I was diagnosed 1 year ago and started Velcade / dex therapy. In July 2014, 25 mg of Revlimid was introduced. As of January 2015, I was considered to be in remission. My myeloma cell involvement went from 80% to 3% and my lambda light chain number went from 149 to 3.32.
I started remission therapy February 1 (10 mg Revlimid). As of March 1, my lambda light chain number went to 9.08 (from 3.32 a month earlier) and, on April 1, it was at 14.29 (the kappa numbers continued to remain very near normal).
My doctor says the increase is not significant and I should not be alarmed. However, I am concerned.
Should I be concerned and should we be reintroducing Velcade into my treatment?
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Re: Should I add Velcade back to my treatment?
Hi garryrse,
A lambda free light chain level of 14.29 mg/L is still within the normal range, which is 5.71 – 26.3 mg/L. So, although I'm not a doctor, I personally would say it's too early to draw any conclusions about whether or not your lambda light chain number is getting out of control.
Are you also keeping track of your M-spike? What has been happening with it?
If you don't do it already, it can be really useful to plot your main myeloma numbers, like your free light chain results (kappa, lambda, and the lambda-kappa ratio), your M-spike. Just use Excel or some other spreadsheet program, and enter the numbers as well as the date of the blood draw, and then graph the numbers over time. It can be really helpful to understand if a trend is developing or if a certain test is just a blip.
Good luck!
A lambda free light chain level of 14.29 mg/L is still within the normal range, which is 5.71 – 26.3 mg/L. So, although I'm not a doctor, I personally would say it's too early to draw any conclusions about whether or not your lambda light chain number is getting out of control.
Are you also keeping track of your M-spike? What has been happening with it?
If you don't do it already, it can be really useful to plot your main myeloma numbers, like your free light chain results (kappa, lambda, and the lambda-kappa ratio), your M-spike. Just use Excel or some other spreadsheet program, and enter the numbers as well as the date of the blood draw, and then graph the numbers over time. It can be really helpful to understand if a trend is developing or if a certain test is just a blip.
Good luck!
Re: Should I add Velcade back to my treatment?
Thank you for responding to my post.
I am not tracking my M-spike. How do I do that calculation?
Also, the normal range my lab uses is 0.57 - 2.63.
I am not tracking my M-spike. How do I do that calculation?
Also, the normal range my lab uses is 0.57 - 2.63.
Re: Should I add Velcade back to my treatment?
Hi garryrse,
Sorry, I made the wrong assumption about the units for your lambda free light chain level. I thought the units being used were mg/L, but apparently they are mg/dL.
Your lambda free light chain (FLC) level of 14.29 mg/dL is equivalent to 142.9 mg/L. This is because there are 10 deciliters in 1 liter. So 1 mg/dL is equal to 10 mg/L. This is why the lower and upper limits of the normal range that you gave are exactly one tenth of the lower and upper limits that I listed.
So your lambda FLC has gone from 33.2 mg/L to 90.8 mg/L to 142.9 mg/L over the course of two months. This certainly suggests that the Revlimid alone is not enough to keep the disease under control.
What exactly your doctor decides to do, however, will probably depend on what is happening with some of your other lab results. For example, she or he may look at your creatinine, hemaglobin, and calcium levels in your blood to see if there are any signs that the myeloma is causing problems in your body. You also may have imaging done (x-rays, MRI, or PET) to look for signs of the disease in your bone.
Your M-spike will be reported on the blood test known as the serum protein electrophoresis (SPEP). It may be described as something like "Abnormal Protein Band" or even specifically as an "M-spike", or as the monoclonal protein level. The units will be either g/dL or g/L.
If your doctor does feel that a change in your treatment regimen is necessary, she or he may opt first to add dexamethasone back to your treatment, rather than Velcade.
I wish I could give you more specific feedback, but it's hard to know what your doctor will do without knowing more about your other test results. I hope this helps a bit, though.
Sorry, I made the wrong assumption about the units for your lambda free light chain level. I thought the units being used were mg/L, but apparently they are mg/dL.
Your lambda free light chain (FLC) level of 14.29 mg/dL is equivalent to 142.9 mg/L. This is because there are 10 deciliters in 1 liter. So 1 mg/dL is equal to 10 mg/L. This is why the lower and upper limits of the normal range that you gave are exactly one tenth of the lower and upper limits that I listed.
So your lambda FLC has gone from 33.2 mg/L to 90.8 mg/L to 142.9 mg/L over the course of two months. This certainly suggests that the Revlimid alone is not enough to keep the disease under control.
What exactly your doctor decides to do, however, will probably depend on what is happening with some of your other lab results. For example, she or he may look at your creatinine, hemaglobin, and calcium levels in your blood to see if there are any signs that the myeloma is causing problems in your body. You also may have imaging done (x-rays, MRI, or PET) to look for signs of the disease in your bone.
Your M-spike will be reported on the blood test known as the serum protein electrophoresis (SPEP). It may be described as something like "Abnormal Protein Band" or even specifically as an "M-spike", or as the monoclonal protein level. The units will be either g/dL or g/L.
If your doctor does feel that a change in your treatment regimen is necessary, she or he may opt first to add dexamethasone back to your treatment, rather than Velcade.
I wish I could give you more specific feedback, but it's hard to know what your doctor will do without knowing more about your other test results. I hope this helps a bit, though.
Re: Should I add Velcade back to my treatment?
Hi Garryrse,
Indeed it appears that low-dose Revlimid alone is not controlling your disease. In the absence of end organ damage (anemia, bone disease, kidney failure), it is reasonable to monitor you closely, but the rate of rise seems such that an intervention may be warranted sooner rather than later.
The International Myeloma Working Group guidelines (Rajkumar et al. Blood 2011) suggest a free light chain increase of 20 mg/dl (and an abnormal kappa:lambda ratio) in a 2 month period warrants therapy.
There are several choices for therapy here; and specific recommendations depend on a variety of factors. First, how old are you? Were you ever considered for a transplant? How did you tolerate Velcade? Dexamethasone? Higher doses of Revlimid? Are you being treated at a center with access to clinical trials?
Certainly, escalating Revlimid and adding dex is one option; adding Velcade is reasonable as well. It is worth a more in depth discussion with your doctor and/or a second opinion from a myeloma expert. The bright side is that many, many options exist.
Best,
Indeed it appears that low-dose Revlimid alone is not controlling your disease. In the absence of end organ damage (anemia, bone disease, kidney failure), it is reasonable to monitor you closely, but the rate of rise seems such that an intervention may be warranted sooner rather than later.
The International Myeloma Working Group guidelines (Rajkumar et al. Blood 2011) suggest a free light chain increase of 20 mg/dl (and an abnormal kappa:lambda ratio) in a 2 month period warrants therapy.
There are several choices for therapy here; and specific recommendations depend on a variety of factors. First, how old are you? Were you ever considered for a transplant? How did you tolerate Velcade? Dexamethasone? Higher doses of Revlimid? Are you being treated at a center with access to clinical trials?
Certainly, escalating Revlimid and adding dex is one option; adding Velcade is reasonable as well. It is worth a more in depth discussion with your doctor and/or a second opinion from a myeloma expert. The bright side is that many, many options exist.
Best,
-
Dr. Heather Landau - Name: Heather Landau, M.D.
Beacon Medical Advisor
Re: Should I add Velcade back to my treatment?
Hello garryrse,
As always, Dr. Landau has given you some helpful feedback. I just wanted to apologize for having missed the fact that your maintenance therapy is with 10 mg Revlimid. So, as Dr. Landau suggests, one thing to consider doing at this point is to increase your dose of Revlimid from 10 mg to perhaps 25 mg. Whether you and your doctor want to do that, however, depends on you've been feeling while taking the Revlimid.
As always, Dr. Landau has given you some helpful feedback. I just wanted to apologize for having missed the fact that your maintenance therapy is with 10 mg Revlimid. So, as Dr. Landau suggests, one thing to consider doing at this point is to increase your dose of Revlimid from 10 mg to perhaps 25 mg. Whether you and your doctor want to do that, however, depends on you've been feeling while taking the Revlimid.
Re: Should I add Velcade back to my treatment?
Thank you both for your responses.
I am 74 yrs old and have chosen not to pursue a transplant. I have no bone or kidney involvement. I have had x-rays and an MRI and everything is normal. My blood panels (CMPM & CBC) show everything is in the normal range or very close to it.
I tolerate dex, Velcade and Revlimid at 25 mg very well. Other than fatigue, I have had no side effects.
I am going to discuss re-introducing dex and Velcade with my doctor. I have an appointment in 3 weeks. Would you recommend I wait until then or make an appointment ASAP?
I am 74 yrs old and have chosen not to pursue a transplant. I have no bone or kidney involvement. I have had x-rays and an MRI and everything is normal. My blood panels (CMPM & CBC) show everything is in the normal range or very close to it.
I tolerate dex, Velcade and Revlimid at 25 mg very well. Other than fatigue, I have had no side effects.
I am going to discuss re-introducing dex and Velcade with my doctor. I have an appointment in 3 weeks. Would you recommend I wait until then or make an appointment ASAP?
Re: Should I add Velcade back to my treatment?
Hi,
I agree with what has been said previously. The rise in the light chain would make me want to change the treatment. You could consider several options that have been mentioned above. In this setting, I usually try and move back to the more effective therapy, which seemed to have been the combination of Velcade, Revlimid, and dex but at least reintroducing the dexamethasone with the Revlimid at standard dosing should be a consideration.
In this case, I would ask for an earlier appointment, perhaps with another check of the labs as well.
I agree with what has been said previously. The rise in the light chain would make me want to change the treatment. You could consider several options that have been mentioned above. In this setting, I usually try and move back to the more effective therapy, which seemed to have been the combination of Velcade, Revlimid, and dex but at least reintroducing the dexamethasone with the Revlimid at standard dosing should be a consideration.
In this case, I would ask for an earlier appointment, perhaps with another check of the labs as well.
-
Dr. Jason Valent - Name: Jason Valent, M.D.
Beacon Medical Advisor
Re: Should I add Velcade back to my treatment?
Thank you all for your help. I met with my doctor yesterday, and we added dex back into my therapy. If that does not help, we will also add back Velcade.
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