title: Changes in serum-free light chain rather than intact monoclonal immunoglobulin levels predicts outcome following therapy in primary amyloidosis.
abstract: Current response criteria for light-chain amyloidosis (AL) relegate FLC response to a subsidiary status relative to serum M-protein response. Given that light chains form the substrate for amyloid fibril formation, we hypothesized that changes in FLC might better predict outcome compared to changes in intact immunoglobulin levels. Two patient cohorts were studied, 347 patients who underwent an autologous stem-cell transplant (SCT) and 96 patients treated with melphalan/dexamethasone. We identified the lowest value following therapy for intact serum M-protein and the difference between involved and uninvolved FLC (FLC-diff). We first examined the relative contribution of M-protein and FLC-diff on the overall survival (OS), and found that FLC reduction, rather than M-protein reduction, significantly impacted OS. The median OS was not reached among those with a 50% decrease in FLC-diff compared to 20 months for the remainder. On regression analysis, a 90% reduction in FLC-diff following SCT best predicted being alive at 3 or 5 years. The median OS among those with a 90% decrease was not reached compared to 37.4 months for the rest P < 0.001. The current study supports the notion that FLC response is a more useful measure of hematological response than M-protein response. It also highlights the importance of achieving at least a 90% reduction in the FLC-diff to improve the outcome of patients with light-chain AL.
authors.affiliation: Division of Hematology, Department of Internal Medicine, Mayo Clinic. Rochester, Minnesota, USA. kumar.shaji@mayo.edu
authors.forename: Shaji K
authors.initials: SK
authors.lastname: Kumar
authors.forename: Angela
authors.initials: A
authors.lastname: Dispenzieri
authors.forename: Martha Q
authors.initials: MQ
authors.lastname: Lacy
authors.forename: Suzanne R
authors.initials: SR
authors.lastname: Hayman
authors.forename: Francis K
authors.initials: FK
authors.lastname: Buadi
authors.forename: Steven R
authors.initials: SR
authors.lastname: Zeldenrust
authors.forename: Tow
authors.initials: T
authors.lastname: Tan
authors.forename: Shirshendu
authors.initials: S
authors.lastname: Sinha
authors.forename: Nelson
authors.initials: N
authors.lastname: Leung
authors.forename: Robert A
authors.initials: RA
authors.lastname: Kyle
authors.forename: S Vincent
authors.initials: SV
authors.lastname: Rajkumar
authors.forename: Morie A
authors.initials: MA
authors.lastname: Gertz
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000686:Amyloidosis / Q000175:diagnosis* / Q000401:mortality / Q000628:therapy*; D000911:Antibodies, Monoclonal; D003907:Dexamethasone / Q000627:therapeutic use; D005260:Female; D018380:Hematopoietic Stem Cell Transplantation; D006801:Humans; D007147:Immunoglobulin Light Chains / Q000032:analysis*; D007136:Immunoglobulins / Q000032:analysis*; D008297:Male; D008558:Melphalan / Q000627:therapeutic use; D008875:Middle Aged; D009194:Myeloma Proteins / Q000032:analysis*; D011237:Predictive Value of Tests; D011379:Prognosis; D016019:Survival Analysis; D016896:Treatment Outcome
chemical_list: D000911:Antibodies, Monoclonal; D007147:Immunoglobulin Light Chains; D007136:Immunoglobulins; D009194:Myeloma Proteins; C085016:multiple myeloma M-proteins; D003907:Dexamethasone; D008558:Melphalan