Good morning everyone.
My mom was diagnosed with multiple myeloma in January this year. After 4 rounds Velcade she had radiation in August, and was put on maintenance Revlimid / dex. Her M-spike at that point was at 0.2 g/dL (2 g/L).
She told me last week her numbers are climbing so they have increased her Revlimid. I have been looking at her labs and as usual am very confused.
Her serum kappa (93.4) and serum lambda (85.6) are both up. Kappa/lambda ratio is still in range at 1.06, but is on the move upward. For the first time, ever her IgA is high at 610 (normal 81 - 463). IgG, IgM, and IgA have never been out of range ever before. M-spike is holding at 0.2.
I read Dr. Libby comments on another thread about kappa lambda and he stated that the specific numbers of each sometimes reference kidney function. My mom's B2M has always been quite high and still is at 5.38. So I was thinking that the specific numbers then are maybe in correlation to that, but I am not sure and the overall number is still in range.
Clearly something is going on since her Revlimid has been doubled. Is it just that the IgA is now out of range? My confusion is that the M-spike is holding and has for a number of months. All the other numbers are up and down all the time.
I don't think I will ever figure it out sometimes.
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Re: Test clarification - why the change in treatment?
Hello from cold (feels like 25 with wind chill factor) Seattle. At least its not raining though ... right?
What was you mother's M-spike (serum protein electrophoresis / SPEP) when she was diagnosed in January ? What is your mother's SPEP result now?
Whenever possible, the SPEP is a better test to use when following your mother's progress.
What type of myeloma does your mother have -- IgA or IgG, kappa or lambda?
Also, I would like to know the units on her serum free light chain measurements. Are they mg/dL or mg/L?
Thank you
What was you mother's M-spike (serum protein electrophoresis / SPEP) when she was diagnosed in January ? What is your mother's SPEP result now?
Whenever possible, the SPEP is a better test to use when following your mother's progress.
What type of myeloma does your mother have -- IgA or IgG, kappa or lambda?
Also, I would like to know the units on her serum free light chain measurements. Are they mg/dL or mg/L?
Thank you
-
Dr. Edward Libby - Name: Edward Libby, M.D.
Beacon Medical Advisor
Re: Test clarification - why the change in treatment?
Hi Dr Libby! Its chilly here, but not 25 ...
She has IgG kappa
Here is the SPEP in January
Report Date: Jan. 21, 2014 12:00 AM
Result Value Units Range Lab
Serum Protein Electrophoresis
Protein, Total 7.5 g/dL 5.9-8.4 LabPak-FMO-jfh
Albumin 45.9 Low % 48.1-59.5 LabPak-FMO-jfh
Alpha-1-Globulin 4.0 % 2.3-4.9 LabPak-FMO-jfh
Alpha-2-Globulin 13.5 High % 6.9-13.0 LabPak-FMO-jfh
Beta Globulin 17.4 % 13.8-19.7 LabPak-FMO-jfh
Gamma Globulin 19.3 % 10.1-21.9 LabPak-FMO-jfh
A/G Ratio 0.9 Calc LabPak-FMO-jfh
MSpike 0.4 High
And in November
Protein, Total and Protein Electrophoresis
Total Protein 6.9 g/dL 6.1-8.1 Quest-TP
Albumin 3.0 Low g/dL 3.5-4.7 Quest-TP
Alpha-1-Globulins 0.3 g/dL 0.1-0.3 Quest-TP
Alpha-2-Globulins 1.0 g/dL 0.5-1.0 Quest-TP
Beta Globulins 1.1 g/dL 0.8-1.4 Quest-TP
Gamma Globulins 1.6 g/dL 0.6-1.6 Quest-TP
MSpike 0.2 High g/dL None Detected Quest-TP
Serum light chain test in November
Immunoglobulin G
IgG 1384 mg/dL 694-1618 Quest-TP
Immunoglobulin M
IgM 193 mg/dL 48-271 Quest-TP
Immunoglobulin A
IgA 610 High mg/dL 81-463 Quest-TP
Kappa/Lambda Light Chains Free With Ratio, Serum
Serum Kappa 93.4 High mg/L 3.3-19.4 Quest-TP
Serum Lambda 85.6 High mg/L 5.7-26.3 Quest-TP
Kappa/Lambda Light Chains Free With Ratio, Serum
1.09 0.26-1.65 Quest-TP
Thank you so much for helping me.
She has IgG kappa
Here is the SPEP in January
Report Date: Jan. 21, 2014 12:00 AM
Result Value Units Range Lab
Serum Protein Electrophoresis
Protein, Total 7.5 g/dL 5.9-8.4 LabPak-FMO-jfh
Albumin 45.9 Low % 48.1-59.5 LabPak-FMO-jfh
Alpha-1-Globulin 4.0 % 2.3-4.9 LabPak-FMO-jfh
Alpha-2-Globulin 13.5 High % 6.9-13.0 LabPak-FMO-jfh
Beta Globulin 17.4 % 13.8-19.7 LabPak-FMO-jfh
Gamma Globulin 19.3 % 10.1-21.9 LabPak-FMO-jfh
A/G Ratio 0.9 Calc LabPak-FMO-jfh
MSpike 0.4 High
And in November
Protein, Total and Protein Electrophoresis
Total Protein 6.9 g/dL 6.1-8.1 Quest-TP
Albumin 3.0 Low g/dL 3.5-4.7 Quest-TP
Alpha-1-Globulins 0.3 g/dL 0.1-0.3 Quest-TP
Alpha-2-Globulins 1.0 g/dL 0.5-1.0 Quest-TP
Beta Globulins 1.1 g/dL 0.8-1.4 Quest-TP
Gamma Globulins 1.6 g/dL 0.6-1.6 Quest-TP
MSpike 0.2 High g/dL None Detected Quest-TP
Serum light chain test in November
Immunoglobulin G
IgG 1384 mg/dL 694-1618 Quest-TP
Immunoglobulin M
IgM 193 mg/dL 48-271 Quest-TP
Immunoglobulin A
IgA 610 High mg/dL 81-463 Quest-TP
Kappa/Lambda Light Chains Free With Ratio, Serum
Serum Kappa 93.4 High mg/L 3.3-19.4 Quest-TP
Serum Lambda 85.6 High mg/L 5.7-26.3 Quest-TP
Kappa/Lambda Light Chains Free With Ratio, Serum
1.09 0.26-1.65 Quest-TP
Thank you so much for helping me.
Re: Test clarification - why the change in treatment?
OK ... great, this is very helpful. IgG kappa.
So the easy things that can be followed with blood testing to see if the myeloma is getting better,worse or is stable are:
#1. The level of total IgG in the blood
#2. The monoclonal IgG protein in the blood (e.g. the M-spike)
#3. The serum free kappa light chains
In general, one should use the M-spike (SPEP) whenever possible, but the starting M-spike (before treatment) should be at least 0.5, and hers was not, which makes it less useful. Therefore the hematologist / oncologist should use the serum free light chains to follow the disease (if they are present at a significant level).
It would be valuable to know what her free light chains were at diagnosis (pre-treatment) to see how much she has responded. Both the kappa and the lambda chains are elevated which suggests that she has abnormal kidney function. The individual free light chain levels are less useful in patients with abnormal kidney function. The free light chain ratio should then be used. The fact that the ratio is normal tells you that there is no real elevation in her free light chains.
So, I have more questions
1. What was her serum IgG level at diagnosis?
2. What is her creatinine (kidney function) and age ?
3. What were her free light chain levels at diagnosis?
Thank you
So the easy things that can be followed with blood testing to see if the myeloma is getting better,worse or is stable are:
#1. The level of total IgG in the blood
#2. The monoclonal IgG protein in the blood (e.g. the M-spike)
#3. The serum free kappa light chains
In general, one should use the M-spike (SPEP) whenever possible, but the starting M-spike (before treatment) should be at least 0.5, and hers was not, which makes it less useful. Therefore the hematologist / oncologist should use the serum free light chains to follow the disease (if they are present at a significant level).
It would be valuable to know what her free light chains were at diagnosis (pre-treatment) to see how much she has responded. Both the kappa and the lambda chains are elevated which suggests that she has abnormal kidney function. The individual free light chain levels are less useful in patients with abnormal kidney function. The free light chain ratio should then be used. The fact that the ratio is normal tells you that there is no real elevation in her free light chains.
So, I have more questions
1. What was her serum IgG level at diagnosis?
2. What is her creatinine (kidney function) and age ?
3. What were her free light chain levels at diagnosis?
Thank you
-
Dr. Edward Libby - Name: Edward Libby, M.D.
Beacon Medical Advisor
Re: Test clarification - why the change in treatment?
Test February, 2014 before starting Velcade
Immunoglobulin G 1422 mg/dL 694-1618 Quest-TP
Immunoglobulin M 138 mg/dL 48-271 Quest-TP
Immunoglobulin A 277 mg/dL 81-463 Quest-TP
Kappa/Lambda Light Chains Free With Ratio, Serum
Serum Kappa 75.4 High mg/L 3.3-19.4 Quest-TP
Serum Lambda 25.7 mg/L 5.7-26.3 Quest-TP
Kappa/Lambda 2.93 High 0.26-1.65 Quest-TP
Test October 1, 2014 after Velcade and 2 month after radiation (these are the lowest numbers she got)
Immunoglobulin G 947 mg/dL 694-1618 Quest-TP
Immunoglobulin M 142 mg/dL 48-271 Quest-TP
Immunoglobulin A 276 mg/dL 81-463 Quest-TP
Kappa/Lambda Light Chains Free With Ratio, Serum
Serum Kappa 61.7 High mg/L 3.3-19.4 Quest-TP
Serum Lambda 67.1 High mg/L 5.7-26.3 Quest-TP
Kappa/Lambda 0.92 0.26-1.65 Quest-TP
Her last creatinine level was on November 17, 2014 was 0.77 mg/dL, 0.60-0.93 range (first time in range since February).
She is 75 years old. She also has rheumatoid arthritis if that matters.
Thank you after 9 months I am beginning to understand.
Immunoglobulin G 1422 mg/dL 694-1618 Quest-TP
Immunoglobulin M 138 mg/dL 48-271 Quest-TP
Immunoglobulin A 277 mg/dL 81-463 Quest-TP
Kappa/Lambda Light Chains Free With Ratio, Serum
Serum Kappa 75.4 High mg/L 3.3-19.4 Quest-TP
Serum Lambda 25.7 mg/L 5.7-26.3 Quest-TP
Kappa/Lambda 2.93 High 0.26-1.65 Quest-TP
Test October 1, 2014 after Velcade and 2 month after radiation (these are the lowest numbers she got)
Immunoglobulin G 947 mg/dL 694-1618 Quest-TP
Immunoglobulin M 142 mg/dL 48-271 Quest-TP
Immunoglobulin A 276 mg/dL 81-463 Quest-TP
Kappa/Lambda Light Chains Free With Ratio, Serum
Serum Kappa 61.7 High mg/L 3.3-19.4 Quest-TP
Serum Lambda 67.1 High mg/L 5.7-26.3 Quest-TP
Kappa/Lambda 0.92 0.26-1.65 Quest-TP
Her last creatinine level was on November 17, 2014 was 0.77 mg/dL, 0.60-0.93 range (first time in range since February).
She is 75 years old. She also has rheumatoid arthritis if that matters.
Thank you after 9 months I am beginning to understand.
Re: Test clarification - why the change in treatment?
Hello again from Seattle,
Gosh ... isn't it amazing how many numbers (data) myeloma doctors use to make decisions?
We know your mothers M-spike was 0.4 in January of 2014 and it has fallen to 0.2. That suggests a response.
Her serum free kappa light chain was 75 mg/L at the same time. Not really very elevated, but abnormal just the same.
The total IgG was 1422 at diagnosis and it now is 1398.
Now the M-spike is 0.2 and the serum kappa free light chain is essentially the same at 61.7 mg/l.
So things haven't gotten worse, but they have not clearly and dramatically gotten better.
The free light chains are confusing and would not lead me to change therapy because both the kappa and the lambda are elevated. This leads me to believe that she is having an inflammatory reaction that is causing the dual elevation in light chains, rather than an increase in her myeloma burden.
Given that she has low levels to follow in the blood, a bone marrow biopsy would be very valuable to see what is actually happening. Having your mother on a higher dose of Revlimid is reasonable, though (the full dose is 25 mg daily), with dexamethasone 20-40 milligrams once weekly.
I agree these numbers are a little confusing.
Gosh ... isn't it amazing how many numbers (data) myeloma doctors use to make decisions?
We know your mothers M-spike was 0.4 in January of 2014 and it has fallen to 0.2. That suggests a response.
Her serum free kappa light chain was 75 mg/L at the same time. Not really very elevated, but abnormal just the same.
The total IgG was 1422 at diagnosis and it now is 1398.
Now the M-spike is 0.2 and the serum kappa free light chain is essentially the same at 61.7 mg/l.
So things haven't gotten worse, but they have not clearly and dramatically gotten better.
The free light chains are confusing and would not lead me to change therapy because both the kappa and the lambda are elevated. This leads me to believe that she is having an inflammatory reaction that is causing the dual elevation in light chains, rather than an increase in her myeloma burden.
Given that she has low levels to follow in the blood, a bone marrow biopsy would be very valuable to see what is actually happening. Having your mother on a higher dose of Revlimid is reasonable, though (the full dose is 25 mg daily), with dexamethasone 20-40 milligrams once weekly.
I agree these numbers are a little confusing.
-
Dr. Edward Libby - Name: Edward Libby, M.D.
Beacon Medical Advisor
Re: Test clarification - why the change in treatment?
Dr. Libby -
I spoke with her doctor today and I think I understand what's going on. He said they initially did not get the response from Velcade / dex that they had hoped for, so they radiated in August.
From that he said they got what is considered a very good response, but not remission. In October her numbers spiked back up. He waited another month to see if perhaps it was a fluke. The number were still up in November, including M-spike up to 0.2 from 0.1 in Sept. He says the IgA is concerning. Light chains up higher in November than in October.
So increase in Revlimid by 10 mg. If the numbers don't get better he will order a PET and switch her to Pomalyst / dex.
I appreciate the explanations you have given me. Today was the first time I wasn't confused speaking with her doctor. He repeated exactly what you stated as far as what he is looking at.
Thank you so much!!
I spoke with her doctor today and I think I understand what's going on. He said they initially did not get the response from Velcade / dex that they had hoped for, so they radiated in August.
From that he said they got what is considered a very good response, but not remission. In October her numbers spiked back up. He waited another month to see if perhaps it was a fluke. The number were still up in November, including M-spike up to 0.2 from 0.1 in Sept. He says the IgA is concerning. Light chains up higher in November than in October.
So increase in Revlimid by 10 mg. If the numbers don't get better he will order a PET and switch her to Pomalyst / dex.
I appreciate the explanations you have given me. Today was the first time I wasn't confused speaking with her doctor. He repeated exactly what you stated as far as what he is looking at.
Thank you so much!!
7 posts
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