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