2 It is essential to use good quality electrophoresis of serum and adequately concentrated urine to screen for paraproteins ,IOd Bence Jones protein. Their absence. using the techniques recommended. will exclude IJIJ'X. of cases of myeloma. It is not justified to pursue negative findings using the more sensitive techniques of isoelectric focusing and imrnunofixation as any paraprotein or Bence Jones protein so revealed will be of doubtful significance.

https://journals.sagepub.com/doi/pdf/10.1177/000456328702400201

The laboratory investigation of paraproteinaemia.

BACKGROUND. Routine electrophoretic analysis fails to detect a monoclonal component (MC) in a considerable portion of AL amyloidosis patients. We investigated whether the combination of immunofixation (IF) on agarose gel electrophoresis and bone marrow plasma cell (BMPC) light chain kappa/lambda ratio analysis could contribute to diagnosis in these cases. The possible use of the BMPC kappa/lambda ratio in monitoring the clone was also investigated. METHODS. We performed BMPC kappa/lambda ratio analysis and IF of serum and urine in 16 selected patients with no detectable MC at routine analysis, despite clinical features suggestive of primary amyloidosis. An anti-idiotypic monoclonal antibody specific for the amyloidogenic immunoglobulin and the BMPC kappa/lambda ratio were used to monitor the clone in a patient who underwent autologous peripheral blood stem cell transplantation. RESULTS. Abnormal kappa/lambda ratios were found in 14 (sensitivity 87.5%), and a MC in 12 (sensitivity 75%). Combination of the two analyses confirmed diagnosis in all cases. In one patient changes in the size of the clone, monitored on serial bone marrow aspirates by an anti-idiotypic antibody, paralleled variations of the kappa/lambda ratio. CONCLUSIONS. This study demonstrates that the combined use of IF and the BMPC kappa/lambda ratio is extremely powerful in AL amyloidosis. In addition, the BMPC kappa/lambda ratio should be considered for monitoring the amyloidogenic clone when serum or urine MC is not quantifiable.

/pdf/diagnostic-approach-to-and-follow-up-of-difficult-cases-of-4ufe7stcrc.pdf

Diagnostic approach to and follow-up of difficult cases of al amyloidosis

Detection and characterization of small IgM paraproteins by immunoelectrophoresis are often difficult because of (a) slow diffusion of the macromolecular immunoglobulin, and (b) the obscuring of the light chain, especially kappa, by the light chains of background polyclonal immunoglobulin (the "umbrella effect"). Various methods of sample pretreatment have been tried in an attempt to overcome this problem. Using immunofixation electrophoresis (IFE), we were able to detect and characterize IgM paraproteins in serum at concentrations as low as 0.25 g/L, even when the polyclonal immunoglobulin background was increased. With routine IFE, our laboratory identified 58 patients with IgM paraproteinemia in a four-year period. In 36, the paraproteins were present at less than 5 g/L; 10 of these were detectable only by IFE.

Sensitivity of immunofixation electrophoresis for detecting IgM paraproteins in serum.

Purpose: Because the clinical significance of immunoglobulin abnormalities reported in relatives of familial Waldenstrom macroglobulinemia (WM) patients is unknown, we initiated a follow-up study of three WM families originally evaluated 27 years previously. Experimental Design: Of 29 eligible first-degree relatives of WM patients, 27 (93%) had originally participated in clinical and electrophoretic evaluations. We re-contacted all participants for prospective follow-up electrophoretic analysis and other studies. Results: Initially, five relatives had IgM monoclonal gammopathy (IgM MG), and four had IgM polyclonal gammopathy (PG). Twenty-two relatives (81%) were re-evaluated. Median follow-up was 17 years (range, 7-27). At re-contact, all IgM MG persisted or progressed, including three that evolved to WM. Among the four with PG, two new IgM MG cases developed. Overall, seven relatives (26%) had IgM MG, and five (18%) had IgM PG. Conclusions: Although based on small numbers, this study provides the longest comprehensive follow-up of WM families to date. IgM MG seems to be a phenotypic marker of WM susceptibility in some families and may have a high risk of progression to WM. IgM PG may also be important in WM families. These observations require validation in larger studies and, if confirmed, may be used to identify a cohort (relatives with IgM MG) for future prevention strategies.

https://clincancerres.aacrjournals.org/content/clincanres/13/17/5063.full.pdf

Long-term Evaluation of Three Multiple-Case Waldenström Macroglobulinemia Families

Various pathogenic factors have been proposed to explain the abnormal hemostasis observed in AL amyloidosis. Since imbalance between clottingfactors and inhibitors could play a pathogenic role in both hemorrhagic and thrombotic manifestations, we investigated the thrombin-antithrombin pathway in 35 patients with AL amyloidosis. Ten patients suffered from bleeding while 3 patients experienced deep venous thrombosis. Thrombin time was prolonged in 29 subjects, the mean values of antithrombin III activity (ATIII Act) were significantly lower than those of antithrombin III antigen (ATIII Ag) with loss of relationship between these two direrent techniques of ATIII detection, normally observed in healthy controls. In 19 patients increased levels of thrombin-antithrombin (TAT) complexes were present. Crossed immunoelectrophoresis of ATIII, performed in presence of heparin, evidenced ATIII forms with reduced binding capacity to heparin and TAT complexes of various electrophoretic mobilities. In conclusion, the im...

Abnormalities in thrombin-antithrombin pathway in AL amyloidosis.

Immunofixation on cellulose acetate has been compared with immunoelectrophoresis on agarose gel. We studied 90 sera containing monoclonal components and 10 containing polyclonal immunoglobulins according to agarose gel screening electrophoresis. Results by the two methods agreed about 80% of the time for monoclonal components in concentrations exceeding 1-2 g/L. Immunofixation appeared more sensitive, but it is more susceptible to technical artifacts. Immunofixation may be adopted as a first-step method for easier cases, but it should be supported by immunoelectrophoresis for difficult cases, such as when there is an uncertain presence of monoclonal components at screening electrophoresis or presence of more and (or) small bands of monoclonal components.

Detection and identification of monoclonal components: immunoelectrophoresis on agarose gel and immunofixation on cellulose acetate compared.

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Detection and identification of monoclonal components: immunoelectrophoresis on agarose gel and immunofixation on cellulose acetate compared.