Can anyone explain how a person with the abnormal protein lambda can have active myeloma if their lambda level is low, kappa normal, but ratio high?
My understanding is when lambda is your abnormal protein, you want a higher ratio based on the formula used to obtain the K/L ratio. However, I've seen a chart on wikilite that says a normal kappa and low lambda with high ratio may indicate monoclonal protein activity. I don't understand how. Below is my one year history.
[Moderator's Note: As a bit of background, Doug explains in a posting later in this thread that he has "been in CR since Jan 2008 and [had] no treatment except Aredia since July 2009", and also that he's had a tandem stem cell transplant.]
If I were to plug my lambda numbers and K/L ratio for the past year, my numbers would show a decline in lambda and a rise in K/L ratio in my most recent two tests. Remember, my abnormal protein is lambda light chain
Normal ranges (ARUP labs):
Lambda 0.057 – 2.63 mg/dL
Kappa 0.33 – 1.94mg/dL.
K/L ratio 0.26 – 1.65
Test history:
Lambda levels:
4/16/13 – 6/10/14: 1.07, 0.80, 0.93, 0.62, 0.33
Kappa levels:
4/16/13 – 6/10/14: 0.86, 0.71, 0.80, 0.80, 0.58
K/L ratio:
4/16/13 – 6/10/14: 0.80, 0.89, 0.86, 1.29, 1.76 (H)
The key element to me as related to this discussion is that my urine/IFE was clear of monoclonal protein in February 14. Since the February testing, my lambda free lights have actually dropped and, since they dropped at a higher rate than kappa, the ratio is high.
Highly unlikely, in my mind, that myeloma has become active while my lambda has dropped. I think it’s more the result of bone marrow function. The chart on wikilite would lead one to believe myeloma is active unless a patient considers note 3 and considers the formula used to calculate the K/L ratio.
Can anyone explain how a person with the abnormal protein lambda can have active myeloma if their lambda count is low, kappa normal, but ratio high?
Thank you
Forums
Re: Declining lambda FLC level & high K/L ratio - meaning?
You may not have active multiple myeloma. Remember, the Wikilite chart should only be looked at as a general guide not a definitive diagnostic tool. Besides the sFLC Assay, I assume you had a SPEP done. Did it reveal an increased M spike in the lambda region?
The sFLC test results showing both the lambda and kappa levels dropping with the Lambda dropping faster, would imply that the higher reading was due to excess kappa. I doubt your multiple myeloma shifted from lambda to kappa. Therefore, the changes in the sFLC assay are not likely due to relapsing multiple myeloma without other evidence. You may instead have some bone marrow impairment.
I would suggest that if you are not having any CRAB symptoms and the SPEP is not showing an increased M spike, that you do not have active multiple myeloma.
Are you under treatment now? Perhaps the readings are caused by the treatment and not the multiple myeloma.
Just speculating at this point, I would discuss this with my oncologist and get his/her take.
Ron
The sFLC test results showing both the lambda and kappa levels dropping with the Lambda dropping faster, would imply that the higher reading was due to excess kappa. I doubt your multiple myeloma shifted from lambda to kappa. Therefore, the changes in the sFLC assay are not likely due to relapsing multiple myeloma without other evidence. You may instead have some bone marrow impairment.
I would suggest that if you are not having any CRAB symptoms and the SPEP is not showing an increased M spike, that you do not have active multiple myeloma.
Are you under treatment now? Perhaps the readings are caused by the treatment and not the multiple myeloma.
Just speculating at this point, I would discuss this with my oncologist and get his/her take.
Ron
-
Ron Harvot - Name: Ron Harvot
- Who do you know with myeloma?: Myself
- When were you/they diagnosed?: Feb 2009
- Age at diagnosis: 56
Re: Declining lambda FLC level & high K/L ratio - meaning?
Thank you Ron, I agree, it's likely bone marrow function. To answer your questions, I had SPEP/IFE with no monoclonal protein. In February I also had SPEP/IFE and UPEP/IFE.
I have been in CR since Jan 2008 and no treatment except Aredia since July 2009. I have a free light assay every 3 months and a full work up with imaging (MRI/PET) bone marrow biopsy, and urine catch every six months
My current results were reviewed by a onco PA and nurse. I did however send them off to my former doctor Guido Tricot since he is always willing to take time to answer questions. I was comfortable with what I thought was truth until I saw that chart on wikilite ... spooked me a bit ... though it shouldn't after all this time.
My bone marrow has never fully recovered from my tandem. My free light numbers have always been skittish and jump all over the place. Even my immunoglobulins struggle to reach low normal levels.
Thank you again for sharing your insight.
I have been in CR since Jan 2008 and no treatment except Aredia since July 2009. I have a free light assay every 3 months and a full work up with imaging (MRI/PET) bone marrow biopsy, and urine catch every six months
My current results were reviewed by a onco PA and nurse. I did however send them off to my former doctor Guido Tricot since he is always willing to take time to answer questions. I was comfortable with what I thought was truth until I saw that chart on wikilite ... spooked me a bit ... though it shouldn't after all this time.
My bone marrow has never fully recovered from my tandem. My free light numbers have always been skittish and jump all over the place. Even my immunoglobulins struggle to reach low normal levels.
Thank you again for sharing your insight.
-
DougC
Re: Declining lambda FLC level & high K/L ratio - meaning?
Hi DougC,
Indeed, when your pathologic protein is lambda, the results that you cite (declining lambda, normal kappa and a high ratio) are not indicative of active disease.
We all have kappa and lambda proteins as part of the normal immune system, and levels will fluctuate due to a variety of stimuli. In that setting, the k/l ratio can be outside of the normal range, although typically not by too much -- similar to yours.
On the other hand, it is true that if your pathologic protein was kappa, rarely the free kappa can be in the normal range yet suppress normal lambda proteins, leading to an abnormal k/l ratio in the direction of the pathologic protein. However, even in this setting, one would expect the ratio to be more abnormal.
I hope this answers your questions ... sounds like you have been doing very well!
Best!
Indeed, when your pathologic protein is lambda, the results that you cite (declining lambda, normal kappa and a high ratio) are not indicative of active disease.
We all have kappa and lambda proteins as part of the normal immune system, and levels will fluctuate due to a variety of stimuli. In that setting, the k/l ratio can be outside of the normal range, although typically not by too much -- similar to yours.
On the other hand, it is true that if your pathologic protein was kappa, rarely the free kappa can be in the normal range yet suppress normal lambda proteins, leading to an abnormal k/l ratio in the direction of the pathologic protein. However, even in this setting, one would expect the ratio to be more abnormal.
I hope this answers your questions ... sounds like you have been doing very well!
Best!
-
Dr. Heather Landau - Name: Heather Landau, M.D.
Beacon Medical Advisor
Re: Declining lambda FLC level & high K/L ratio - meaning?
Thank you Dr Landau. I appreciate you taking the time to add clarity and answer my question. 
PS: Dr Landau - Please tell Abby S. that the Huntsman misses the world's greatest PA ... at least I know I do. Thanks again.
PS: Dr Landau - Please tell Abby S. that the Huntsman misses the world's greatest PA ... at least I know I do. Thanks again.
-
DougC
Re: Declining lambda FLC level & high K/L ratio - meaning?
I certainly will!
-
Dr. Heather Landau - Name: Heather Landau, M.D.
Beacon Medical Advisor
Re: Declining lambda FLC level & high K/L ratio - meaning?
I've been wondering about my FLC ratio for the last 3 months. I've been in CR since June 2013. In sCR almost as long. But, as of October my FLC ratio indicated that I'm no longer in sCR. I'm IgG kappa. No M-spike since June 2013. My doctor said, by definition, it's true that I'm not in sCR. But, I should not worry as long as kappa is normal.
My question is - is this truly an indicator of active myeloma?
Last test results:
Free Kappa Serum 8.78
Free Kappa/Lambda Ratio 8.608
Free Lambda Serum 1.02
My question is - is this truly an indicator of active myeloma?
Last test results:
Free Kappa Serum 8.78
Free Kappa/Lambda Ratio 8.608
Free Lambda Serum 1.02
- Screen Shot 2014-12-12 at 1.11.14 PM.png (53.66 KiB) Viewed 4006 times
-
Stan W. - Name: Stan
- Who do you know with myeloma?: Myself
- When were you/they diagnosed?: SMM-April 2012
- Age at diagnosis: 58
Re: Declining lambda FLC level & high K/L ratio - meaning?
Hello Stan,
These are minor fluctuations in free light chains, and the ratio is abnormal because the involved (lambda) free light chain is very low. Such minor fluctuations in the FLC levels do not have clinical relevance in general.
You did state that you have IgG kappa now. Free light chains should not be interpreted in isolation. Additional information would be required about the other monoclonal protein studies, including immunoglobulin and immunofixation results.
These are minor fluctuations in free light chains, and the ratio is abnormal because the involved (lambda) free light chain is very low. Such minor fluctuations in the FLC levels do not have clinical relevance in general.
You did state that you have IgG kappa now. Free light chains should not be interpreted in isolation. Additional information would be required about the other monoclonal protein studies, including immunoglobulin and immunofixation results.
-
Dr. Prashant Kapoor - Name: Prashant Kapoor, M.D.
Beacon Medical Advisor
Re: Declining lambda FLC level & high K/L ratio - meaning?
Dr. Kapoor,
Are you referring to my FLC numbers? My serum IFE is negative. And IgG is below normal due to Revlimid, I guess.
Dr. Jagannath mentioned in his email that "significance unknown" regarding the ratio. Just that I should be concerned with the kappa being normal. I was under the impression that an abnormal ratio indicates active myeloma.
Are you referring to my FLC numbers? My serum IFE is negative. And IgG is below normal due to Revlimid, I guess.
Dr. Jagannath mentioned in his email that "significance unknown" regarding the ratio. Just that I should be concerned with the kappa being normal. I was under the impression that an abnormal ratio indicates active myeloma.
-
Stan W. - Name: Stan
- Who do you know with myeloma?: Myself
- When were you/they diagnosed?: SMM-April 2012
- Age at diagnosis: 58
Re: Declining lambda FLC level & high K/L ratio - meaning?
Thanks for providing the additional information, Stan.
I would like to first clarify my last response, which I had framed taking into account all the previous postings (including Doug's) under this heading.
Clearly, lambda is the uninvolved FLC in your case (and not 'involved' as erroneously stated previously in my reply). The K/L ratio is abnormal due to profound lambda suppression rather than an increase in kappa FLC. The significance of these readings in unknown, but we do come across such readings during the immune reconstitution phase post transplantation or in patients receiving other anti-myeloma therapy. Based on the information that you have provided, there is fortunately no evidence of active myeloma currently.
I would recommend monitoring the monoclonal protein studies periodically and I wish you many many more years of sustained complete remission.
Prashant
I would like to first clarify my last response, which I had framed taking into account all the previous postings (including Doug's) under this heading.
Clearly, lambda is the uninvolved FLC in your case (and not 'involved' as erroneously stated previously in my reply). The K/L ratio is abnormal due to profound lambda suppression rather than an increase in kappa FLC. The significance of these readings in unknown, but we do come across such readings during the immune reconstitution phase post transplantation or in patients receiving other anti-myeloma therapy. Based on the information that you have provided, there is fortunately no evidence of active myeloma currently.
I would recommend monitoring the monoclonal protein studies periodically and I wish you many many more years of sustained complete remission.
Prashant
-
Dr. Prashant Kapoor - Name: Prashant Kapoor, M.D.
Beacon Medical Advisor
11 posts
• Page 1 of 2 • 1, 2