paraprotein j glaysher140213 lecture

8/12/2019 Paraprotein J Glaysher140213 Lecture

1/41

Paraproteins

Jennifer Glaysher

Principal Clinical Scientist, Aintree University Hospital


2/41

Plan

Basic immunoglobulins Paraproteins

Laboratory diagnosis

Serum electrophoresis (SEP)

Bence Jones Protein (BJP)

Other useful tests

Causes of paraproteins Malignant

Multiple myeloma

Benign Monoclonal gammopathy of unknown significance

Smouldering Myeloma

Cryoglobulins


3/41

Basic Immunoglobulin
http://localhost/var/www/apps/conversion/tmp/scratch_5//upload.wikimedia.org/wikipedia/commons/3/31/Mono-und-Polymere.svghttp://localhost/var/www/apps/conversion/tmp/scratch_5//upload.wikimedia.org/wikipedia/commons/f/f6/Antibody_svg.svg


4/41

Paraprotein Production


5/41

Paraprotein

Proliferation of onespecific clone of malignant /hyper stimulated B cell in bone marrow

Presence of monoclonal band in serum

Over production of one clone of immunoglobulin

One type of heavy chain -> G,A,M, D,E

One type of light chain ->

May have more than one monoclonal band

bi / triclonal paraprotein!


6/41

IgG, 56%IgM, 20%

IgA, 12%

Light

chains,

5.50%

Biclonal,

6%

IgD,

0.50%


7/41

Initial Presentation

Anaemia - Weakness or fatigue

Back / Bone pain or fractures

Renal insufficiency

Incidental

High total protein

Raised globulin

Raised ESR

Hypercalcaemia

Immunoglobulin pattern


8/41

Laboratory diagnosis

Clinical suspicion /incidental finding

Serum protein

electrophoresis

Immunofixation

Band Quantitation

Bence Joneselectrophoresis

(Urine)

Urine

immunofixation

Bone marrow

biopsy

Serum free lightchains


9/41

Sebia Hydrasys Product Insert


10/41

*

**


11/41

Band quantitation

Semi-quantitative

StagingMonitoring progression

Response to treatment

Date Band conc.(g/L)

11/08 8.9

01/09 9.2

07/09 8.7

02/10 7.2

09/10 8.1

02/11 8.8

02/12 8.9


12/41

Immunofixation

Ref range (g/L)

Total protein 79 60-80 g/L

Albumin 42 3550 g/L

Globulin 37 2232 g/L

IgG 8.30 616 g/L

IgA 4.10 0.82.8 g/L

IgM 13.84 0.51.9 g/L


13/41

AACB Guidelines

Gel based and capillary zone electrophoresis

Report in g/L to nearest whole number.


14/41

Bence Jones Proteins

20 % not detectable in serum

Presence of free light chains in urine

Glomerular filtration

Cleared in proximal tubules

Renal thresholdnephrotoxic


15/41


16/41

Serum free light chains

Serum half life 2-6 hrs

Normal / ratio 2:1

Polyclonalratio unchanged

Myelomaskewed ratio

Useful for

Light chain disease

Non secretory Monitor response to treatment


17/41

Causes of paraproteinaemia


18/41

Causes of paraprotein - 1 2

Malignant or uncontrolled production

Multiple myeloma

Waldenstroms macroglobulinaemia

Malignant lymphoma

Chronic lymphocytic leukaemia

Primary amyloidosis

Plasma cell leukaemia

Heavy chain disease


19/41

Multiple Myeloma

~4000 new cases / year

Incidence : 6070 per million5

Increased incidence with age (15%


20/41

Diagnostic Criteria

1. Monoclonal protein in serum / urine

2. Increased plasma cells in bone marrow (>10%)

3. End organ disease

1. Bone disease -Bone pain / pathological fractures (80-90%)

2. Renal impairment - (50%)

3. Anaemia -Normochromic normocytic anaemia (or macrocytic)

4. Hypercalcaemia -(30%)anorexia, nausea, polydipsia

5. Hyperviscosity - IgM>>IgA>IgG

6. Amyloidosis

7. Recurrent infection - 2 immuneparesis


21/41

myeloma.org.au

Skull

SpineSpinal cord compression

Pelvis

Hips

Ribs

Shoulder


22/41

International staging system

Stage CriteriaMedian survival

(months)

I Serum 2M


23/41

Other Investigations

Biochemistry Haematology Radiology

Bone profile FBCMRI Scan

(spine compressions)

LFTs ESR CT scan

Renal profile Blood film Skeletal survey

IgG, IgA, IgM Bone marrow aspirate

B12 / Ferritin / Folate Plasma cell phenotyping

2Microglobulin

Serum free light chains


24/41

Treatment2

Supportive

Rehydration

Bisphosphonates

Transfusion

Plasmapharesis

Antibiotics / Immunoglobulin infusion

Intensive therapy (


25/41

Benign or stable production2

Monoclonal gammopathy of unknown significance

Solitary plasmacytoma

Chronic cold haemoglutinin disease Transient (e.g. with infections)

AIDS

Gauchersdisease Rarely with carcinoma and other conditions

Causes of Paraprotein - 2


26/41

MGUS1 & 3

Approx. 2 - 3% of individuals aged >50 yrs & 5% aged >70 yrs.

Criteria1

Serum paraprotein


27/41

1
http://asheducationbook.hematologylibrary.org/content/2005/1/340/F1.large.jpg


28/41

Lancet 2004;363:875


29/41

Smouldering multiple myeloma 1

Criteria Serum paraprotein >30g/L OR

bone marrow >10% plasma cells

BUT absence of anaemia, hypercalcaemia, lytic bone disease or

renal failure attributed to proliferative disorder

10-20% per year risk of progression 1


30/41

Examples


31/41

1 2 3 4 5 6

MONOCLONAL COMPONENT

BICLONAL GAMMOPATHY

HYPERGAMMAGLOBULINEMIA

WEAK MONOCLONAL COMPONENT

FIBRINOGEN IN PLASMA

HYPOGAMMAGLOBULINEMIA


32/41

213

6


33/41


34/41

Cases

66y female

Presented to GP complaining of back pain

Sodium 134 mmol/L

Potassium 4.0 mmol/L

Urea 7.3 mmol/L

Creatinine 130 umol/L

Total protein 84 g/L

Albumin 38 g/L /

Globulin 46 g/L

Adj Ca 2.75 mmol/L

ALP 80 IU/L

Haemoglobin 10 g/dl


35/41


36/41

Month/year

Band

concentration g/L

Feb-09 11

Mar-09 11.8

Jun-09 12.3

Jul-09 11.9

Sep-09 13.8

Jan-10 13.6

May-10 18.6

Jun-10 17.3

Oct-10 21

Jan-11 29.9

Jan-11 29

Mar-11 33.6

May-11 41.4

Jul-11 49.3

Aug-11 39.9

Sep-11 42

Sep-11 39.3

Oct-11 42.3

Nov-11 40.5

Dec-11 23.4

0

10

20

30

40

50

60

Paraproteinq

uantitatio

ng

/L

Velcade a & DXM

Lanilomide &

DXM


37/41

Cryoglobulinaemia


38/41

Cryoglobulinaemia

Precipitate at temp lower than normal body temp

Most polyclonal Ig complexes, nearly half monoclonal

(mainly IgM)

Type I Monoclonal,

lymphoproliferative disorders

Hyperviscosity & thrombosis

Type II & III Mixedwith rheumatoid factor

Chronic inflamatory conditions -> SLE, Sjorgens syndrome

Joints, fatigue,


39/41

10ml blood from vein without tourniquet in to warmed plain bottle

Place sample in 37C sand

Leave to clot at 37C (may put in 37C water bath)

Centrifuge 3 mins

Separate serum and divide between two tubes

One tube fridge for 7days

Second in incubator at 37C

Inspect refrigerated sample regularly? Precipitate (compare with 37C)

Centrifuge cold tube at 4C for 10 minsno pptnegative

Precipitate observedwash ppt with cold saline (i.e. resuspend, centrifuge, decant)

Resuspend in saline and incubate at 37C for 30 mins

If redisolvestrue cryoglobulin (if doesnt may be fibrin i.e. pt on anticoagulant therapy)

Perform electrophoresis (keep all equipment at 37C), if band presentIFX


40/41

Conclusions

Paraproteins may present with clinical features such as bone

pain / anaemia / renal failure or may be an incidental finding

Paraproteins can be detected by serum / urine electrophoresis

Type can be identified by immunofixation

Paraproteins may be benign i.e. MGUS or malignant i.e.multiple myeloma

Laboratories play a role in identification / diagnosis /monitoring /determining response to treatment


41/41

Referenceshttp://www.patient.co.uk/doctor/Myeloma.htm

Myeloma.org.uk

1) MGUS and smoldering multiple myeloma: update on pathogenesis, naturalhistory and management. Rajkumar Hematology. 2005 p340

2) Essential HaematologyHoffbrand, Moss & Pettit P216

3) Monoclonal gammopathy of undetermined significance. Kyle R & Rajkumar S.British journal of Haematology, 134, 573-589.

4) Multiple myeloma: Diagnosis and treatment NAU K & Lewis W. American Family\physician 78 (7) 2008. P853-

5) Guidelines for the diagnosis and management of multiple myeloma2011.British Journal of Haematology, 154,32-75
http://www.patient.co.uk/doctor/Myeloma.htmhttp://www.patient.co.uk/doctor/Myeloma.htm

paraprotein j glaysher140213 lecture

Documents