[torifrog]

Diagnosed with MGUS, confused by lab results

by torifrog on Mon Sep 05, 2016 3:16 am

Hi Beaconites

I've spent some time in the last week or two reading here at the Beacon, and have learned a great deal, but am still confused with some of my results.

I live in Brisbane, Australia, and having been Type 1 diabetic for 47 years, I routinely get a number of blood tests done every 3-6 months. My calcium had been mildly high since I can remember, and I am mildly osteopenic. For a while my endocrinologist thought I had hyper­parathyroidism as the PTH was also high. Now it appears to be back to normal, and he sus­pects it may be a condition called familial hypocalciuric hypercalcemia. I see him at the end of next week, and hopefully some more clarity will present. In the meantime, being an incredibly thorough doctor, he had some tests for MGUS / multiple myeloma run in early May, and referred me to the local cancer clinic for follow-up.

I saw them last week and a diagnosis of IgM MGUS was made, with the next planned follow-up in 6 months

Below are my test results:

1 May 2016

Corrected calcium 2.70 mmol/l (2.25-2.65)
Ionised calcium 1.32 mmol/l (1.18-1.30)
Alk phosphate 129 U/L (30-115)
All other CBC results normal

FLC serum

Kappa FLC 38 mg/L (up to 20)
Lambda FLC 24 mg/L (up to 30)
Kappa-lambda ratio 1.6 (03 - 1.6)

Serum protein electrophoresis pattern

Total Protein 71 g/L (60-82)
Albumin 40 g/L (35-50)
Alpha 1-Globulin 3 g/L (1-4)
Alpha 2-Globulin 8 g/L (6-10)
Beta 1-Globulin 4 g/L (3-5)
Beta 2-Globulin 3 g/L (2-5)
Gamma Globulin 11 g/L (7-15)

Paraprotein conc. 3 g/L gamma location
Paraprotein conc. 1 3 g/L, location 1 gamma
Paraprotein conc. 2 <1 g/L location 2 gamma

Interpretation
The pattern reveals two discrete bands in the gamma region with no apparent suppression of the normal gamma globulin.

Serum protein immunofixation studies

Interpretations

Serum immunofixation electrophoresis studies indicate the two discrete bands noted in the EPP to be co-migrating kappa IgM and lambda IgM paraprotein (band size: 3 g/L) and a kappa IgG band of < 1 g/L. Due to the co-migration, specific paraprotein quantitation is not possible.

25 August 2016

24hr UPEP came back clear
Skeletal survey showed no lesions
WBC 3.4 x10^9/L (4.0-11.0)
Neutrophils 1.4 x10^9/L (2.0-7.5)
AST 55U/L (0-41)
All other tests normal

FLC serum

Kappa FLC 38 mg/L (up to 20)
Lambda FLC 28 mg/L (up to 30)
Kappa-lambda ratio 1.4 (0.3 - 1.6)

Serum protein electrophoresis pattern

Total Protein 68 g/L (60-82)
Albumin 39 g/L (35-50)
Alpha 1-Globulin 3 g/L (1-4)
Alpha 2-Globulin 7 g/L (6-10)
Beta 1-Globulin 4 g/L (3-5)
Beta 2-Globulin 3 g/L (2-5)
Gamma Globulin 10 g/L (7-15)

Paraprotein conc.: 3 g/L gamma location
Paraprotein conc. 1: 3 g/L, location 1 gamma
Paraprotein conc. 2: <1 g/L location 2 gamma
Interpretation:
The pattern reveals two discrete bands in the gamma region with no apparent suppression of the normal gamma globulin.

Serum protein immunofixation studies
Interpretations
Serum immunofixation electrophoresis studies confirm the persistence of the co-migrating kappa IgM and lambda IgM paraproteins in the mid-gamma region (band size: 3 g/L). Due to the co-migration, specific paraprotein quantitation is not possible.

I'm most confused about the co-migration of IgM kappa and lambda and the inability to quantify results. Can anyone give any input? Thanks heaps

[Multibilly]

Re: Diagnosed with MGUS, confused by lab results

by Multibilly on Mon Sep 05, 2016 8:40 am

Hi Tori,

Welcome to the forum. I think the really good news here is that your total M-spike level is quite small (3 g/L = 0.3 g/dL) and your free light chain (FLC) ratio is still within the normal range. It looks like your doctor caught this condition at a very early stage.

1. Did your doctor run a quantitative immunoglobulin (IgG, IgA, IgM) test? I'm guessing that with your small M-spikes that your immunoglobulins are still within the normal range?

2. I'm also guessing that the lambda-IgM and kappa-IgM M-spikes are very close together on the SPEP graph, making it hard to quantify the exact amount of the smaller of the two M-spikes, especially since both of these M-spikes are so small and your are hitting the limit of what can be measured accurately with an SPEP. But this is only a guess on my part. You would need to look at the SPEP graph (which some lab reports include) to see if this might be the case.

3. Note that IgM MGUS is quite rare and requires some special attention over time. You might want to read this article.

J Mikhael, "Ask the Hematologist: A Diagnostic Approach to Patients with an IgM monoclonal protein," The Hematologist, Sep 15, 2014 (full text of article)

[Wobbles]

Re: Diagnosed with MGUS, confused by lab results

by Wobbles on Mon Sep 05, 2016 8:35 pm

Hi Tori,

I first developed MGUS more than 10 years. Like you, I only had a small amount of paraprotein and I had lab comments about the difficulty in quantifying the actual concentration of my paraprotein. It was co-migrating with other proteins in the gamma region. (However, I also got comments that there was a suppression of my normal gamma globulin. You look okay in this regard.)

The determination of the amount of protein in a blood serum sample is done using a technique called electrophoresis. Basically, the lab prepares a sample of your blood serum and inserts this into a gel. At this point an electric field (battery and two separated electrodes plus fancy additions) is applied to the gel. Because the individual protein molecules have different masses, sizes and charges, they travel at different speeds inside the gel. In short the various proteins spatially separate according to their properties; this gives valuable information about the quantities and types of proteins in a person’s blood system. Score one for science.

The gamma region is where normal immunoglobulins reside. The clonal paraproteins often co-migrate with the the normal immunoglobulins. If you have a small amount of paraprotein, then the signal can get lost in the “noise”. I'm sure your lab folks are very skilled at extracting as much information as they can.

Your lab clearly says you have a paraprotein spike. You should have zero paraproteins in your blood serum. That's the important point.

Over ten years my paraprotein spike became more noticeable with a concentration reaching 10 g/L a year ago. Then it suddenly quadrupled over a six month period to 40 g/L. Bone marrow biopsy confirmed that I had developed a myeloma that needed to be treated. I was shocked. Still am.

I also noticed that you are neutropenic. I was both neutropenic and anemic from the start. That has presented a lot of problems for me as I’ve had to battle some very nasty infections; I also get three units of red blood cells transfused every three weeks.

Over the years I kept good records. I made up spreadsheets that I am constantly updating. You might consider doing this.

Welcome to the site,

Joe

[torifrog]

Re: Diagnosed with MGUS, confused by lab results

by torifrog on Tue Sep 06, 2016 9:41 pm

Hi Multibilly and Joe

Thank you both for the welcome and the information!!

Multibilly, your explanation for the co-migration makes sense, and I'm happy to go along with it in the absence of anything that makes more sense I expect if the M-protein increases, the migration might separate and be measurable, but I'm more than happy for it to stay right where it is!

No, no quantitative immunoglobulin measures were taken either time, so I'm guessing the broader measurements in the CBC / biochem indicated things were okay? In any case, I think I'm in good hands and if needed in the future those will be done. Thanks also for the very interesting and useful link, some of which I knew, much of which I did not.

Joe, I'm sorry to read of your recent increase in M-spike but I very much appreciate your ex­pla­na­tion of how the protein electrophoresis is done, as that explains very clearly. I've been neutro­penic / lymphopenic on and off for the last 5 or 6 years, but due to my diabetes and 6-10 blood glucose tests per day, I tend to get early warning of any infections as the blood glucose spikes un­expectedly and inexplicably. Type 1 diabetics need to be a bit anal with blood glucose levels to mini­mise any kind of festering infections, so I will definitely be even more carefully on the lookout given the warning.

Again, thank you both so much. It is very very appreciated