title: Multiple myeloma and multiple plasmacytomas associated with free gamma heavy chain, free kappa light chain and IgGk paraproteins: an unusual triple gammopathy.
abstract: Multiple myeloma is a malignant plasma cell dyscrasia that is becoming more prevalent in an increasingly ageing population. It is a complex disease with clinical phases ranging from the premalignant monoclonal gammopathy of undetermined significance to asymptomatic (smouldering) myeloma and then symptomatic myeloma; the latter occasionally terminating in the clonal proliferation of plasma cells outside the bone marrow. We present a patient whose clonally evolved disease from monoclonal gammopathy of undetermined significance to multiple myeloma demonstrated the presence of an unusual combination of monoclonal immunoproteins. Capillary electrophoresis demonstrated the presence of three paraproteins in the gamma region (γ-region), two of which were additional to the IgGk paraprotein which migrated in the slow γ-region at initial diagnosis. Subsequent isotypic identification of the new paraproteins was not possible by immunotyping and initial immunofixation studies failed to definitively characterize the monoclonal proteins. After reduction with beta-mercaptoethanol, two paraproteins were detected by both capillary and gel electrophoresis. However, only immunofixation was able to resolve three distinct monoclonal bands, confirming the presence of free monoclonal kappa light chains in the mid-gamma region and free monoclonal heavy chains in the fast gamma region. Triple gammopathies in themselves are uncommon; this case presents a very unusual combination of paraproteins which required various electrophoretical and immunochemical techniques to identify and characterize them. The change of electrophoretic signature from the monoclonal gammopathy of undetermined significance phase to the diagnosis of multiple myeloma suggested that a number of genetically distinct subclones were present in the pretreatment clonal evolution of the disease.
authors.affiliation: 1 Department of Clinical Chemistry, Altnagelvin Hospital, Londonderry, N. Ireland.
authors.forename: William I
authors.initials: WI
authors.lastname: Deighan
authors.affiliation: 1 Department of Clinical Chemistry, Altnagelvin Hospital, Londonderry, N. Ireland.
authors.forename: Maurice J
authors.initials: MJ
authors.lastname: O'Kane
authors.affiliation: 2 Department of Haematology, Altnagelvin Hospital, Londonderry, N. Ireland.
authors.forename: Feargal P
authors.initials: FP
authors.lastname: McNicholl
authors.affiliation: 3 Department of Pathology, University of Michigan, Ann Arbor, MI, USA.
authors.forename: David F
authors.initials: DF
authors.lastname: Keren
mesh_terms: D000368:Aged; D060965:Clonal Evolution; D018450:Disease Progression; D019075:Electrophoresis, Capillary; D004591:Electrophoresis, Polyacrylamide Gel; D005260:Female; D006801:Humans; D007145:Immunoglobulin kappa-Chains / Q000276:immunology / Q000302:isolation & purification*; D008623:Mercaptoethanol / Q000737:chemistry; D008998:Monoclonal Gammopathy of Undetermined Significance / Q000175:diagnosis* / Q000276:immunology / Q000473:pathology; D009101:Multiple Myeloma / Q000175:diagnosis* / Q000276:immunology / Q000473:pathology; D009194:Myeloma Proteins / Q000276:immunology / Q000302:isolation & purification*; D010266:Paraproteins / Q000276:immunology / Q000302:isolation & purification*; D010954:Plasmacytoma / Q000175:diagnosis* / Q000276:immunology / Q000473:pathology
chemical_list: D007145:Immunoglobulin kappa-Chains; D009194:Myeloma Proteins; D010266:Paraproteins; C085016:multiple myeloma M-proteins; D008623:Mercaptoethanol
keywords: Franklin’s disease; Heavy chain disease; beta-mercaptoethanol; capillary electrophoresis; free light chains; heavy chain escape; immunofixation; immunotyping; light chain escape