donna e. reece, m.d. princess margaret hospital 23 october 2010 myeloma canada conference

Donna E. Reece, M.D.

Princess Margaret Hospital

23 October 2010

MYELOMA CANADA CONFERENCE

What’s in your blood?

Formed elements made in the bone marrowRed blood cells: carry oxygen to tissues

Measured by hemoglobin, hematocrit (packed cell volume), number of RBCs

White blood cells (leukocytes):several types; fight infectionNeutrophils first line of defenseLymphocytes invovled in more complicated

immune reactionsPlatelets: clot the blood

Complete Blood Count (CBC) Determination

Courtesy of Dr. A. Xenocostas

Normal Blood CountsNormal Hgb (Hemoglobin)

Men 140-160Women 210-140

Normal WBC (Leukocytes)Total 4.0-10.0Differential

Neutrophils (Polys, ANC) Lymphocytes Eosinophils Monocytes Basophils

Normal platelets150-350

Fatigue possible if < 100-110Transfusion if < 80

Risk of infection if neutrophils <1.0

Risk of bleeding if <10

Example of CBC Results

Manual White Blood Cell Differential

Courtesy of Dr. A. Xenocostas

Normal Peripheral Blood Film

Lazarchick, J. ASH Image Bank 2001;2001:100185

Example of CBC Results

What’s in your blood?

Sugars (glucose)FatsMinerals (potassium, sodium, calcium, zinc)Breakdown products of metabolism (carbon

dioxide, other cellular wastes)CreatinineUric acid

What’s in your blood?

ProteinsCarrier proteins (for hormones, nutrients, vitamins)Albumin: good protein made by the liverBeta 2 microglobulinEnzymesAntibodies/immunoglobulins

Fight invaders like germs by adhering to them and neutralizing them (very specific)

Automatic Chemistry Analyzer

Courtesy of Dr. A. Xenocostas

Bone Marrow Aspirate

Courtesy of Dr. A. Xenocostas

Bone Marrow Aspirate

Courtesy of Dr. A. Xenocostas

Copyright ©2002 American Society of Hematology. Copyright restrictions may apply.

Bone Marrow Findings in MyelomaBone Marrow Aspirate

Normal bone marrow makes all types of blood cells (RBCs,

WBCs and platelets)

Plasma cells make antibodies

Normal bone marrow has less than 5 % plasma cells

Bone Marrow Aspirate in Multiple Myeloma

Lazarchick, J. ASH Image Bank 2001;2001:100185

Antibodies/Immunoglobulins

Plasma cells make antibodies (immunoglobulins, Igs) which consist of 2 heavy chains and 2 light chains

One type of antibody is made to bind with one foreign substance (virus, bacteria, etc.)

Patterns of Antibody Production

FLC-producing plasma cells

FLC-producing plasma cells

Free Light Chain ProductionKAPPA LAMBDA

Types of Multiple Myeloma

Multiple Myeloma

Diagnosis based on finding over 10% plasma cells (antibody forming cells) in bone marrow

In most cases, these excess plasma cells make an excess of one kind of antibody (monoclonal antibody)

Symptomatic myeloma characterized by “CRAB” Anemia (low hemoglobin*)Bone lesions (found on xrays)Kidney damage (elevated creatinine*)Elevated blood calcium*

*Blood tests

Blood Tests in Myeloma

To measure the burden/amount of myeloma Measurements of the product of the myeloma cells

(Monoclonal antibody level in blood and/or urine)To measure extent of myeloma damage

CBC: complete blood count (includes Hgb, WBC, platelets)

Creatinine (kidney function)Calcium (comes from bone destruction)

To assess prognosisBeta 2-microglobulin (high is unfavourable)Albumin level (high is favourable)

Criteria for Symptomatic (Active)Myeloma

Bone marrow plasma cells > 10%Evidence of end organ damage

Calcium > 2.8 mmol/L HypercalcemiaHgb < 100 g/L (or 20 g/L below normal)AnemiaCreatinine > 176 umol/L Renal dysfunctionLytic bone lesions

Myeloma without symptoms (“smouldering myeloma) does not need treatmentThe disease may smoulder for months or years

without causing problems

Findings at Diagnosis in Symptomatic Myeloma

• Anemia or low hemoglobin: 80%• Renal (kidney) dysfunction: 20%• Hypercalcemia: 25%• Bone destruction: 70%• Hyperviscosity: <5%

How do we measure antibodies?

Protein electrophoresisCan be done on the blood (serum) or urineTells if there is a monoclonal antibody (M-spike, M protein)Requires interpretation

How do we measure antibodies?

Quantitative immunoglobulinsGives the total amounts of IgG, IgA and IgMConcentration in g/L

Normal total IgG Normal total IgA Normal total IgM

Does not indicate if there is a monoclonal antibody presentAutomated

How do we measure antibodies?

Serum free light chain assay (Freelite)Measures free kappa and lambda light chains in the bloodCan detect tiny levels, before light chains spill into the urine

Serum Protein Electrophoresis

Lazarchick, J. ASH Image Bank 2001;2001:100185

Protein Electrophoresis--Densitometer

Courtesy of Dr. A. Xenocostas

Serum Protein Electrophoresis (SPEP)

Normal SPEP Multiple Myeloma

Kyle RA and Rajkumar SV. Cecil Textbook of Medicine, 22nd Edition, 2004

Densitometer can measure M spike in g/L

Serial Quantitative Immunoglobulins and M spike from Serum Protein Electrophoresis

Inductionwith dex

After ASCT

Progression

2005

2006

2007

Electrophoresis/Immunofixation

Uses of Immunofixation:

- Identify monoclonal protein

- More sensitive than EP

Multiple Myeloma – Immunofixation

Total protein =2.21 g/day

Name % g/day

31.5 0.70

M-protein 67.5 1.49

1.0 0.02

Abnormal Urine Protein Electrophoresis

24-Hour Urine Protein Results with Electrophoresis

Serial 24-Hour Urine Protein Results

Serum Free Light Chain Assay (sFLC)

Hidden surface

Antibody target

Free Lambda

Free Kappa

Antibody target

Intact Ig

Normal Ranges1

Serum

• Free Kappa 3.3-19.6 mg/L• Free Lambda 5.6-26.3mg/L• Kappa/Lambda: 0.26-1.65

1Katzmann et al. Clin Chem. 2002;48:1437–1444.

Previously hidden surface

• Increased sensitivity

• Electrophoresis can detect 0.5- 2.0 g/L• Immunofixation can detect 0.15-0.5 g/L• Serum FLC assay can detect < 0.005 g/L

• Serum is easier to work with than urine

• Serum FLCs have a short half-life compared to intact monoclonal immunoglobulins • can detect changes in myeloma cell growth or regrowth faster

Serum Free Light Chain Assay (sFLC)-Advantages-

Serum lambda FLCBortezomib

IgA paraprotein

Robson, E. Unpublished data

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Free Light Chain Escape

Monitoring Myeloma

Increasing M protein and

IgG levels

Anemia

New skeletal findings

ResearchTrial

Bortezomib + Vorinostat

Courtesy of Dr. A. Xenocostas

Myeloma Lab TestsKey Points

Need to determine the best test for monitoring the activity of the myeloma cellsSerum M spike (Intact IgG or Ig A)Quantitative IgA level in about 5-8% of patientsUrine M spike (kappa or lambda light chain)Freelite in serum (kappa or lambda)

The “trend” is importantSome variability in results is inherent in the testsResults have to be interpreted in context of overall

status of the patient