FREE LIGHT CHAIN ESCAPE IN MULTIPLE MYELOMA: IS IT AN EARLY CLUE OF AGGRESSIVE PROGRESSION?


Yavuz B., Karataş A. F., Erdoğan Yücel E., Güven S., Alacacıoğlu İ., Demirkan F., ...More

8. International Congress on Leukemia Lymphoma Myeloma, 21 - 22 May 2021, no.40, pp.57-58

  • Publication Type: Conference Paper / Summary Text
  • Page Numbers: pp.57-58
  • Dokuz Eylül University Affiliated: Yes

Abstract

Free light chain escape is a rare phenomenon seen in 3% of multiple myeloma patients [1]. It is characterized by rise of involved free light chain levels without involvement the heavy chain component. It often accompanies extramedullary disease progression[2] or rapid renal impairment[3]. Here we present 3 multiple myeloma cases with free light chain escape and a review of the literature. Case A: 52-year-old female patient, who has no known comorbid conditions, undergoes an operation after a tarsal bone fracture in September 2019 and applies to our clinic after the pathology result is compatible with plasmacytoma. IgGλ paraproteinemia and multiple bone lesions are detected and is considered to be R-ISS stage III and treatment is started immediately with weekly bortezomib + cyclophosphamide + dexamethasone (VCD). When she came for the 15th day of the first course it was observed that her general condition deteriorated; anemia, hypercalcemia, and a high creatinine level compatible with acute kidney damage is detected. At the same time, free λ light chain escape is detected. The patient is hospitalized and 1 volume plasma exchange is performed 4 times every other day. In our patient, a 40% free λ reduction was achieved with 4 sessions of plasma exchange. This data appears to be consistent with the Mayo Clinic data, where free λ reduction of 36.6–93.3% was observed with a median of 8 sessions (4 to 23) of plasma exchange [4]. Case B: A 46-year-old male patient was evaluated in June 2010 with complaints of low back pain and fatigue and IgAλ paraproteinemia was detected. He had anemia and diffuse bone involvement and diagnosed with multiple myeloma R-ISS: I. The patient has a history of treatment with VCD, autologous stem cell transplantation (in 2011 and 2018), lenalidomide use has been followed up with pomalidomide treatment since July 2019, he applied to the orthopedic clinic due to back pain in July 2020. Magnetic resonance imaging with T2-weighted images revealed an extramedullary mass lesion with significant compression of the spinal cord at C7-T1-T2 and free chain escape is simultaneously detected. Patient underwent allogeneic stem cell transplant(ASCT) after radiotherapy and remission induction. Case C: 56-year-old female patient is referred with mild anemia and hypercalcemia and diagnosed with IgGκ multiple myeloma R-ISS: II. She received high dose chemotherapy with autologous stem cell support after achieving partial response with four courses of VCD. Relapsed after 8 months and received lenalidomide+dexamethasone (LenDex) with no response. Carfilzomib is added to the treatment and she progressed with many cervical lymph nodes and left pleural effusion. Light chain escape has been detected. She underwent ASCT after remission induction. Our cases show that in during the treatment of myeloma, a clone that may be selected which can lead to light chain escape and disease progression. Also light chain escape can accompany extramedullary/extraosseous disease progression or rapid renal impairment as suggested by literature. It has also been put forward that serum free light chain follow-up during treatment could be useful in identifying this phenomenon [3]. We suggest surveying free light chain levels in addition to intact immunoglobulin levels and serum protein electrophoresis during the course of treatment of myeloma patients.