I am keen to know more about what an elevated kappa/lambda ratio denotes in IgG lambda multiple myeloma.
My mother's most recent kappa-lambda ratio is 2.4 and the figures are kappa=60 and lambda=25. This is the first time since the start of the treatment that the ratio has gone above 2. All other parameters are within range.
I would really appreciate inputs on what the rising kappa levels indicate.
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Anu_India - Name: Anu_India
- Who do you know with myeloma?: Mother
- When were you/they diagnosed?: Jan 2011
- Age at diagnosis: 57
Re: High kappa-lambda FLC ratio in IgG lambda myeloma?
Hi Anu,
What is your mother's treatment history (date and type of treatment), and what sort of response did she get to her most recent treatment regimen?
I see from your profile that your mother was diagnosed in January 2011, had a stem cell transplant in December 2011, and has been on thalidomide maintenance therapy. But it's not clear when she started the maintenance therapy. Usually, one starts maintenance therapy after a transplant, but that would mean your mother has been on thalidomide maintenance for three years. That's a long time for thalidomide therapy, although it's certainly not unheard of.
Also, has your mother's kappa free light chain level been steadily increasing, or is this a one-time spike?
Finally, what has been going on with her M-spike (monoclonal protein, m-protein, paraprotein)? Has it been changing?
Please include units with any results you share -- they vary from lab to lab, and from country to country, for free light chain levels and for M-spike results.
What is your mother's treatment history (date and type of treatment), and what sort of response did she get to her most recent treatment regimen?
I see from your profile that your mother was diagnosed in January 2011, had a stem cell transplant in December 2011, and has been on thalidomide maintenance therapy. But it's not clear when she started the maintenance therapy. Usually, one starts maintenance therapy after a transplant, but that would mean your mother has been on thalidomide maintenance for three years. That's a long time for thalidomide therapy, although it's certainly not unheard of.
Also, has your mother's kappa free light chain level been steadily increasing, or is this a one-time spike?
Finally, what has been going on with her M-spike (monoclonal protein, m-protein, paraprotein)? Has it been changing?
Please include units with any results you share -- they vary from lab to lab, and from country to country, for free light chain levels and for M-spike results.
Re: High kappa-lambda FLC ratio in IgG lambda myeloma?
Hi Cheryl,
Appreciate your prompt response.
My mother was diagnosed with multiple myeloma in January 2011 and was put on the Velcade protocol for 4 cycles, which did not give satisfactory results. Subsequently, she was moved to a Revlimid protocol for 3 cycles and she responded well but had acute side effects.
She underwent an autologous stem cell transplant (ASCT) in December 2011 and was started on a thalidomide 50 mg maintenance therapy. She was started as early as February 2012 and was on 50 mg dose for 3 months, post which it was increased to 100 mg for next 3 months. The increased dosage resulted in severe side effects, so the maintenance was stopped for a short while.
She was restarted on 50 mg thalidomide in December 2012 had has been on the 50 mg protocol till date. So it has been almost 3 years of maintenance therapy. Is this kind of long maintenance therapy fine? The doctor suggests continuity until signs of any progression.
The free light chain results(in the unit of mg/L) across the treatment has been as follows:
Feb 2011 - kappa = 22, lambda = 1600, ratio = < .014 (time of diagnosis)
Jul 2012 - kappa = 38, lambda = 23, ratio = 1.65
Jan 2013 - kappa = 43, lambda = 42, ratio = 1.03
Sep 2013 - kappa = 78, lambda = 45, ratio = 1.73
(I do not have the results for the 2014 tests, though will share soon.)
Feb 2015 - kappa = 60, lambda = 25, ratio = 2.4
Her creatinine levels have been stable around 1-1.2mg% for the last many results. I do not have the M-spike numbers immediately, but will get those from my mom and share.
Looking at the free chain level ratio, it is obvious that her lambda chain is under control but the variation in the kappa chain is something I do not quite understand. Can treatment for a light chain elevated levels cause the other to rise too?
Appreciate your prompt response.
My mother was diagnosed with multiple myeloma in January 2011 and was put on the Velcade protocol for 4 cycles, which did not give satisfactory results. Subsequently, she was moved to a Revlimid protocol for 3 cycles and she responded well but had acute side effects.
She underwent an autologous stem cell transplant (ASCT) in December 2011 and was started on a thalidomide 50 mg maintenance therapy. She was started as early as February 2012 and was on 50 mg dose for 3 months, post which it was increased to 100 mg for next 3 months. The increased dosage resulted in severe side effects, so the maintenance was stopped for a short while.
She was restarted on 50 mg thalidomide in December 2012 had has been on the 50 mg protocol till date. So it has been almost 3 years of maintenance therapy. Is this kind of long maintenance therapy fine? The doctor suggests continuity until signs of any progression.
The free light chain results(in the unit of mg/L) across the treatment has been as follows:
Feb 2011 - kappa = 22, lambda = 1600, ratio = < .014 (time of diagnosis)
Jul 2012 - kappa = 38, lambda = 23, ratio = 1.65
Jan 2013 - kappa = 43, lambda = 42, ratio = 1.03
Sep 2013 - kappa = 78, lambda = 45, ratio = 1.73
(I do not have the results for the 2014 tests, though will share soon.)
Feb 2015 - kappa = 60, lambda = 25, ratio = 2.4
Her creatinine levels have been stable around 1-1.2mg% for the last many results. I do not have the M-spike numbers immediately, but will get those from my mom and share.
Looking at the free chain level ratio, it is obvious that her lambda chain is under control but the variation in the kappa chain is something I do not quite understand. Can treatment for a light chain elevated levels cause the other to rise too?
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Anu_India - Name: Anu_India
- Who do you know with myeloma?: Mother
- When were you/they diagnosed?: Jan 2011
- Age at diagnosis: 57
Re: High kappa-lambda FLC ratio in IgG lambda myeloma?
As a general rule (with rare exception), the clonal plasma cells in myeloma retain their light chain specificity. This means that, if the original malignant cells produce a lambda free light chain, they will on relapse too. Som when the ratio is skewed AWAY from the clonal free light chain (as in this case), it is generally not a concern.
Why does this occur? Well, as the immune system is affected by treatment and recovers, as the kidney function fluctuates subtly, and as the infections come and go, there will be some fluctuations in both light chains.
Of course, if the changes are progressive and/or come with other elevations in myeloma labs (e.g. m-spike), then further evaluation may be needed.
In this case, I suspect all is well, and that no changes in her care are needed. As an aside, if Revlimid is available, I would certainly favor it over thalidomide as maintenance.
Why does this occur? Well, as the immune system is affected by treatment and recovers, as the kidney function fluctuates subtly, and as the infections come and go, there will be some fluctuations in both light chains.
Of course, if the changes are progressive and/or come with other elevations in myeloma labs (e.g. m-spike), then further evaluation may be needed.
In this case, I suspect all is well, and that no changes in her care are needed. As an aside, if Revlimid is available, I would certainly favor it over thalidomide as maintenance.
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Dr. James Hoffman - Name: James E. Hoffman, M.D.
Beacon Medical Advisor
Re: High kappa-lambda FLC ratio in IgG lambda myeloma?
Thanks for your response, Dr. Hoffman, and clarifying my main concern.
My mother's hematologist also wanted her to start on Revlimid as the maintenance but she was reluctant due to severity of the side effects during the 3 cycles of chemo. She has been managing well with 50 mg of thalidomide, except mild neuropathy.
Are there any side effects to long-term usage of thalidomide? Does Revlimid work exceptionally better than thalidomide as maintenance? And should she change to Revlimid now that almost 3 years of maintenance have passed, or wait for signs for progression?
I think her M-protein levels has been fine so far, though I do not have the m-protein figures now. The Hb has been good at 14.7 but her platelets and WBC levels have been on the lower side at 194,000 cc mm and 3700 cu mm respectively. Again how is this of significance?
I sincerely appreciate your effort and help.
My mother's hematologist also wanted her to start on Revlimid as the maintenance but she was reluctant due to severity of the side effects during the 3 cycles of chemo. She has been managing well with 50 mg of thalidomide, except mild neuropathy.
Are there any side effects to long-term usage of thalidomide? Does Revlimid work exceptionally better than thalidomide as maintenance? And should she change to Revlimid now that almost 3 years of maintenance have passed, or wait for signs for progression?
I think her M-protein levels has been fine so far, though I do not have the m-protein figures now. The Hb has been good at 14.7 but her platelets and WBC levels have been on the lower side at 194,000 cc mm and 3700 cu mm respectively. Again how is this of significance?
I sincerely appreciate your effort and help.
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Anu_India - Name: Anu_India
- Who do you know with myeloma?: Mother
- When were you/they diagnosed?: Jan 2011
- Age at diagnosis: 57
Re: High kappa-lambda FLC ratio in IgG lambda myeloma?
Revlimid tends to be more effective and more tolerable, but every person is different. Thalidomide can cause progressive irreversible neuropathy over time. Those blood counts are ok.
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Dr. James Hoffman - Name: James E. Hoffman, M.D.
Beacon Medical Advisor
Re: High kappa-lambda FLC ratio in IgG lambda myeloma?
Thanks for the additional information, Anu, and I'm glad Dr. Hoffman shared his thoughts on this issue.
If you have your mother's light chain numbers from last year, as well as her M-spike values, then it would be interesting to see those, just to confirm that there aren't any bad trends developing.
From the values you posted, though, it looks like the elevation in your mother's kappa-lambda ratio was mainly due to a drop in your her lambda FLC levels, which isn't all that bad a thing.
It's great, by the way, that your mother has been tolerating the thalidomide maintenance so well. As Dr. Hoffman mentioned, a key concern with that sort of treatment is the development of neuropathy, so she should be constantly on the lookout for it.
If you have your mother's light chain numbers from last year, as well as her M-spike values, then it would be interesting to see those, just to confirm that there aren't any bad trends developing.
From the values you posted, though, it looks like the elevation in your mother's kappa-lambda ratio was mainly due to a drop in your her lambda FLC levels, which isn't all that bad a thing.
It's great, by the way, that your mother has been tolerating the thalidomide maintenance so well. As Dr. Hoffman mentioned, a key concern with that sort of treatment is the development of neuropathy, so she should be constantly on the lookout for it.
Re: High kappa-lambda FLC ratio in IgG lambda myeloma?
Thanks Dr. Hoffman and Cheryl for your responses.
I will definitely ask her to have a chat with her doctor during the next visit about Revlimid. It might be a good idea to consider it, if it is more effective in the long run.
Yes, the drop in the lambda FLC chain has been a good indication. Checked the last m-protein test results, but it is reported as 'normal pattern' without providing any values. Request if someone could share information on how the M-band / spike values are reported in the serum electrophoresis test. I plan to check with the lab to get specific values.
I will definitely ask her to have a chat with her doctor during the next visit about Revlimid. It might be a good idea to consider it, if it is more effective in the long run.
Yes, the drop in the lambda FLC chain has been a good indication. Checked the last m-protein test results, but it is reported as 'normal pattern' without providing any values. Request if someone could share information on how the M-band / spike values are reported in the serum electrophoresis test. I plan to check with the lab to get specific values.
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Anu_India - Name: Anu_India
- Who do you know with myeloma?: Mother
- When were you/they diagnosed?: Jan 2011
- Age at diagnosis: 57
Re: High kappa-lambda FLC ratio in IgG lambda myeloma?
"Normal pattern" means no M spike (zero) … a normal result.
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Dr. James Hoffman - Name: James E. Hoffman, M.D.
Beacon Medical Advisor
Re: High kappa-lambda FLC ratio in IgG lambda myeloma?
Thanks Dr Hoffman.
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Anu_India - Name: Anu_India
- Who do you know with myeloma?: Mother
- When were you/they diagnosed?: Jan 2011
- Age at diagnosis: 57
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