My mother had been diagnosed with Plasmacytoma last August after she suffered pathological fracture in her right humerus bone. After that she was given thalidomide for 5 months. Her Kappa-lambda light chain ratio kept on increasing and the last ratio before she was given Velcade IV was 8.19. Doctor started her on Velcade and gave her 6 cycles of Velcade, one every week. Today she again went for her ratio test and the ratio has reduced to 1.32 which is in normal range. But her B2 micro globulin is 3220 ng/ml and her ESR is 48 millimeters/hr. Her Hb is 11.8 and WBC is 4300. Currently she doesnt take thalidomide. I wasnt sure what would increase the B2 microglobulin and ESR levels. Are this values very high and of concern or because her ratio is back to normal, we should not be worried much about this values as they can increase due to some other factors?
Can Velcade increase B2 Microglobulin value? Because her B2 Microglobulin value prior to giving Velcade was 2700 ng/ml and after 6 doses of Velcade went up to 3220. The doctor has decided to give 2 more doses of Velcade because of high B2 Microglobulin value.
Forums
5 posts
• Page 1 of 1
Re: High ESR and B2 microglobulin values
I am assuming that you mom presented with a pathologic fracture because of a plasmacytoma and was then staged and found to have active multiple myeloma (systemic disease not isolated to the femur). I say this only because the treatment of solitary plasmacytomas is definitive radiation therapy to the area of the mass, not systemic therapy.
It sounds like your mother has low level kappa light chain disease only, based on normal k/l ratio, normal hgb and WBCs. (I would also make sure the creatinine and calcium are within normal limits, and there are no new signs of bone disease). It appears that her disease is likely in control.
In cases of light chain only disease (and in this case small amounts of light chain) treatment decisions can be made on the SFLCs as the barometer of disease burden. Beta 2 microglobulin and ESR are not disease specific, believe it or not -- even though beta2-microglobulin is used in the ISS staging system for myeloma.
Individuals with oligosecretory disease or light chain only disease are a challange to follow. So, you need to look at the entire picture and use the clinical as well disease-specific parameters. If there is a question of disease status and no other way to measure, then I would recommend a bone marrow biopsy to compare with her initial marrow.
If she has not already received radiation to the site of the fracture, I would also recommend that be carried out.
It sounds like your mother has low level kappa light chain disease only, based on normal k/l ratio, normal hgb and WBCs. (I would also make sure the creatinine and calcium are within normal limits, and there are no new signs of bone disease). It appears that her disease is likely in control.
In cases of light chain only disease (and in this case small amounts of light chain) treatment decisions can be made on the SFLCs as the barometer of disease burden. Beta 2 microglobulin and ESR are not disease specific, believe it or not -- even though beta2-microglobulin is used in the ISS staging system for myeloma.
Individuals with oligosecretory disease or light chain only disease are a challange to follow. So, you need to look at the entire picture and use the clinical as well disease-specific parameters. If there is a question of disease status and no other way to measure, then I would recommend a bone marrow biopsy to compare with her initial marrow.
If she has not already received radiation to the site of the fracture, I would also recommend that be carried out.
-
Dr. Ken Shain - Name: Ken Shain, M.D., Ph.D.
Beacon Medical Advisor
Re: High ESR and B2 microglobulin values
Dr. Shain thank you so much for your reply. I forgot to mention that she was already given radiation. So basically what happened was that last August my mother (58 years old) fell down and broke her right shoulder bone. The doctor noticed in Xray that she had a lesion in her bone and futher biopsy revealed that she had solitary non-secretory plasmacytoma. Her PET scan results showed that there was malignant activity only in her right shoulder and nowhere else in her body. Because of her fracture the doctor had to operate her and put a plate and after 3 weeks of healing from surgery she was given radiation for almost 20 days.
After radiation doctor put her on thalidomide. And after 2 months of her radiation treatment and thalidomide her kappa lamba ratio was detected to be 4.62. Doctor thought that the ratio might have increased because of her surgery, so he waited another 2 months and her next ratio was 5.44 and then another 2 months later it was 8.12. Physically she was fit and her right shoulder was also recovering well.This happened in March and during this time period she complained of slight pain in her left shoulder as well (very minute pain). So her MRI was done. Full body MRI revealed that she had 3 lesions, two in thigh bone and 1 in left shoulder. But doctor looking at her MRI images said that this might be Calcium deposits as MRI is a very sensitive technique and the lesions did not look specific like Plasmacytoma. Xrays done on thigh and left shoulder bone did not reveal anything. But he decided to start her on Velcade as her ratio was increasing and he thought that it might affect her kidney if that was neglected. So he gave her 6 cycles of Velcade once every week. After one shot of Velcade pain in her left shoulder disappeared(still not sure if it was due to frozen shoulder that above 50 woman have or due to multiple myeloma).
After that below are results of her blood work,
lambda kappa light chain ratio: 1.32
Hb: 11.8
RBC: 4.12
ESR: 48 multiple myeloma/hr
Platelets: 240000
WBC: 4300
B2 Microglobulin: 3220 ng/ml
Urea: 15mg/dl
BUN: 7 mg/dl
Serum Ig G: 1040 mg/dl
Serum Ig A: 225 mg/dl
Serum Ig M: 35 mg/dl
The doctor says that she has non-secretory plasmacytoma which has not yet progressed to multiple myeloma.
Is this plasmacytoma or, because she was having increase in her lambda kappa ratio, is it multiple myeloma or smoldering multiple myeloma? Any suggestions for the treatment she has been given so far?
Because her current B2 microglobulin value is high, doctor has decided to give her 2 more doses of Velcade, tomorrow and other after 15 days.
After radiation doctor put her on thalidomide. And after 2 months of her radiation treatment and thalidomide her kappa lamba ratio was detected to be 4.62. Doctor thought that the ratio might have increased because of her surgery, so he waited another 2 months and her next ratio was 5.44 and then another 2 months later it was 8.12. Physically she was fit and her right shoulder was also recovering well.This happened in March and during this time period she complained of slight pain in her left shoulder as well (very minute pain). So her MRI was done. Full body MRI revealed that she had 3 lesions, two in thigh bone and 1 in left shoulder. But doctor looking at her MRI images said that this might be Calcium deposits as MRI is a very sensitive technique and the lesions did not look specific like Plasmacytoma. Xrays done on thigh and left shoulder bone did not reveal anything. But he decided to start her on Velcade as her ratio was increasing and he thought that it might affect her kidney if that was neglected. So he gave her 6 cycles of Velcade once every week. After one shot of Velcade pain in her left shoulder disappeared(still not sure if it was due to frozen shoulder that above 50 woman have or due to multiple myeloma).
After that below are results of her blood work,
lambda kappa light chain ratio: 1.32
Hb: 11.8
RBC: 4.12
ESR: 48 multiple myeloma/hr
Platelets: 240000
WBC: 4300
B2 Microglobulin: 3220 ng/ml
Urea: 15mg/dl
BUN: 7 mg/dl
Serum Ig G: 1040 mg/dl
Serum Ig A: 225 mg/dl
Serum Ig M: 35 mg/dl
The doctor says that she has non-secretory plasmacytoma which has not yet progressed to multiple myeloma.
Is this plasmacytoma or, because she was having increase in her lambda kappa ratio, is it multiple myeloma or smoldering multiple myeloma? Any suggestions for the treatment she has been given so far?
Because her current B2 microglobulin value is high, doctor has decided to give her 2 more doses of Velcade, tomorrow and other after 15 days.
Re: High ESR and B2 microglobulin values
It is difficult to be a physician from afar- "as a back seat MD." So, I apologize for the vagueness of my answers or if I am simply not understanding. Are you seeing or have you been seen by a myeloma expert? I recommend that every myeloma or plasma cell dycrasia try to get to a myeloma center of excellence at least once. If you are, then I would feel comfortable that you are being treated well (and you may be regardless). That being said, systemic treatment is only necessary (called for) if there is evidence of active multiple myeloma. Plasma cells within the bone marrow (>10%)are necessary , monoclonal paraprotein (>3gm -unless oligo or non-secretory), as well as ongoing myeloma-induced end organ damage: CRABI criteria-. HyperCalcemia, Renal insufficiency (kidney), Anemia, Boney Lesions (in addition to the solitary plasmacytoma already irradiated), and serious Infections.
Her labs look excellent (I don't see a creatinine (kidney function), but with the BUN low-normal I will assume that her kidney function is good). Once someone has a solitary plasmacytoma and undergoes radiation therapy watching is appropriate depending on the confort of the physician and patient/care givers.
1. Did you mother have a bone marrow biopsy done at diagnosis (not the pathology from her fracture) initially or at any point for treatment descisions? This would be for a number of reasons- i) the burden of plasma cells in the marrow, ii) risk, iii) light chain expression among other issues (kappa vs lambda within the plasma cells), and iv) clonality of the kappa light chain-by the ratio her kappa light chains are being over expressed.
2. Did the biopsy of her femoral fracture reveal kappa light chain expressing plasma cells?
3. Did she undergo biopsies of the other "lesions" to demonstrate that they were myelomatous? It sounds like they are not myeloma-from the radiologist and therefore did not need to be.
Again, I do not want to introduce questions to your mother's care. It may all be well undercontrol and appropriate. However, if she has no evidence of myeloma outside the single lesion and it was irradiated with at least 45cGy, I would suggest that you sit back and observe expectantly with labs every three months adn imaging annually unless otherwise clinically indicated.
Her labs look excellent (I don't see a creatinine (kidney function), but with the BUN low-normal I will assume that her kidney function is good). Once someone has a solitary plasmacytoma and undergoes radiation therapy watching is appropriate depending on the confort of the physician and patient/care givers.
1. Did you mother have a bone marrow biopsy done at diagnosis (not the pathology from her fracture) initially or at any point for treatment descisions? This would be for a number of reasons- i) the burden of plasma cells in the marrow, ii) risk, iii) light chain expression among other issues (kappa vs lambda within the plasma cells), and iv) clonality of the kappa light chain-by the ratio her kappa light chains are being over expressed.
2. Did the biopsy of her femoral fracture reveal kappa light chain expressing plasma cells?
3. Did she undergo biopsies of the other "lesions" to demonstrate that they were myelomatous? It sounds like they are not myeloma-from the radiologist and therefore did not need to be.
Again, I do not want to introduce questions to your mother's care. It may all be well undercontrol and appropriate. However, if she has no evidence of myeloma outside the single lesion and it was irradiated with at least 45cGy, I would suggest that you sit back and observe expectantly with labs every three months adn imaging annually unless otherwise clinically indicated.
-
Dr. Ken Shain - Name: Ken Shain, M.D., Ph.D.
Beacon Medical Advisor
Re: High ESR and B2 microglobulin values
Thank you Dr. Shain for reading about our case and replying. It means a lot to us. Thanks.
We are from India and do not have a myeloma expert as such in our state. A famous Hemato oncologist in our city is treating my mother. He has studied and practiced in USA.
Just a quick recap, my mother was diagnosed with Non Secretary Solitary Plasmacytoma when she had a pathological fracture at the right humerus.
Needle Biopsy reports confirmed Plasmacytoma. It mentioned infiltration by plasma cells - 3 dimensional clusters and sheets of neoplastic cells with high N:C ratio.
Kappa/Lambda ratio at this time was 3.27.
Biochemical profile reports(SGPT, Billirubin, etc) were normal.
Calcium reports were normal as well.
A PET-CT scan was done which detected activity only at the site of the pathological fracture (right humerus) and no where else in the body..
A bone marrow biopsy was also done with the following findings -
Findings: There is no evidence of increased plasma cells or increased fibrosis, atypical cells or blasts, granulomas, parasites or malignancy.
Comments: Mild Erythroid Hyperplasia (Normoblastic)
Thereafter, surgery was done, titanium plate was fixed, and radiation was given for 20 days.
Next Kappa/Lambda ratio test was done 2 weeks after radiation therapy ended. It had increased to 4.62.
Beta 2 microglobulin value was 2730 (normal: 810-2190ng/ml).
ESR was 43.
Then thalidomide drug was continued and Zolendronic acid injection was given.
Next Kappa/Lambda ratio test was done after another 2 months. It was 5.44.
ESR was 30.
Biochemical Profile reports were normal.
Doctor suggested here to continue with thalidomide and monitor.
Next Kappa/Lambda ratio test was done after another 2 months. It was 8.19.
Also MRI was done which revealed 3 probable lesions - 1 in the left shoulder and 2 in the thighs.
From the structure of these lesions as seen in the MRI and the X ray reports, doctor felt they might not be lesions but since the Kappa/Lambda ratio was increasing, some activity is going on.
Here I will add that my mother was feeling pain in the left shoulder since a month before this MRI was done. X ray reports had been done then but they revealed nothing so no action was taken then.
No biopsies have been done on these 'lesion like' things found in MRI. (Would you suggest biopsy be done?)
Now as the ratio was steadily increasing, Doctor decided to start treatment.
6 injections of Velcade (Bortezomib) were given, one each week and also dexamethasone was given.
After 6 week course, Kappa/Lambda ratio was now at 1.32.
Beta 2 microglobulin was 3220 (normal: 810-2190 ng/ml)
ESR was 48.
Since Beta 2 microglobulin value is still out of range, Doctor has decided to give two more injections of Velcade to bring it down of which 1 has been given already.
In general, all the blood and urine related reports have been normal except for Kappa/Lambda ratio, ESR and Beta 2 microglobulin.
How does the treatment so far look ? is it proper? How is the treatment response? Is it plasmacytoma still or can it be multiple myeloma? How does the overall situation look?
We are from India and do not have a myeloma expert as such in our state. A famous Hemato oncologist in our city is treating my mother. He has studied and practiced in USA.
Just a quick recap, my mother was diagnosed with Non Secretary Solitary Plasmacytoma when she had a pathological fracture at the right humerus.
Needle Biopsy reports confirmed Plasmacytoma. It mentioned infiltration by plasma cells - 3 dimensional clusters and sheets of neoplastic cells with high N:C ratio.
Kappa/Lambda ratio at this time was 3.27.
Biochemical profile reports(SGPT, Billirubin, etc) were normal.
Calcium reports were normal as well.
A PET-CT scan was done which detected activity only at the site of the pathological fracture (right humerus) and no where else in the body..
A bone marrow biopsy was also done with the following findings -
Findings: There is no evidence of increased plasma cells or increased fibrosis, atypical cells or blasts, granulomas, parasites or malignancy.
Comments: Mild Erythroid Hyperplasia (Normoblastic)
Thereafter, surgery was done, titanium plate was fixed, and radiation was given for 20 days.
Next Kappa/Lambda ratio test was done 2 weeks after radiation therapy ended. It had increased to 4.62.
Beta 2 microglobulin value was 2730 (normal: 810-2190ng/ml).
ESR was 43.
Then thalidomide drug was continued and Zolendronic acid injection was given.
Next Kappa/Lambda ratio test was done after another 2 months. It was 5.44.
ESR was 30.
Biochemical Profile reports were normal.
Doctor suggested here to continue with thalidomide and monitor.
Next Kappa/Lambda ratio test was done after another 2 months. It was 8.19.
Also MRI was done which revealed 3 probable lesions - 1 in the left shoulder and 2 in the thighs.
From the structure of these lesions as seen in the MRI and the X ray reports, doctor felt they might not be lesions but since the Kappa/Lambda ratio was increasing, some activity is going on.
Here I will add that my mother was feeling pain in the left shoulder since a month before this MRI was done. X ray reports had been done then but they revealed nothing so no action was taken then.
No biopsies have been done on these 'lesion like' things found in MRI. (Would you suggest biopsy be done?)
Now as the ratio was steadily increasing, Doctor decided to start treatment.
6 injections of Velcade (Bortezomib) were given, one each week and also dexamethasone was given.
After 6 week course, Kappa/Lambda ratio was now at 1.32.
Beta 2 microglobulin was 3220 (normal: 810-2190 ng/ml)
ESR was 48.
Since Beta 2 microglobulin value is still out of range, Doctor has decided to give two more injections of Velcade to bring it down of which 1 has been given already.
In general, all the blood and urine related reports have been normal except for Kappa/Lambda ratio, ESR and Beta 2 microglobulin.
How does the treatment so far look ? is it proper? How is the treatment response? Is it plasmacytoma still or can it be multiple myeloma? How does the overall situation look?
5 posts
• Page 1 of 1
Return to Treatments & Side Effects