In May 2010, I had an auto stem cell transplant, and, in November 2011, I relapsed. At that point, I was put on 25 mg of Revlimid plus dex. This brought the disease under control.
However, between February 2014 and today, my lambda free light chain has increased from normal to 236 (kappa has stayed within normal range), and I have developed a "faint monoclonal band". With regard to the CRAB criteria, the only issue is I am borderline anemic (some months yes, some no).
The free light ratio of lambda to kappa has stayed well below 100, which I believe is a criteria for newly diagnosed patients who are not on any medication. However, I am not sure what the criteria is for patients being treated.
It appears the disease is coming back, but I am not sure at what point I should be considering switching treatments. I feel good, so I am not anxious to go under some new treatment, but also do not want to delay the treatment and cause some permanent damage to my kidney or other organs.
Does anyone have any knowledge of criteria to use for analyzing free light chain results for patients under medication or any other thoughts?
Thanks
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bgmiller80 - Name: Bob
- Who do you know with myeloma?: self
- When were you/they diagnosed?: 2010
- Age at diagnosis: 58
Re: Free light chain criteria for relapse?
Bob,
You might want to see Dr. Libby's definitions of relapse outlined in this posting (note the mg/dL units of measure for the FLC value).
You might want to see Dr. Libby's definitions of relapse outlined in this posting (note the mg/dL units of measure for the FLC value).
In patients who do not have clinical relapse, a significant paraprotein relapse is defined as doubling of the M-component in 2 consecutive measurements separated by less than or equal to 2 months; or an increase in the absolute levels of serum M protein by more than or equal to 1 g/dL, or urine M-protein by more than or equal to 500 mg/24 hours, or involved FLC level by more than or equal to 20 mg/dL (plus an abnormal FLC ratio) in 2 consecutive measurements separated by less than or equal to 2 months."
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Multibilly - Name: Multibilly
- Who do you know with myeloma?: Me
- When were you/they diagnosed?: Smoldering, Nov, 2012
Re: Free light chain criteria for relapse?
Thanks for the response.
Would you please help me verify one additional point with regard to the FLC level? The criteria indicates the "FLC level by more than 20 mg/dl". My test measurements are in mg/L. Thus, using this measurement, the increase would have to be 200 mg/L – right?
My largest increase has been 40 mg/L, and I am currently at 236 mg/L. This seems like by the time I have 200+ level increases, I could be at a fairly high absolute level. Am I missing something? If not, is the change more critical than the absolute level?
Thanks for any insights.
Bob
Would you please help me verify one additional point with regard to the FLC level? The criteria indicates the "FLC level by more than 20 mg/dl". My test measurements are in mg/L. Thus, using this measurement, the increase would have to be 200 mg/L – right?
My largest increase has been 40 mg/L, and I am currently at 236 mg/L. This seems like by the time I have 200+ level increases, I could be at a fairly high absolute level. Am I missing something? If not, is the change more critical than the absolute level?
Thanks for any insights.
Bob
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bgmiller80 - Name: Bob
- Who do you know with myeloma?: self
- When were you/they diagnosed?: 2010
- Age at diagnosis: 58
Re: Free light chain criteria for relapse?
Bob and Multibilly,
I don't know if this is relevant for the definition of relapse, but, for disease progression, the change in M-spike that is usually used to say whether a patient has progressed is the change from the lowest M-spike achieved. It's not the change from one test to the next.
So if a patient achieved a complete response, with their M-spike going down to 0, and 3 years later started having M-spike measurements of 0.1, 0.3, and 0.6 during monthly tests, the changes that would matter for determining whether disease progression has occurred are not the changes from 0 to 0.1, 0.1 to 0.3, and 0.3 to 0.6. The change that would determine if disease progression occurred would always be based on the latest value compared to the lowest value (which is 0 in this case).
Like I said, it may be different for the definition of relapse. But I thought I would mention it because it could help pin things down.
I don't know if this is relevant for the definition of relapse, but, for disease progression, the change in M-spike that is usually used to say whether a patient has progressed is the change from the lowest M-spike achieved. It's not the change from one test to the next.
So if a patient achieved a complete response, with their M-spike going down to 0, and 3 years later started having M-spike measurements of 0.1, 0.3, and 0.6 during monthly tests, the changes that would matter for determining whether disease progression has occurred are not the changes from 0 to 0.1, 0.1 to 0.3, and 0.3 to 0.6. The change that would determine if disease progression occurred would always be based on the latest value compared to the lowest value (which is 0 in this case).
Like I said, it may be different for the definition of relapse. But I thought I would mention it because it could help pin things down.
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JimNY
Re: Free light chain criteria for relapse?
Hi Bob,
Your math is right. Your current lambda FLC value is 236 mg/L, which = 23.6 mg/dL. So, your lambda would have to rise 200 mg/L in the span of 2 months for it to be considered a paraprotein relapse.
But one thing to also consider is that there is a difference between disease relapse and disease progression, as Jim alludes to. Disease progression is defined by the IMWG (International Myeloma Working Group) as:
Increase of ≥ 25% from lowest response value in any one or more of the following:
Your math is right. Your current lambda FLC value is 236 mg/L, which = 23.6 mg/dL. So, your lambda would have to rise 200 mg/L in the span of 2 months for it to be considered a paraprotein relapse.
But one thing to also consider is that there is a difference between disease relapse and disease progression, as Jim alludes to. Disease progression is defined by the IMWG (International Myeloma Working Group) as:
Increase of ≥ 25% from lowest response value in any one or more of the following:
- Serum M-component and/or (the absolute increase must be ≥ 0.5 g/dL)
- Urine M-component and/or (the absolute increase must be ≥200 mg/24 h)
- Only in patients WITHOUT measurable serum and urine M-protein levels; the difference between involved and uninvolved FLC levels. The absolute increase must be > 10 mg/dL
- Bone marrow plasma cell percentage; the absolute percentage must be ≥ 10%
- Definite development of new bone lesions or soft tissue plasmacytomas or definite increase in the size of existing bone lesions or soft tissue plasmacytomas
- Development of hypercalcaemia (corrected serum calcium > 11.5 mg/dL or 2.65 mmol/L) that can be attributed solely to the plasma cell proliferative disorder
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Multibilly - Name: Multibilly
- Who do you know with myeloma?: Me
- When were you/they diagnosed?: Smoldering, Nov, 2012
Re: Free light chain criteria for relapse?
Thanks Jim and Multibilly. Much to consider.
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bgmiller80 - Name: Bob
- Who do you know with myeloma?: self
- When were you/they diagnosed?: 2010
- Age at diagnosis: 58
Re: Free light chain criteria for relapse?
Hello Bob,
I like to use mg/dL for units. Free light chain results can be converted back and forth (in terms of units) easily just by dividing or multiplying by 10.
Your current serum free light chains are 23.6 mg/dL. Not really very high for multiple myeloma. To gauge the significance of this elevation, it would be valuable to know what your SPEP and serum free light chains were when you were originally diagnosed.
My current practice (in patients not on a study) in patients having a "chemical relapse" – meaning their SPEP and/or serum free light chains and/or 24 hour urine for Bence Jones proteins are rising BUT the patient does not have CRAB symptoms – is to observe them and follow the IMWG recommendations mentioned already in this discussion.
I would also treat patients with a chemical relapse if the following things were detected:
#1. The free light chain ratio (involved / uninvolved) is > 100
#2. A repeat bone marrow biopsy showed > 60% plasma cells
#3. A bone marrow MRI showed new focal lesions
Based on what you have told us about your case so far, I would probably continue the Revlimid and dexamethasone and follow you closely. If you have not been restaged in the last 6-12 months, a bone marrow biopsy and bone marrow MRI could be helpful to decide if a switch in treatment is required at this time.
Best of luck to you Bob!
I like to use mg/dL for units. Free light chain results can be converted back and forth (in terms of units) easily just by dividing or multiplying by 10.
Your current serum free light chains are 23.6 mg/dL. Not really very high for multiple myeloma. To gauge the significance of this elevation, it would be valuable to know what your SPEP and serum free light chains were when you were originally diagnosed.
My current practice (in patients not on a study) in patients having a "chemical relapse" – meaning their SPEP and/or serum free light chains and/or 24 hour urine for Bence Jones proteins are rising BUT the patient does not have CRAB symptoms – is to observe them and follow the IMWG recommendations mentioned already in this discussion.
I would also treat patients with a chemical relapse if the following things were detected:
#1. The free light chain ratio (involved / uninvolved) is > 100
#2. A repeat bone marrow biopsy showed > 60% plasma cells
#3. A bone marrow MRI showed new focal lesions
Based on what you have told us about your case so far, I would probably continue the Revlimid and dexamethasone and follow you closely. If you have not been restaged in the last 6-12 months, a bone marrow biopsy and bone marrow MRI could be helpful to decide if a switch in treatment is required at this time.
Best of luck to you Bob!
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Dr. Edward Libby - Name: Edward Libby, M.D.
Beacon Medical Advisor
Re: Free light chain criteria for relapse?
Thanks everyone. I was thinking that, with the normal range based on the lab test being 5.7-26.3 mg/L (assume 0.57-2.63 mg/dL), that my 236 mg/L was way outside the range. But now I can put it in perspective.
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bgmiller80 - Name: Bob
- Who do you know with myeloma?: self
- When were you/they diagnosed?: 2010
- Age at diagnosis: 58
8 posts
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