[greenrobin]

Flow cytometry results: implications for next treatment?

by greenrobin on Thu Aug 04, 2016 11:19 pm

Hi Everyone,

My brother just received his first ever flow cytometry test results and I am sharing them here. Hopefully it helps. I've never seen a full report and have searched pretty well online.

My brother is 12 months post stem cell transplant, after which he was deemed in stringent complete response (sCR). Initial therapy was 5 rounds of cyclophosphamide, Velcade, and dexamethasone (CyBorD). FISH test never completed, 1 lesion (gone now),

An early relapse that has presented as doubling IgA and serum kappa light chains with a rising K/L ratio 12.29, IFE showing igA Kappa band present, SPEP negative for M-spike, decreasing IgM and IgG This has been coming on for the past 3 months. Decreasing WBC, platelets, RBC and Hgb - all below normal now. TP, calcium, BUN, creatinine, and albumin norma.l B2M 1.9 in May. PET done 2 days ago negative for any hyper metabolic activity.

His local hematologist has recommended: Revlimid, Kyprolis, and dexamethasone asap. Appointment with specialist Monday to hear another opinion.

I am anxious to know if the flow cytometry test results do help predict prognosis or response to currently available therapies. I've spent months and months learning about multiple myeloma and various treatments, but this is my first brush with a relapse and flow cytometry results. And while I read the Beacon several times a week, I have not kept up with the latest treatments. I have a lot of work to do.

Any thoughts are appreciated. Still getting my mind around the fact that my brother has relapsed and working on getting my notes and questions ready for Monday. Things are moving quickly.

Thanks and all the best to you all.

Bone marrow biopsy showing: Interpretation:

Bone marrow (site not specified), aspiration, clot sections and core biopsy:

1. Normocellular bone marrow with decreased trilineage hematopoiesis and ~60-70% kappa-monoclonal plasma cell infiltrates, consistent with a plasma cell myeloma. See comment. 2. Decreased bone marrow iron stores.
3. Mildly increased reticulin fibrosis.
4. No morphologic evidence of acute leukemia, increased blasts, b- or t-cell lymphoproliferative neoplasm or myeloid neoplasm.

Peripheral blood, smear:
- Thrombocytopenia, macrocytosis, and leukopologenia with mild neutropenia.

The patient has a history of an IgA kappa multiple myeloma, status post-chemotherapy and stem cell transplant. Current CBC data shows pancytopenia.

Flow cytometry results:

Comments:

- Kappa-monoclonal plasma cell population (~3.9% of total), consistent with recurrent / persistent plasma cell myeloma.
- Left-shifted granulocytic maturation
- See comments.

The patient has a history of an IgA-kappa multiple myeloma, status post chemotherapy and stem cell transplant. Current CBC data shows pancytopenia.

A left-shifted granulocytic maturation is a non-specific atypical finding that may be seen in reactive / recovery processes and in myeloid neoplasia.
Cytogenetics and FISH analyses have been ordered to evaluate for genetic abnormalities associated with plasma cell neoplasm.

Note: Plasma cells tend to be underrepresented in flow cytometry studies due to poor cell survival during test preparation. The true percentage of plasma cells may be higher in bone marrow sections or optimal aspirate smears.

(Specimen Viability: 100%) (Cell yield: 20.2 Million )

Immunophenotyping: Markers performed: CD3, CD4, CD5, CD7, CD8, CD10, CD11b, CD13, CD14, CD15, CD16, CD19, CD20, CD33, CD34, CD38, CD45, CD56, CD64, CD117, CD138, HLA-DR, sKappa, sLambda, cKappa, cLambda.

Microscopic Smear and cytospin slides were reviewed for QA purposes.

Description:
14.9% 20.5% Mature polytypic small B cells [CD19(+), CD20(+) and a Kappa/Lambda ratio = 1.23:1] 57.3% Mature small T cells: [CD3(+), CD5(+), CD7(+) and CD4/CD8 ratio = 3.49:1]
10.1% NK (Natural-Killer) cells: [CD3(-), CD5(-), CD7(+), CD16(+), CD56(+)]
1.8% Monocytes: [CD4(+), CD11b(+), CD13(+), CD14(+), CD33(+), CD45(bright +), CD64(+)]
53.1% Maturing granulocytes with left-shift: [CD10(+/-), CD11b(+), CD13(+/-), CD15(+), CD16(+/-), CD33 (+)]
4.9% Myeloblasts (not increased): [CD33(+), CD34(+), CD117(+), HLA-DR(+)]
23.3% Erythroid cells and debris: [CD45(-)]
3.93% See abnormal cells (below)

Monoclonal plasma cells (~3.9% of total): CD38(bright +), CD138(+), CD56(+), CD45(-), CD19(-), cKappa(+).

[JPC]

Re: Flow cytometry results: implications for next treatment?

by JPC on Fri Aug 05, 2016 6:53 am

Good morning Green Robin:

I think the key thing in there is that the plasma cell population is 3 to 9%. In normal people, plasma cell % could be up to 5%, but after ASCT and induction, it is typically suppressed, and the number should be around 3%. As was explained to me, when they say 3% to 9%, what they mean is that the myeloma is "patchy", in some locations, it looks normal, and in some areas, at the high end, it looks like almost 10%. Anything above 5% is definitely a sign of active myeloma. I would highly suspect that they will say that it is good that it is still low, still, it appears to be moving up at the moment.

Kyprolis, Revlimid, and dexamethasone is new, however, and it has shown to be successful, with longer remission times than with Velcade, cyclophosphamide, and dexamethasone (CyBorD). It also seems to handle most adverse cytogenetic risk factors better than the older drugs. My one suggestion to you is to ask about Darzalex, and whether or not that is an option for your brother at that time. Good luck to you both.

[greenrobin]

Re: Flow cytometry results: implications for next treatment?

by greenrobin on Mon Aug 08, 2016 7:39 am

Hi JPC,

Thanks for our reply. Complex stuff. But for me, at least knowing a bit about how the results of flow cytometry are interpreted puts me in a better place to think. Darzalex is on the list for discussion. Hope today goes well.

If anyone feels inclined - Please feel free to add to and or clarify my crib notes below. I find recognizing the options for treatment by name and having an idea for how they work - allows me to hear more of what is being said at an appointment.

Monoclonal Antibody - Marks cancer cells to make more visible to immune system. May help block formation of blood vessels that feed cancer. Empliciti (elotuzumab), Darzalex (daratumumab).

IMIDs - Immune modifying drugs. Can be used to help the immune system fight multiple myeloma. May help keep them from multiplying. Thalidomide, Revilimid, Pomalyst (pomalidomide).

Proteasome Inhibitor - Inhibits proteasome function, leading to the accumulation of defective proteins, which can trigger cell death. Velcade (bortezomib), Kyprolis (carfilzomib), Ninlaro (ixazomib).

HDAC Inhibitor - Farydak (panobinostat).

Steroid - Dexamethasone.

[Davidg]

Re: Flow cytometry results: implications for next treatment?

by Davidg on Wed Aug 17, 2016 5:12 pm

The fact that the monoclonal cells are strongly positive for CD38 suggests that Darzalex (dara­tu­mu­mab) should be helpful in your brother's case.