Paraproteins

Jennifer Glaysher
Principal Clinical Scientist, Aintree University Hospital
Plan
Basic immunoglobulins
Paraproteins
Laboratory diagnosis
Serum electrophoresis (SEP)
Bence Jones Protein (BJP)
Other useful tests

Causes of paraproteins
Malignant
Multiple myeloma
Benign
Monoclonal gammopathy of unknown significance
Smouldering Myeloma

Cryoglobulins

Basic Immunoglobulin
Paraprotein Production
Paraprotein
Proliferation of one specific clone of malignant /
hyper stimulated B cell in bone marrow

Presence of monoclonal band in serum

Over production of one clone of immunoglobulin
One type of heavy chain -> G,A,M, D,E
One type of light chain ->

May have more than one monoclonal band
bi / triclonal paraprotein!
IgG, 56%
IgM, 20%
IgA, 12%
Light
chains,
5.50%
Biclonal,
6%
IgD,
0.50%
Initial Presentation
Anaemia - Weakness or fatigue
Back / Bone pain or fractures
Renal insufficiency
Incidental
High total protein
Raised globulin
Raised ESR
Hypercalcaemia
Immunoglobulin pattern
Laboratory diagnosis
Clinical suspicion /
incidental finding
Serum protein
electrophoresis
Immunofixation
Band Quantitation
Bence Jones
electrophoresis
(Urine)
Urine
immunofixation
Bone marrow
biopsy
Serum free light
chains
Sebia Hydrasys Product Insert
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*
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Band quantitation
Semi-quantitative
Staging
Monitoring progression
Response to treatment
Date Band conc.(g/L)
11/08 8.9
01/09 9.2
07/09 8.7
02/10 7.2
09/10 8.1
02/11 8.8
02/12 8.9
Immunofixation
Ref range (g/L)
Total protein 79 60-80 g/L
Albumin 42 35 50 g/L
Globulin 37 22 32 g/L
IgG 8.30 6 16 g/L
IgA 4.10 0.8 2.8 g/L
IgM 13.84 0.5 1.9 g/L
AACB Guidelines
Gel based and capillary zone electrophoresis

Report in g/L to nearest whole number.
<1 g/L Small band cannot be quantitated readily
Bands may be visible solely by immunofixation

Non-gamma region
Report as + beta

Subsequent specimens
Do not repeat immunofixation unless
Change in mobility
Additional band
Band no longer visible
Large polyclonal background
Bence Jones Proteins
20 % not detectable in serum

Presence of free light chains in urine

Glomerular filtration

Cleared in proximal tubules

Renal threshold nephrotoxic

<10g/L trace

Serum free light chains
Serum half life 2-6 hrs

Normal / ratio 2:1
Polyclonal ratio unchanged
Myeloma skewed ratio

Useful for
Light chain disease
Non secretory
Monitor response to treatment

Causes of paraproteinaemia
Causes of paraprotein - 1
2
Malignant or uncontrolled production

Multiple myeloma

Waldenstroms macroglobulinaemia

Malignant lymphoma

Chronic lymphocytic leukaemia

Primary amyloidosis

Plasma cell leukaemia

Heavy chain disease
Multiple Myeloma
~4000 new cases / year

Incidence : 60 70 per million
5

Increased incidence with age (15% <60y)


Median age at presentation:70y
4

Median survival 3-4 years
1

Bias
Racial
Between sexes
Diagnostic Criteria
1. Monoclonal protein in serum / urine
2. Increased plasma cells in bone marrow (>10%)
3. End organ disease
1. Bone disease -Bone pain / pathological fractures (80-90%)
2. Renal impairment - (50%)
3. Anaemia -Normochromic normocytic anaemia (or macrocytic)
4. Hypercalcaemia - (30%) anorexia, nausea, polydipsia
5. Hyperviscosity - IgM>>IgA>IgG
6. Amyloidosis
7. Recurrent infection - 2 immuneparesis

myeloma.org.au
Skull
Spine Spinal cord compression
Pelvis
Hips
Ribs
Shoulder
International staging system
Stage Criteria
Median survival
(months)
I Serum 2M <3.5 mg/L and albumin 35g/l 62
II Neither I or III 45
III Serum 2M 5.5 mg/L 29

International staging system ISS for multiple myeloma.
5

Other Investigations
Biochemistry Haematology Radiology
Bone profile FBC
MRI Scan
(spine compressions)
LFTs ESR CT scan
Renal profile Blood film Skeletal survey
IgG, IgA, IgM Bone marrow aspirate
B12 / Ferritin / Folate Plasma cell phenotyping

2
Microglobulin
Serum free light chains
Treatment
2

Supportive
Rehydration
Bisphosphonates
Transfusion
Plasmapharesis
Antibiotics / Immunoglobulin infusion

Intensive therapy (<65y and symptomatic)
Stem cell collection
Multiple courses of chemotherapy (i.e. cyclophosphamide,
dexamethasone, thalidomide)
Autologous stem cell transplant after high dose chemo

Non intensive therapy
Oral alkylating agent melphalan prednisolone

Benign or stable production
2

Monoclonal gammopathy of unknown significance
Solitary plasmacytoma
Chronic cold haemoglutinin disease
Transient (e.g. with infections)
AIDS
Gauchers disease
Rarely with carcinoma and other conditions


Causes of Paraprotein - 2
MGUS
1 & 3
Approx. 2 - 3% of individuals aged >50 yrs & 5% aged >70 yrs.

Criteria
1
Serum paraprotein <30 g/L
<10% bone marrow plasma cells
absence of end organ damage: anaemia, hypercalcaemia, lytic bone lesions or
renal failure attributable to the gammopathy

Follow up monitor every 6 months, then annually if stable
1% per year risk of progression to myeloma
Predictors of progression
Larger band = increased risk
Non-IgG (IgM or IgA) > IgG
Abnormal serum-FLC ratio
1
Lancet 2004;363:875
Smouldering multiple myeloma
1
Criteria
Serum paraprotein >30g/L OR
bone marrow >10% plasma cells
BUT absence of anaemia, hypercalcaemia, lytic bone disease or
renal failure attributed to proliferative disorder

10-20% per year risk of progression
1

Examples
1 2 3 4 5 6
MONOCLONAL COMPONENT
BICLONAL GAMMOPATHY
HYPERGAMMAGLOBULINEMIA



WEAK MONOCLONAL COMPONENT
FIBRINOGEN IN PLASMA
HYPOGAMMAGLOBULINEMIA


2
1
3
6
Clinical Case
Cases
66y female
Presented to GP complaining of back pain

Sodium 134 mmol/L
Potassium 4.0 mmol/L
Urea 7.3 mmol/L
Creatinine 130 umol/L
Total protein 84 g/L
Albumin 38 g/L /
Globulin 46 g/L
Adj Ca 2.75 mmol/L
ALP 80 IU/L
Haemoglobin 10 g/dl
Month/year
Band
concentration g/L
Feb-09 11
Mar-09 11.8
Jun-09 12.3
Jul-09 11.9
Sep-09 13.8
Jan-10 13.6
May-10 18.6
Jun-10 17.3
Oct-10 21
Jan-11 29.9
Jan-11 29
Mar-11 33.6
May-11 41.4
Jul-11 49.3
Aug-11 39.9
Sep-11 42
Sep-11 39.3
Oct-11 42.3
Nov-11 40.5
Dec-11 23.4
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40
50
60
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Velcade a & DXM
Lanilomide &
DXM
Cryoglobulinaemia
Cryoglobulinaemia
Precipitate at temp lower than normal body temp

Most polyclonal Ig complexes, nearly half monoclonal
(mainly IgM)

Type I
Monoclonal,
lymphoproliferative disorders
Hyperviscosity & thrombosis

Type II & III
Mixed with rheumatoid factor
Chronic inflamatory conditions -> SLE, Sjorgens syndrome
Joints, fatigue,


10ml blood from vein without tourniquet in to warmed plain bottle
Place sample in 37C sand
Leave to clot at 37C (may put in 37C water bath)
Centrifuge 3 mins
Separate serum and divide between two tubes
One tube fridge for 7days
Second in incubator at 37C
Inspect refrigerated sample regularly ? Precipitate (compare with 37C)
Centrifuge cold tube at 4C for 10 mins no ppt negative
Precipitate observed wash ppt with cold saline (i.e. resuspend, centrifuge, decant)
Resuspend in saline and incubate at 37C for 30 mins
If redisolves true cryoglobulin (if doesnt may be fibrin i.e. pt on anticoagulant therapy)
Perform electrophoresis (keep all equipment at 37C), if band present IFX
Conclusions
Paraproteins may present with clinical features such as bone
pain / anaemia / renal failure or may be an incidental finding

Paraproteins can be detected by serum / urine electrophoresis

Type can be identified by immunofixation

Paraproteins may be benign i.e. MGUS or malignant i.e.
multiple myeloma

Laboratories play a role in identification / diagnosis /
monitoring /determining response to treatment
References
http://www.patient.co.uk/doctor/Myeloma.htm

Myeloma.org.uk

1) MGUS and smoldering multiple myeloma: update on pathogenesis, natural
history and management. Rajkumar Hematology. 2005 p340

2) Essential Haematology Hoffbrand, Moss & Pettit P216

3) Monoclonal gammopathy of undetermined significance. Kyle R & Rajkumar S.
British journal of Haematology, 134, 573-589.

4) Multiple myeloma: Diagnosis and treatment NAU K & Lewis W. American Family
\physician 78 (7) 2008. P853-

5) Guidelines for the diagnosis and management of multiple myeloma
2011.British Journal of Haematology, 154,32-75