[Myeloma Fighter]

Two M-spikes - IgG lambda and IgG kappa

by Myeloma Fighter on Tue Jan 20, 2015 12:08 pm

I was diagnosed in February of 2014 with IgG lambda, at the age of 54. I have t(4,14) and gain on the 1q. I have trisomy of the 11 chromosome, with deletion of the chromosome 13. I am considered high risk, although the Mayo clinic might consider me to be intermediate. I had 70% plasma cells at the time of detection. PET and MRI show no lesions. At commencement of therapy, my M-Spike was 4.0. My therapy was Car-BiRd. For more info on Car-BiRd you can read this Beacon abstract:

TM Mark et al, "Car-Bird [Carfilzomib, Clarithromycin(Biaxin®), Lena­lido­mide / (Rev­limid®), Dexamethasone) For Newly-Diagnosed Multiple Myeloma," ASH 2013 annual meeting abstract 3216.

Car-BiRd is carfilzomib (Kyprolis) (45 mg twice a week for 3 weeks of a 28 day cycle) and dex (40 mg each week of the 28 day cycle) until a plateau is reached (the "Car" portion), then consolidation with "Bird", which is Revlimid for 21 days of a 28 day cycle (25 mg daily), dex (40 mg weekly for of the 28 day cycle) and Biaxin (clarithromycin) daily.

My M-spike went from 4.0 g/dL (40 g/L) to 0.1 g/dL (1 g/L) on the Car portion. I had 3 cycles of the Bird, which did not lower my M-Spike. I am now on Revlimid maintenance - which is 10 mg for 21 days and then 7 days off in a 28 day cycle.

After my first cycle of maintenance, blood tests showed that my IgG lambda M-spike was still 0.1 g/dL, but an M-spike of IgG kappa (0.05 g/dL) was also detected.

My blood work is now normal with hemoglobin of 14.9 (it was hovering at 10 when I was first diagnosed) and creatinine levels of 1.2 (it was 1.6 at the time I was diagnosed, and once hit 2.0 during the Car therapy). So, before this "discovery" of a second M-spike, I was feeling pretty good, all things considered.

Does anyone have any experience with a person having both a lambda and kappa M-spike?

[goldmine848]

Re: Two M-spikes - IgG lambda and IgG kappa

by goldmine848 on Tue Jan 20, 2015 8:03 pm

Having experienced a version of this as detailed in my column a few months ago, I can offer a few comments.

It may be that your first cycle of treatment produced secondary MGUS. It is also possible that you had biclonal disease at the outset and the testing failed to detect the second clone until later.

Ordinarily, when one is experiencing secondary MGUS, the initial clone disappears and is replaced by the secondary clone. You did not mention if your initial clone is still present. I am not aware of documented instances of secondary MGUS being the result of Car-Bird therapy, but I did not concentrate on that in my own research since my initial therapy was VRD (Velcade, Revlimid, and dex).

If you do searches online for secondary MGUS and ASIP (atypical serum immunofixation patterns) you will find a number of studies reporting on this phenomenon.

[Multibilly]

Re: Two M-spikes - IgG lambda and IgG kappa

by Multibilly on Tue Jan 20, 2015 8:09 pm

This phenomenon does sometimes occur in patients.

If you read through one of Andrew's threads below:

"Secondary MGUS pre- and post-transplant?," forum disc. started Aug 28, 2014

You will note the references to a BiRd study and this phenomenon in the second link of the above thread:

C Fernandez de Larrea et al, "Emergence Of Oligoclonal Bands In Patients With Multiple Myeloma In Complete Remission After Induction Chemotherapy: Association With The Use Of Novel Agents," Haematologica, January, 2011 (full text).

Abstract:

The emergence of oligoclonal bands is associated with a favorable outcome after autologous stem cell transplantation in multiple myeloma. The aim of this study was to determine the prevalence of immunoglobulin oligoclonality in 33 patients with multiple myeloma in complete remission achieved with primary therapy with either cytotoxic agents (n=18, 54.5%) or new induction regimens incorporating novel drugs (n=15, 45.4%). Eleven patients (33.3%) developed oligoclonal bands. In the group treated with novel agents, this oligoclonal immune response was observed in 60% (9 of 15) of the patients versus only 11.1% (2 of 18) of those given cytotoxic therapy (P=0.003). This is the first report showing a different frequency of oligoclonal humoral response in patients in complete remission achieved after conventional cytotoxic therapy versus induction incorporating novel agents. This difference could be due to a higher antitumor effect associated with the use of novel drugs, a stronger immune reconstitution, or both

Excerpt:

" .... With the progressive use of novel drugs the complete remission rate and consequently the proportion of patients who develop an oligoclonal immune response with oligoclonal bands will likely increase. In fact, in the BiRD study, Mark et al. reported that 33% of patients treated with clarithromycin, lenalidomide and dexamethasone developed ASIPs (atypical serum IFE patterns) consisting in the emergence of monoclonal and oligoclonal immunoglobulins unrelated to the original monoclonal protein."

Last edited by Multibilly on Wed Jan 21, 2015 12:10 pm, edited 1 time in total.

[Dr. Jonathan Kaufman]

Re: Two M-spikes - IgG lambda and IgG kappa

by Dr. Jonathan Kaufman on Wed Jan 21, 2015 11:44 am

I suspect this is an oligoclonal band typically seen after remission induced by transplant. It can be seen in highly effective therapies like you are on. I don't think it represents any new myeloma-related clone. I think it most likely represents a robust recovery of your normal immune system. I view this as good news.

Best wishes with your treatment and ongoing remission.

Jlk

[Myeloma Fighter]

Re: Two M-spikes - IgG lambda and IgG kappa

by Myeloma Fighter on Wed Jan 21, 2015 11:25 pm

Thank you Andrew, MultiBilly, and Dr. Kaufman for your quick and detailed responses. I have since spoken with my oncologist, who said essentially what Dr. Kaufman said. I have to admit that it is counterintuitive for me to view the emergence of a second paraprotein as good news. But I'll take good news whenever I have the opportunity.

Fingers crossed!