Initial Investigation Protocol

Conventional laboratory analysis has involved serum protein electrophoresis (SPE) or capillary zone electrophoresis (CZE) plus urine protein electrophoresis (UPE) (for Light Chain Multiple Myeloma, Bence Jones Protein), followed by immunofixation electrophoresis (IFE).
Now, with Freelite, a more sensitive and specific protocol can be implemented to significantly increase detection of B cell dyscrasia.

In the initial laboratory investigation a strategy of performing serum protein electrophoresis and serum Freelite analysis will allow identification of all significant monoclonal proteins and negate the requirement for urine Bence Jones protein samples for screening.

Laboratory Investigation with Freelite

Requests for investigation of multiple myeloma require a serum sample. The sample should be analysed by both SPE and Freelite kappa and lambda assays, as proposed below:

 

Image 3

Evidence for the Initial Investigation Protocol

In all recent studies the addition of serum Freelite assays to SPE as a first line test increased the detection of B cell dyscrasia.

A prospective analysis in a veterans population, published in Spring 2006 showed adoption of the Freelite plus SPEP protocol resulted in the additional detection of 15 Multiple Myeloma, 1 lymphoma and 1 patient with bladder transitional cell carcinoma.1

Further evidence from a prospective study of 1003 serum samples published in August 2005, indicated detection increased by 56% when Freelite assays were added to CZE.2
Shortly after that, (December 2005), Freelite assays were shown to be "...significantly more sensitive for detecting monoclonal FLC than urine IFE analysis".3

Using data from retrospective studies4-7, the table below shows the "pick up" rate for all Multiple Myeloma, AL amyloidosis, Light Chain Multiple Myeloma and Nonsecretory Multiple Myeloma using different combinations of screening tests.
It can be seen that the optimal pick up rate for all paraproteins can be achieved using simply SPE or CZE and Freelite.

This screening strategy replaces the need for urine testing for Bence Jones proteins

 

Accuracy of different diagnostic approaches for monoclonal testing
Protocols % of Paraproteins detected
  *Myeloma AL LCMM NSMM
SPE/CZE alone 90 50 45 0
SPE/CZE, serum IFE 95 70 75 0
SPE/CZE and UPE 95 75 90 0
SPE/CZE, UPE serum and urine IFE 97 90 95 0
FLC alone 96 98 100 68**
SPE/CZE and FLC 99 98 100 68**
SPE/CZE, FLC and serum IFE 99 98 100 68**

*Myeloma is inclusive of samples from patients identified with Intact Immunoglobulin Multiple Myeloma, Light Chain Multiple Myeloma and Nonsecretory Multiple Myeloma.

**A further 4/28 patients with suppression of one or both free light chains were identified in addition to this 68% equaling 82%.7

Replacement of urine tests for Bence Jones protein

Two recently published studies indicate clearly that if you replace urine Bence Jones Protein tests with serum assays including Freelite free light chains, during the initial investigation for Multiple Myeloma, all patients requiring medical intervention are identified.

"Urine tests are no longer necessary as part of the screening algorithm for identifying monoclonal gammopathies..."8

"..no significant pathology would have been missed by replacing BJP with serum FLCs."9

In a screening study of 923 serum samples seven patients with monoclonal gammopathy and one patient with malignant lymphoma were detected by the presence of an abnormal kappa/lambda ratio among 43 patients who were negative by SPE.9 Importantly, this study also analysed 370 urine samples and the results were compared to corresponding serum FLC results for those patients.

Freelite

The serum FLC test showed much higher specificity than urine protein electrophoresis. All significant pathology was detected by a combination of serum electrophoresis and serum FLC.9

 

Benefits of Freelite

International One Day Conference, September 10th 2004

Applications of serum free light chain tests in Haematology

The latest data on diagnosis and monitoring with Freelite was presented to over 150 haematologists, biochemists and immunologists who attended the third UK symposium on applications of free light chain assays.

Eminent speakers included Professor Robert Kyle and Professor Philip Greipp from the Mayo Clinic, USA, Professor Michel Attal, Hôpital de Toulouse, France and Dr Helen Lachmann, UK National Amyloid Reference Centre, Royal Free Hospital, London.

The final session was a Summary and Discussion of a Free Light Chain Consensus Statement. The panel was Robert Kyle, Michel Attal, Philip Greipp, Helen Lachman and Jo Bradwell.

Consensus Statement - Application of Serum Free Light Chain Testing

The following summarises the consensus view for laboratory application of serum free light chain immunoassays in comparison to other methods:

Consensus Statement
Test Procedures For Diagnosis For Monitoring
SPE/CZE Inadequate/Good Inadequate/Good
SPE/CZE + IFE + UPE Good/Best Practice Good/Best Practice
SPE/CZE + Freelite* Best Practice Best Practice
Choice of statements - Best practice, Good, Indequate
*Urine testing is important in occasional patients

Feedback from delegates highlighted that:

References

  1. Jude M. Abadie and Daniel D. Bankson.
    "Assessment of Serum Free Light Chain Assays for Plasma Cell Disorder Screening in a Veterans Affairs Population"
    Annals of Clinical and Laboratory Science, 36 (2): 157 - 162.

    Reference: MKG310 Quantity:

  2. Nasir A, Bakshi, Ronald Gulbranson, Dabiel Gartska, Arthur R. Bradwell, and David F. Keren.
    "Serum free light chain FLC measurement can aid capillary zone electrophoresis in detecting subtle FLC-producing M proteins"
    Am J Clin Pathol 2005;124:214-218

    Reference: MKG261 Quantity:

  3. Mohammad R Nowrousian, Dieter Brandhorst, Christiane Sammet, Michaela Kellert, Rainer Daniels, Philipp Schuett, Miriam Poser, Siemke Mueller, Peter Ebeling, Anja Welt, Arthur R. Bradwell, Ulrike Buttkereit, Bertram Opalka, Michael Flasshove, Thomas Moritz and Siegfried Seeber.
    "Serum Free Light Chain Analysis and Urine Immunofixation Electrophoresis in Patients with Multiple Myeloma"
    Clin Cancer Res 2005;11 (24) 8706-8714

    Reference: MKG291 Quantity:

  4. G. P. Mead, H. D. Carr-Smith, M. T. Drayson, G. J. Morgan, J. A. Child and A. R. Bradwell.
    "Serum free light chains for monitoring multiple myeloma"
    BJH 2004;126:348-354

    Reference: MKG228 Quantity:

  5. Helen J. Lachmann, Ruth Gallimore, Julian D. Gillmore, Hugh D. Carr-Smith, Arthur R. Bradwell, Mark B. Pepys and Philip N. Hawkins.
    "Outcome in systemic AL amyloidosis in relation to changes in concentration of circulating free immunoglobulin light chains following chemotherapy"
    BJH 2003;122:78-84

    Reference: MKG200 Quantity:

  6. Arthur R Bradwell, Hugh D Carr-Smith, Graham P Mead, Timothy C Harvey, Mark T Drayson.
    "Serum test for assessment of patients with Bence Jones myeloma"
    Lancet 2003;361:489-491

    Reference: MKG189 Quantity:

  7. Mark Drayson, Liang X. Tang, Roger Drew, Graham P. Mead, Hugh Carr-Smith, and Arthur R. Bradwell.
    "Serum free light-chain measurements for identifying and monitoring patients with nonsecretory multiple myeloma"
    Blood 2001;97:9:2900-2902

    Reference: MKG183 Quantity:

  8. Jerry A. Katzmann, Angela Dispenzieri, Robert A. Kyle, Melissa R. Snyder, Matthew F. Plevak, Dirk R. Larson, Roshini S. Abraham, John A. Lust, L. Joseph Melton III, and S. Vincent Rajkumar.
    "Elimination of the Need for Urine Studies in the Screening Algorithm for Monoclonal Gammopathies by Using Serum Immunofixation and Free Light Chain Assays"
    Mayo Clin Proc. 2006;81(12):1575-1578

    Reference: MKG343 Quantity:

  9. Peter G. Hill, Julia M. Forsyth, Baldeep Rai, and Stewart Mayne
    "Serum Free Light Chains: An Alternative Test to Urine Bence Jones Proteins When Screening for Monoclonal Gammopathies"
    Clin Chem 2006 52: 1743-1748.

    Reference: MKG326 Quantity: