo Studio e la Cura dei Tumori, Milan, Italy
| | - Daniele Morelli
- Laboratory Medicine Unit-IRCCS Istituto Nazionale per lo Studio e la Cura dei Tumori, Milan, Italy
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31
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Frings VG, Röding K, Strate A, Rosenwald A, Roth S, Kneitz H, Goebeler M, Geissinger E, Wobser M. Paraproteinaemia in Primary Cutaneous Marginal Zone Lymphoma. Acta Derm Venereol 2018; 98:956-962. [PMID: 30085323 DOI: 10.2340/00015555-3016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Primary cutaneous marginal zone lymphomas (PCMZL) frequently exhibit lymphoplasmacytoid/plasmacytic differentiation, implying the capacity to produce monoclonal immunoglobulins. As these paraproteins are secreted, and thus are measurable in blood and urine, they may correlate with disease burden and serve as tumour markers reflecting therapeutic response. This study retrospectively analysed the records of 23 patients with PCMZL. During treatment and follow-up, laboratory tests, including full blood count, lactate dehydrogenase, serum protein electrophoresis and turbidimetric analyses, were conducted. Thirty-nine percent of cases showed a suspicious serum protein electrophoresis in terms of paraproteinaemia. In 44% of cases the heavy and light chain restriction in tissue samples correlated with serological findings. Altogether, 89% of the PCMZL patients with paraproteinaemia eventually experienced a relapse, in contrast to 62% of the group without paraproteinaemia. This study analysed the incidence and clinical implications of paraproteinaemia in patients with PCMZL. A clear correlation was found between paraproteinaemia, tumour relapse and therapeutic intervention.
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Affiliation(s)
- Verena G Frings
- Department of Dermatology Venereology and Allergology, University Hospital Würzburg, Josef-Schneider-Straße 2, DE-97080 Würzburg, Germany.
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32
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Abstract
This case study presents a patient with multiple myeloma whose serum specimen exhibits 2 distinct bands in serum protein electrophoresis but only one band in immunofixation electrophoresis. This latter, single band corresponds to the M-spike. An investigation is presented to determine the identity of this disappearing or phantom band. Furthermore, this case is used as a teaching point to explain the criteria used for staging multiple myeloma, how a cell can become a myeloma propagating cell, methods that can be used to identify unexpected bands in serum protein electrophoresis, possible explanations for bands in the beta region, the usual treatment regimens in multiple myeloma and finally specimen collecting and handling procedures for serum protein electrophoresis.
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Affiliation(s)
- Linda Mamone
- Department of Pathology and Laboratory Medicine, Temple University Hospital, Philadelphia, PA
| | - Jessica Jones
- Technical Services Unit, Helena Laboratories, Beaumont, TX
| | - Shiguang Liu
- Department of Pathology and Laboratory Medicine, Temple University Hospital, Philadelphia, PA
| | - Yanhua Li
- Department of Pathology and Laboratory Medicine, Temple University Hospital, Philadelphia, PA
| | - Barbara Goldsmith
- Division of Pathology, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Adil I Khan
- Department of Pathology and Laboratory Medicine, Temple University Hospital, Philadelphia, PA
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33
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Deighan WI, O'Kane MJ, McNicholl FP, Keren DF. Multiple myeloma and multiple plasmacytomas associated with free gamma heavy chain, free kappa light chain and IgGk paraproteins: an unusual triple gammopathy. Ann Clin Biochem 2016; 53:706-711. [PMID: 27166317 DOI: 10.1177/0004563216646594] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Multiple myeloma is a malignant plasma cell dyscrasia that is becoming more prevalent in an increasingly ageing population. It is a complex disease with clinical phases ranging from the premalignant monoclonal gammopathy of undetermined significance to asymptomatic (smouldering) myeloma and then symptomatic myeloma; the latter occasionally terminating in the clonal proliferation of plasma cells outside the bone marrow. We present a patient whose clonally evolved disease from monoclonal gammopathy of undetermined significance to multiple myeloma demonstrated the presence of an unusual combination of monoclonal immunoproteins. Capillary electrophoresis demonstrated the presence of three paraproteins in the gamma region (γ-region), two of which were additional to the IgGk paraprotein which migrated in the slow γ-region at initial diagnosis. Subsequent isotypic identification of the new paraproteins was not possible by immunotyping and initial immunofixation studies failed to definitively characterize the monoclonal proteins. After reduction with beta-mercaptoethanol, two paraproteins were detected by both capillary and gel electrophoresis. However, only immunofixation was able to resolve three distinct monoclonal bands, confirming the presence of free monoclonal kappa light chains in the mid-gamma region and free monoclonal heavy chains in the fast gamma region. Triple gammopathies in themselves are uncommon; this case presents a very unusual combination of paraproteins which required various electrophoretical and immunochemical techniques to identify and characterize them. The change of electrophoretic signature from the monoclonal gammopathy of undetermined significance phase to the diagnosis of multiple myeloma suggested that a number of genetically distinct subclones were present in the pretreatment clonal evolution of the disease.
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Affiliation(s)
- William I Deighan
- 1 Department of Clinical Chemistry, Altnagelvin Hospital, Londonderry, N. Ireland
| | - Maurice J O'Kane
- 1 Department of Clinical Chemistry, Altnagelvin Hospital, Londonderry, N. Ireland
| | | | - David F Keren
- 3 Department of Pathology, University of Michigan, Ann Arbor, MI, USA
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34
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Milani P, Palladini G, Merlini G. Serum-free light-chain analysis in diagnosis and management of multiple myeloma and related conditions. Scand J Clin Lab Invest Suppl 2016; 245:S113-8. [PMID: 27467897 DOI: 10.1080/00365513.2016.1210337] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The introduction of the serum-free light-chain (S-FLC) assay has been a breakthrough in the diagnosis and management of plasma cell dyscrasias, particularly monoclonal light-chain diseases. The first method, proposed in 2001, quantifies serum-free light-chains using polyclonal antibodies. More recently, assays based on monoclonal antibodies have entered into clinical practice. S-FLC measurement plays a central role in the screening for multiple myeloma and related conditions, in association with electrophoretic techniques. Analysis of S-FLC is essential in assessing the risk of progression of precursor diseases to overt plasma cell dyscrasias. It is also useful for risk stratification in solitary plasmacytoma and AL amyloidosis. The S-FLC measurement is part of the new diagnostic criteria for multiple myeloma, and provides a marker to follow changes in clonal substructure over time. Finally, the evaluation of S-FLC is fundamental for assessing the response to treatment in monoclonal light chain diseases.
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Affiliation(s)
- Paolo Milani
- a Amyloidosis Research and Treatment Center, Foundation IRCCS Policlinico San Matteo and Department of Molecular Medicine , University of Pavia , Pavia , Italy
| | - Giovanni Palladini
- a Amyloidosis Research and Treatment Center, Foundation IRCCS Policlinico San Matteo and Department of Molecular Medicine , University of Pavia , Pavia , Italy
| | - Giampaolo Merlini
- a Amyloidosis Research and Treatment Center, Foundation IRCCS Policlinico San Matteo and Department of Molecular Medicine , University of Pavia , Pavia , Italy
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35
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Gwathmey TM, Willis MS, Tatreau J, Wang S, McCudden CR. Clinical Relevance of Trace Bands on Serum Electrophoresis in Patients Without a History of Gammopathy. EJIFCC 2015; 26:114-24. [PMID: 27683487 PMCID: PMC4975357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Serum protein electrophoresis (SPE) and immunofixation is commonly used to screen for plasma cell dyscrasias. Interpretation of these tests is qualitative by nature and can yield trace, faint, or scarcely visible immunoglobulin bands (TFS), which can be difficult to classify. Whether these bands should be reported at all is challenging given their unknown clinical significance. In the present study, we retrospectively analyzed 14,036 physician-ordered protein SPE and immunofixation electrophoresis (IFE) tests on serum and urine specimens (from 4,091 patients) during the period of 2000-2010. We found that 17% of all IFE results evaluated for the presence of monoclonal gammopathies (2,389 out of 14,036) contained TFS bands, representing 4.2% (173 out of 4091) of all patients evaluated. Sixty of these patients (42%) had no previous history of gammopathy, and were clinically evaluated over a mean period of up to five years from the original diagnosis of plasma cell pathology. None of these patients had progressed to multiple myeloma, lymphoplasmacytic lymphoma, plasmacytoma, or leukemia. The remaining 82 patients (58%) had a previous history of gammopathy, but had not progressed to any symptomatic plasma cell dyscrasia. Evaluation of these patients was followed for a median period of 4.3 years, with a mean of 21.5 IFE tests per individual. These data suggest that for patients without a previous history of gammopathy, the presence of TFS bands on serum protein electrophoresis does not warrant frequent follow up investigation as commonly practiced. Routine follow up of patients with a prior history of gammopathy, conversely, are warranted and may contribute to overall survival with multiple treatment options now available. For those interpreting IFE results, it may be worth considering these data when composing comments regarding suggested repeat testing frequency by SPE/IFE or alternate test methods.
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Affiliation(s)
- TanYa M. Gwathmey
- Hypertension and Vascular Research Center, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA
| | - Monte S. Willis
- University of North Carolina, Department of Pathology & Laboratory Medicine, Chapel Hill, NC, USA
| | - Jason Tatreau
- University of North Carolina, School of Medicine, Chapel Hill, NC, USA
| | - Shaobin Wang
- University of North Carolina, Department of Internal Medicine, Chapel Hill, NC, USA
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Cabañas-Perianes V, Macizo M, Salido E, Blanquer M, Araico F, Melero-Amor A, Garcia-Candel F, Muñoz-Garcia MI, Martinez-Villanueva M, Muñoz-Esparza C, Guzmán-Aroca F, Pérez-López R, Moraleda JM. 'Management multiple myeloma during pregnancy: a case report and review'. Hematol Oncol 2014; 34:108-114. [PMID: 25491088 DOI: 10.1002/hon.2184] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 10/29/2014] [Accepted: 11/03/2014] [Indexed: 12/17/2022]
Abstract
Multiple myeloma (MM) is a hematologic neoplasm characterized by plasma tumor cell proliferation in the bone marrow. It's a rare malignancy before a 40-year-old and it is extremely uncommon during pregnancy. We report the case of a 37-year-old woman with a newly diagnosed IgG λ MM (Durie-Salmon stage IIIA, International Staging System II and good prognosis cytogenetic) at the 27th week of her pregnancy. Our management during pregnancy, the delivery, and initiation of anti-myeloma treatment with bortezomib, lenalidomide, and dexamethasone are published. There are a few reviews reporting the most common features and management of MM during pregnancy. We perform a comprehensive review of all 32 cases reported between 1965 and 2014 in which a MM was diagnosed during pregnancy including score, cytogenetic results, labor characteristics, and response to therapy. About 53% of pregnant women did not start treatment before partum. Cesarean section was the most common form of delivery (82%). About 88% of newborns were healthy, although most of them were premature (73%). Management of a MM diagnosed during pregnancy should be based on the presence of myeloma-related organ damage to secure survival of the mother without fetal adverse effects related to treatment. Serial fetal ultrasound may be helpful in order to avoid complications. The cesarean section may be preferred depending on maternal and fetus prognosis. Whole-body diffusion-weighted imaging minimal response could be an appropriate technique to discard plasmacytomas during pregnancy in critical situations such as the appearance of symptoms of spinal cord compression. Therapeutic choices should be agreed with the pregnant after a thorough discussion of the prognostic factors of the disease and the potential risk for the fetus and the patient. While awaiting partum, dexamethasone is a non-toxic treatment. Triple therapy including a proteasome inhibitor should be started quickly after delivery. Copyright © 2014 John Wiley & Sons, Ltd.
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Affiliation(s)
| | - Maribel Macizo
- Department of Obstetrics, Virgen de la Arrixaca University Hospital, Murcia, Spain
| | - Eduardo Salido
- Department of Hematology, Virgen de la Arrixaca University Hospital, Murcia, Spain
| | - Miguel Blanquer
- Department of Hematology, Virgen de la Arrixaca University Hospital, Murcia, Spain
| | - Fernando Araico
- Department of Obstetrics, Virgen de la Arrixaca University Hospital, Murcia, Spain
| | - Antonia Melero-Amor
- Department of Hematology, Virgen de la Arrixaca University Hospital, Murcia, Spain
| | | | | | | | - Carmen Muñoz-Esparza
- Department of Internal Medicine, Virgen de la Arrixaca University Hospital, Murcia, Spain
| | | | - Raúl Pérez-López
- Department of Hematology, Virgen de la Arrixaca University Hospital, Murcia, Spain
| | - Jose Maria Moraleda
- Department of Hematology, Virgen de la Arrixaca University Hospital, Murcia, Spain
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Jerzykowska S, Cymerys M, Gil LA, Balcerzak A, Pupek-Musialik D, Komarnicki MA. Primary systemic amyloidosis as a real diagnostic challenge - case study. Cent Eur J Immunol 2014; 39:61-6. [PMID: 26155101 DOI: 10.5114/ceji.2014.42126] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 02/21/2014] [Indexed: 12/28/2022] Open
Abstract
Primary amyloidosis (AL) is a rare variety of plasma cell dyscrasia, the diagnosis of which is often difficult to establish. Pathogenesis of amyloidosis involves extracellular deposition of insoluble protein fibrils in tissues, leading to insufficiency of affected organs. According to various sources, mean survival rate of patients with primary amyloidosis ranges from 12 to 24 months, making primary amyloidosis a disease with a very poor prognosis. Survival rate is significantly lowered in case of cardiac manifestation of amyloidosis (about 6 months survival in untreated patients). In recent years a considerable progress in AL treatment has been observed. Nowadays we are able not only to delay progression of amyloidosis, but also to improve the function of the affected organs. Unfortunately as first signs and symptoms of AL are usually nonspecific, the diagnosis of AL is often delayed, resulting in late introduction of optimal therapy. There are many diagnostic tests which can be used in diagnostic process of amyloidosis, i.e. electrophoresis, serum and urine immunofixation or affected organs and bone marrow biopsy. On establishing the diagnosis in a patient with suspected amyloidosis it should be remembered that particular diagnostic methods vary considerably in sensitivity. The aim of this paper is to present a case report of a 27-year-old patient with primary amyloidosis focusing on diagnostic aspect of this condition. On the basis of this case, the authors would like to emphasize the value of precise diagnostic process, with immunological techniques playing undoubtedly a crucial role.
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Rahlff J, Trusch M, Haag F, Bacher U, Horst A, Schlüter H, Binder M. Antigen-specificity of oligoclonal abnormal protein bands in multiple myeloma after allogeneic stem cell transplantation. Cancer Immunol Immunother 2012; 61:1639-51. [PMID: 22350072 PMCID: PMC11029419 DOI: 10.1007/s00262-012-1220-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2011] [Accepted: 02/06/2012] [Indexed: 12/29/2022]
Abstract
Myeloma patients may develop oligoclonal immunoglobulins, so-called abnormal protein bands (APB), after stem cell transplantation. APB do not correspond to the patient's paraprotein and confer a good prognosis. We set out to investigate whether such APB represent a humoral anti-myeloma immune response by screening immunoglobulins of 15 myeloma patients after allogeneic stem cell transplantation and a control group of healthy donors for reactivity with myeloma protein extracts. While the immunoglobulins of healthy donors did not react with myeloma protein extracts, patient-derived immunoglobulins showed variable levels of interaction, depending on the presence of APB on immunofixation. Most commonly, we detected interactions with heat-shock proteins, followed by neutral alpha-glucosidase, alpha-enolase and vimentin, as well as proliferating cell nuclear antigen and MAGEA4. More than 80% of targets were upregulated in myeloma. Heat-shock protein 60 (HSP60) was subsequently evaluated as an exemplary antigen. We found that HSP60 was aberrantly displayed on the surface of primary myeloma cells. Indeed, patient-derived APB-containing immunoglobulins recognized surface HSP60 suggesting that this antigen becomes accessible to the immune system after aberrant membrane exposition. We conclude that immunoglobulin fractions with APB recognize recurrent myeloma antigens and that this humoral response may contribute to the more favorable prognosis in patients with APB.
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Affiliation(s)
- Janina Rahlff
- Department of Oncology and Hematology, BMT with Section Pneumology, University Cancer Center Hamburg, University Medical Center Hamburg-Eppendorf, Hubertus Wald Tumorzentrum, Martinistrasse 52, 20246 Hamburg, Germany
| | - Maria Trusch
- Department of Clinical Chemistry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Friedrich Haag
- Institute of Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ulrike Bacher
- Department for Stem Cell Transplantation, University Cancer Center Hamburg, University Medical Center Hamburg-Eppendorf, Hubertus Wald Tumorzentrum, Hamburg, Germany
| | - Andrea Horst
- Department of Clinical Chemistry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hartmut Schlüter
- Department of Clinical Chemistry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mascha Binder
- Department of Oncology and Hematology, BMT with Section Pneumology, University Cancer Center Hamburg, University Medical Center Hamburg-Eppendorf, Hubertus Wald Tumorzentrum, Martinistrasse 52, 20246 Hamburg, Germany
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