[AlexM]

Results of 4 months of CyBorD therapy - a few questions

by AlexM on Thu Sep 22, 2016 12:36 pm

Hi All,

First, I would like to thank this community for such amazing and invaluable information posted on this forum and on the website. While it is unfortunate that many, if not all, of the members on this forum have been somehow affected by this disease, we are fortunate to have such a great community that cares and is willing to share so much.

Background: My father lives in Brazil and was diagnosed with kappa multiple myeloma in April 2016 after an emergency X-ray showed a mass on his rib. X-ray was done due to kidney stones as he was having a lot of pain in the area and had released a kidney stone when he went to pee one day. Long story short, after blood tests and PET/CT, he with diagnosed with multiple myeloma kappa type and started cyclophosphamide, Velcade (bortezomib), and dexa­metha­sone (CyBorD). "Residues" of kidney stones were confirmed as well.

What I am finding confusing is his response to treatment as evidenced by the tests done at diagnosis and the tests done recently after the 4-month cycle of CyBorD. Important to note that the tests were done in 2 different labs (I know, probably not the best decision and possibly the reason for confusion). Additionally, due to low platelets during treatment (sub 50K), my dad did not take cyclophosphamide for the last 2 months out of 4 total months.

CyBorD was given as dexamethasone + Velcade (subcutaneous) 1.5 mg/m2 once every week + IV cyclophosphamide 600 mg/m2 every other week. Plus Zometa once a month.

Summary of test results below (doing my best to translate from Portuguese):

Test & Imaging Results - Time of Diagnosis (April 2016)

Beta 2 Microglobulin 2.9 mg/L (< 2.4 mg/L)
Calcium 1.31 mmol/L (1.11 - 1.40 mmol/L)
Creatinine 1.10 mg/dL (0.70-1.30 mg/dL)

Electrophoresis

Result g/dL % g/dL %
Albumin 4.22 63.9 (3.50-4.85) (54.0-60.0)
Alpha-1 globulin 0.23 3.5 (0.22-0.43) (3.4-5.3)
Alpha-2 globulin 0.66 10.0 (0.55-1.08) (8.4-13.3)
Beta-1 globulin 0.38 5.8 (0.32-0.54) (4.9-6.6)
Beta-2 globulin 0.30 4.5 (0.24-0.54) (3.6-6.6)
Gamma globulin 0.81 12.3 (0.74-1.75) (11.4-21.6)
Total 6.60 (6.50-8.10)
Albumin / Globulin 1.8 (0.9-2.0)

Obs: Presence of monoclonal component on Beta-2-globulin.

IgA 135 mg/dL (50-400 mg/dL)
IgG 1080 mg/dL (600-1500 mg/dL)
IgM 19 mg/dL (50-300 mg/dL)

Imunofixation Urine. Bence-Jones
Positive. Presence of kappa and impossible to quantify
given low quantity.

Imunofixation Serum
Presence of monoclonal component of kappa

Serum Free Light Chain
Kappa : 370.50 mg/dL (0.33-1.94 mg/dL)
Lambda: 1.07 mg/dL (0.57-2.63 mg/dL)
kappa/lambda.: 346.26 (0.26-1.65)

PET/CT scan very short summary:

Plasmacytoma on rib RUV Max = 4.7
Lesion 2 on another rib RUV Max = 2.9
Thyroid gland SUV Max = 6.3

Tests & Imaging After CyBorD for 4 months (Sep 12, 2016)

Creatinine 0.81 mg/dL (0.7-1.2 mg/dL)
Calcium 9.29 mg/dL (8.8-10.2 mg/dL)

Electrophoresis

Test g/dL % g/dL %
Albumin 4.00 63.6 (3.51-5.42) (55.8-66.1)
Alpha-1 globulin 0.30 4.8 (0.18-0.40) (2.9- 4.9)
Alpha-2 globulin 0.90 14.3 (0.45-0.96) (7.1-11.8)
Beta-1 globulin 0.50 7.9 (0.30-0.59) (4.7- 7.2)
Beta-2 globulin 0.40 6.4 (0.20-0.53) (3.2- 6.5)
Gamma globulin 1.00 15.9 (0.70-1.54) (11.1-18.8)
Total Protein: 6.29 (6.30-8.20)

IgA 161 mg/dL 70-400 mg/dL
IgG 930 mg/dL 700-1600 mg/dL
IgM 26 mg/dL 40-230 mg/dL

Serum Free Light Chain

Kappa 214.0 mg/dL (170-370 mg/dL)
Lambda 100.0 mg/dL (90-210 mg/dL)
Kappa/lambda 2.14 (1.35-2.65)

Imunofixation Urine
Presence of multiple bands of IgG. kappa. lambda.

PET/CT Scan:

Plasmacytoma on rib RUV Max = 3.6 from 4.7
Lesion 2 on another rib: no sign of increase of metabolism there
anymore
New multiple nodular opacities on the inferior lobe of the lung
with size up to 1.0 cm
Thyroid gland increased metabolism remains but no RUV Max was given.

There are my questions:

1. Urine test results: Only kappa was detected, but now IgG, kappa, and lambda were detected. Does it mean the multiple myeloma has mutated already, or could it be error from one lab to the other?

2. Serum free light chain results: Very big difference on reference levels for each lab. Could this be due to "method of analysis" or something along those lines? Also, while kappa did come down, the ratio came down mostly because lambda went from 1.07 to 100. If my dad were to have developed lambda multiple myeloma, could it be that the increase in lambda, together with the kappa diagnosis, actually made the ratio look "normal"?

3. PET/CT: I'm worried that the "multiple new nodular opacities in the inferior lobe of the lung" could be due to pulmonary amyloidosis. Any thoughts on that?

Any other insights greatly appreciated. Apologies for the long message.

[TerryH]

Re: Results of 4 months of CyBorD therapy - a few questions

by TerryH on Thu Sep 22, 2016 2:40 pm

Alex,

Welcome to the forum.

I don't have answers to all your questions, but I do have some quick feedback on your father's light chain results.

I believe the light chain test that was done after his CyBorD treatment measured his TOTAL light chain levels, not his FREE light chain levels.

Here is a web page with the same reference levels listed as those for the second light chain test results you include in your post:

http://nslijlab.testcatalog.org/show/KAPPA-LAMBDA-1

It does not say "free light chain" levels, just "light chain".

Quest laboratories lists the following reference ranges for its test of serum total light chain levels:

Kappa: 74-295 mg/dL
Lambda: 32-156 mg/dL
Kappa/Lambda Ratio: 1.3-2.7

They are not exactly the same as the reference ranges you list, but similar.

You really want to focus on changes in your father's free light chain results. They capture the impact of treatment on his disease much better changes in the total light levels and ratio.

Good luck!

[AlexM]

Re: Results of 4 months of CyBorD therapy - a few questions

by AlexM on Thu Sep 22, 2016 4:18 pm

TerryH,

Thank you for the reply. Very helpful, I now understand. I'm wondering why the doctor asked for the total kappa/lambda, rather than the "free" ones, as the latter is the relevant one. We have a con­sultation with him on Monday, so I will definitely ask the question.