[Ron Harvot]

Re: No M-spike on SPEP or IFE, but abnormal K/L ratio?

by Ron Harvot on Fri Jan 09, 2015 5:50 pm

I had just got the same type of result on my test yesterday. I have IgG kappa multiple myeloma. My light chain readings have been in the normal range, with the last test showing my kappa FLC at 8.5 and my lambda at 0.91, for a ratio of 9.3..

Prior to this last test, my lambda level had bounced between 5 and 6, so for it to fall so much in one test (I have only been tested once every 12 weeks) was disturbing. But, like others, all of the other tests came back within the range they have been. So it could be an anomaly or a bad lab test. My oncologist was not concerned but will continue to monitor it.

A normal mid range number of the involved light chain is what is focused on. However, the high ratio cannot be ignored. Although it may not mean that multiple myeloma is going into relapse, it could mean that the bone marrow is not healthy and the treatment may have to be adjusted. That is why the other counts have to be monitored to make sure the immune system is not being compromised.

Ron

[Ron Harvot]

Re: No M-spike on SPEP or IFE, but abnormal K/L ratio?

by Ron Harvot on Fri Jan 09, 2015 6:19 pm

Here is a reprint out of Wikilite. Note comment #3 below the table. A reading of normal kappa with low lambda and a high ratio is an indication of monoclonal gammopathy with bone marrow suppression.

Table 26.1. Classification of monoclonal gammopathies according to serum FLC con­cen­tra­tions (also see Figure 26.2). BM: bone marrow. MG: monoclonal gammopathy. pIg: raised polyclonal immunoglobulin.

FLCScenarios.png (10.48 KiB) Viewed 1055 times

1. Normal samples. Serum κ, λ and κ/λ ratio are all within the normal ranges. If accompanying serum electrophoretic tests are normal it is most unlikely that the patient has a monoclonal gammopathy.
    
2. Abnormal κ/λ ratios. Support the diagnosis of a monoclonal gammopathy and require an appropriate tissue biopsy. Borderline elevated κ/λ ratios occur with renal impairment and may require appropriate renal function tests.
    
3. Low concentrations of κ, λ or both. Indicate bone marrow function impairment.
    
4. Elevated concentrations of both and with a normal ratio. May be due to the following:-
   - Renal impairment (common).
   - Over-production of polyclonal FLCs from inflammatory conditions (common).
   - Biclonal gammopathies of different FLC types (rare).
    
5. Elevated concentrations of both κ and λ with an abnormal κ/λ ratio. Suggest a combination of monoclonal gammopathy and renal impairment.
    
   (link to Wikilite source page)

It should be kept in mind that one test does not indicate a trend and thus a series of tests is needed to see if a true change has taken place.

Ron

[Castaway]

Re: No M-spike on SPEP or IFE, but abnormal K/L ratio?

by Castaway on Sat Jan 10, 2015 11:52 am

Ron,

Thanks for all the info. Great stuff. I am subtype IgA kappa light chain. I also was concerned about the high ratio. My oncologist didn't seem too concerned, but he really wants to do another bone marrow biopsy due to my last SPEP and IFE test results. He was excited about the results from them, but he suggested a bone marrow biopsy to confirm these results in more detail.

He will probably hold off on the biopsy due to my stem cell harvest coming up around the first of March. The transplant hospital wants a large amount of testing, including a bone marrow biopsy, before they do the harvest. So there's no reason to do two of them back to back.

Thank You,Castaway

K_Shash,

Sorry I didn't get back to you sooner, but there has been a lot going on. I just wanted to say that I have been told that the actual procedure of extracting the cells is kind of boring in itself, and I will be sitting for 5 or 6 hours, and to be sure to bring an iPad or some reading material. Others that have posted have given great feedback on the pre-harvest part of the process.

From what my transplant doctor told me, I would be getting one high dose chemo followed by daily self injections for about 5 to 10 days leading up to harvest. My oncologist told me that my hair could thin quite a bit from the chemo, but that doesn't concern me. Also, he will give me some anti-nausea meds, if needed. The central line will be placed on a Monday and harvest will start on Tuesday. Someone will have to drive me for the central line placement. Due to the hospital policies, I cannot drive for 24 hours after the central line placement.

You asked about my treatments, so I will try and make this as short as possible. My original diagnosis showed my IgA close to 4000. My treatments started out with Revlimid 25 mg 21 on with 7 off, dex once per week at 40 mg, 325 mg aspirin daily, Caltrate 600+D twice per day.

Then, due to a severe rash from Revlimid, I stopped treatments of Revlimid for a few weeks before starting Velcade. Still taking the same dex at 40 mg. Stopped the aspirin. Also have just started Zometa treatments.

In February it will be a year since I started treatments. It's been with some issues, but has been a long time waiting for these latest test results from my SPEP and IFE. This is why i really want my cells harvested ASAP. After cell harvest, and up to the time when I decide to transplant, my treatments will be lowered to a maintenance level. Not sure at what level as of yet, but will soon find out.

Thanks and Good Luck, Castaway

[mikeb]

Re: No M-spike on SPEP or IFE, but abnormal K/L ratio?

by mikeb on Sat Jan 10, 2015 2:55 pm

First of all, thanks a lot for the kind words, K_Shash. I'm glad that link was a help to you.

And thanks, Ron, for the information, especially the table from Wikilite. My FLC numbers have been bouncing around some too. In 5 out of the past 8 months, the k/l ratio has been normal, including from Wednesday's clinic visit. Yay! At other times, both k and l have been normal, but the ratio high, or k normal and l low, also making the ratio high. My myeloma specialist has said not to worry about these small fluctuations, but it's hard not to.

My doctor also made another point to me when we talked about this Wednesday. I asked if I'm still considered to be in sCR with the FLC k/l ratio bouncing around for me as it has. He said you need to have all the appropriate test results together at one time, including bone marrow biopsy, not just blood results, in order to say anything about sCR, CR, etc. So, technically speaking, since I had all of those tests done together in July, and all the results were good, we can say that I was sCR in July. Because I have not had a BMB since July, we can't say anything about where I'd be classified since then.

That all made sense to me when I thought about it, but was a little different than how I'd been thinking about it before. So you can only say where you are with sCR, CR, VGPR, etc. at the point in time when you have had all the appropriate tests done together, not at points in time in between.

Mike

[K_Shash]

Re: No M-spike on SPEP or IFE, but abnormal K/L ratio?

by K_Shash on Sat Jan 10, 2015 4:17 pm

Hi Castaway and mikeb,

Thank you both for sharing the valuable information about your treatment and experience.

Castaway,

I have the IgG kappa myeloma. The complication I have is all my IgG leaks into the urine and that total protein has been around 2,650 in two separate 24-hour urine collections, and the lab reports showed 85% of that was all IgG. The serum levels of all my immunoglobulins were a little below the low end of the normal range. My kappa FLCs have been around 1,000 in the blood tests. I have small but distinct lesions on my large bones and possibly on the skull, and my BMB showed 30% plasma cells. The oncologist wanted to make sure that I had all these 'flags' before starting the treatment.

The reason I had asked about your dosage was my oncologist had discussed the Velcade + dex, Revlimid + dex or the RVD (all three) as the possible options. I had already read a fair amount of discussion on the Myeloma Beacon (and a few other articles via the general web search) by this time in early December, a month ago. I was eager to get this induction phase started and aggressively treat this myeloma. Therefore, I chose the RVD and fortunately I have been able to tolerate the side effects, so far.

As I mentioned in my January 7 post, my doses are much milder; dex 20 mg weekly, Revlimid 15 mg daily (3 weeks on and one week off) and the Velcade 2.67. I understood from the chemo nurses that the Velcade is computed based on 1.3 X the patients "surface area" (skin?). I came across a few other posts where the patients started with high dex or Revlimid and only after strong reactions and a few trials and errors had their dose levels adjusted to the 'optimum' level. That is the big concern for me:

If my side effects are tolerable, are the nasty plasma cells getting wiped out as fast they should be? Should I ask for a higher dose of Revlimid?

From a lot of articles, I gathered that the dex is more a catalyst that enhances the effectiveness of Revlimid and Velcade (and possibly help with some of their side effects, as mikeb has written about). And the Velcade is standardized to one's 'surface area'. That only leaves the Revlimid dose for me.

As it happens, my monthly blood test is scheduled for Monday, January 12, and I have the oncologist's appointment on Tuesday, January 13. The oncologist already advised me that he would get all the info he needs from the blood panel (including the kappa and lambda FLCs) and he does not need to order any urine tests. Therefore, my concerns about the progress of my treatment and whether the Revlimid dose should be increased, etc., will all be addressed soon.

K_Shash