Freelite & Hevylite. Together Freelite & Hevylite provide optimal detection of monoclonal gammopathies

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1 Freelite & Hevylite Together Freelite & Hevylite provide optimal detection of monoclonal gammopathies

2 Monoclonal Gammopathy Monoclonal gammopathies are diseases of the bone marrow and are associated with monoclonal proliferation of plasma cells. The most common monoclonal gammopathy is malignant Multiple Myeloma. The tumour products formed are monoclonal immunoglobulins and / or free light chains. These are secreted into the serum and are surrogate markers of tumour burden. Plasma cell Lambda FLC Kappa FLC Laboratory testing plays an important role at various patient management stages: Intact Immunoglobulin Multiple Myeloma ~90% produce FLCs Light Chain Multiple Myeloma Only produce FLCs Nonsecretory Multiple Myeloma ~70% produce FLCs AL amyloidosis ~80% produce FLCs Diagnosis - to confirm disease state Prognosis - to predict patient outcomes Monitoring - to measure response to treatment FLCs = Free Light Chains

3 Freelite Freelite is a sensitive, specific marker of kappa (κ) and lambda (λ) free light chains (FLCs) in serum and provides quantitative measurement of: κ FLCs λ FLCs κ/λ FLC ratio Freelite is a simple, polyclonal antibody blood test, providing rapid and highly sensitive results....the serum FLC assay in combination with serum PEL and serum IFE is sufficient to screen for pathological monoclonal plasmaproliferative disorders other than AL, which requires all the serum tests as well as the 24-h urine IFE. The International Myeloma Working Group Guidelines 1 state that Freelite should be used for the diagnosis, prognosis and monitoring of monoclonal gammopathies including: Light Chain Multiple Myeloma (LCMM) Nonsecretory Multiple Myeloma (NSMM) Intact Immunoglobulin Multiple Myeloma (IIMM) Smouldering Multiple Myeloma (SMM) Solitary Plasmacytoma AL amyloidosis Monoclonal Gammopathy of Undetermined Significance (MGUS) Improve your accuracy in detecting monoclonal gammopathies PEL = Protein Electrophoresis FLCs = Free Light Chains AL = AL amyloidosis IFE = Immunofixation Electrophoresis

4 Hevylite Hevylite quantifies the different light chain types of each immunoglobulin class - IgGκ, IgGλ, IgAκ, IgAλ, IgMκ and IgMλ. The molecules are assessed in pairs e.g. IgGκ/IgGλ to produce heavy/light chain ratios; an abnormal ratio indicates monoclonality. Hevylite uniquely measures both the involved and the uninvolved immunoglobulin, giving useful information about immunosuppression of the uninvolved isotype e.g. IgAκ in an IgAλ patient. The Hevylite assay works by targeting epitopes between the heavy chain and light chain constant regions. Ig indicates IgG, A or M Hevylite analysis allows improved management of Multiple Myeloma patients

5 Freelite and Hevylite in Monoclonal Gammopathy testing Diagnosis SPE + Freelite Freelite is now a myeloma defining event* Freelite plus SPE is an efficient diagnostic screen Recommended to rule out myeloma kidney Hevylite Baseline with appropriate Hevylite pair for monitoring Prognosis Freelite + Hevylite Provides risk stratification for MGUS and AL amyloidosis Are prognostic indicators in Myeloma, 1, 2 AL amyloidosis, 1 WM, 3, 4 SMM 5 Monitoring Freelite dflc improves serial monitoring Ratio helps define stringent CR Use when only free light chains detected - LCMM, NSMM, AL amyloidosis To detect light chain escape Freelite + Hevylite Oligosecretory MM or low level <10g/L Difficult to measure monoclonal protein due to co-migration, diffuse bands Minimal residual disease Clonal differences SPE = Serum Protein Electrophoresis MGUS = Monoclonal Gammopathy of Undetermined Significance MM = Mutiple Myeloma WM = Waldenström s Macroglobulinaemia SMM = Smouldering Mutiple Myeloma CR = Complete Response LCMM = Light Chain Multiple Myeloma NSMM = Nonsecretory Multiple Myeloma * Involved:uninvolved sflc ratio 100 and involved Freelite 100mg/L

6 Diagnosis Use Freelite and Hevylite together The IMWG guidelines recommend Freelite for the diagnosis of monoclonal gammopathies. 1 The assay quantitatively measures free light chains providing improved accuracy compared to traditional methods. At Diagnosis SPE/CZE and Freelite ratio Positive Negative Freelite should be used with SPE/CZE in the initial testing of patients to detect monoclonal gammopathies; this allows urine testing to be used more selectively. 6,7 A Hevylite result at diagnosis provides a baseline value that is useful in monitoring and prognosis. Type with IFE Establish baseline with relevant/appropriate Hevylite pair Suspect AL amyloidosis, 24hr urine Establish Freelite baseline SPE = Serum Protein Electrophoresis CZE = Capillary Zone Electrophoresis IFE = Immunofixation Electrophoresis

7 Optimising your Diagnostic Approach for Monoclonal Gammopathy Testing A combination of SPE/CZE and Freelite is a clinically sensitive strategy for diagnosis of monoclonal gammopathies. Protocols % of Paraproteins detected *Myeloma 7 AL amyloidosis 7 LCMM 8,9,10 NSMM 11 SPE alone Serum IFE n.d. 0 SPE, serum IFE, urine IFE n.d. 0 SPE/CZE and Freelite SPE/CZE, Freelite and serum IFE * Myeloma is inclusive of 467 patients with MM (451), NSMM (4), Plasma cell leukaemia (4), Osteosclerotic MM (1), and Indolent Myeloma (7). Detect more monoclonal gammopathies with Freelite SPE = Serum Protein Electrophoresis IFE = Immunofixation Electrophoresis FLCs = Free Light Chains n.d. = no data CZE = Capillary Zone Electrophoresis LCMM = Light Chain Multiple Myeloma NSMM = Nonsecretory Multiple Myeloma

8 2014 IMWG Guidelines for Diagnosis of Multiple Myeloma New IMWG Criteria for MM diagnosis 12 Clonal bone marrow plasma cells 10% or biopsy-proven bony or extramedullary plasmacytoma PLUS a myeloma defining event: One or more biomarkers of malignancy: Clonal bone marrow plasma cells 60% Involved:uninvolved sflc ratio 100* >1 focal lesion on MRI studies * Involved Freelite concentration must be >100mg/L OR Evidence of end-organ damage that can be attributed to the underlying plasma cell proliferative disorder: Hypercalcaemia } Renal insufficiency CRAB Anaemia features Bone lesions Freelite now forms part of the IMWG diagnostic criteria for MM. It is recommended that patients meeting these criteria be treated for myeloma sflc = serum Free Light Chain IMWG = International Myeloma Working Group MM = Multiple Myeloma MRI = Magnetic Resonance Imaging

9 Detect Myeloma Kidney early to increase the chance of renal recovery The majority of Multiple Myeloma patients produce an excess of monoclonal serum free light chains (FLCs). Freelite quantifies these potentially nephrotoxic FLCs enabling a rapid initial investigation for Myeloma Kidney (Cast Nephropathy). The International Kidney and Monoclonal Gammopathy Research Group have developed a screening algorithm for new unexplained AKI. 13 A clonal FLC 500mg/L is indicative of Cast Nephropathy in new unexplained AKI. They recommend Freelite plus SPE for diagnosis of monoclonal gammopathies in these patients. Clonal FLC 500 mg/l Probable FLC tubular interstitial pathology Requires hematology work-up Initiation of disease-specific treatment to reduce serum FLC levels FLC clone Alternative monoclonal FLC pathology New AKI Exclude myeloma kidney Assessment for FLC clone* Clonal FLC <500 mg/l Either Incidental MGUS Requires renal biopsy Consider hematology work-up No FLC clone AKI of another cause *To exclude the presence of an intact monoclonal immunoglobin, serum FLC assays should be combined with serum protein electrophoresis. If detected early, renal impairment due to Cast Nephropathy is reversible AKI = Acute Kidney Injury FLCs = Free Light Chains SPE = Serum Protein Electrophoresis MGUS = Monoclonal Gammopathy of Undetermined Significance

10 Prognosis MGUS risk stratification improves patient management MGUS group Criteria Recommended follow-up Low risk Lowintermediate risk Highintermediate risk High risk No risk factors present Any one risk factor present Any two risk factors present All three risk factors present 6 months initially & if stable, follow up every 2-3 years or when symptoms suggest a plasma cell malignancy 6 months initially, then annually and upon any change in the patient s clinical condition Risk factors: Abnormal FLC ratio Serum monoclonal protein >15g/L IgA or IgM monoclonal protein type To optimise counselling and followup, IMWG guidelines recommend MGUS patients should be risk stratified at diagnosis using Freelite (alongside SPE/IFE). 14 By identifying those at low risk (~40%), Freelite saves time, money and patient discomfort as fewer clinic visits and tests are needed. Hevylite pair suppression is also an independent risk factor for MGUS progression. 15 Smouldering Multiple Myeloma SMM patients with a serum involved/uninvolved free light chain ratio 8 16 (but <100) are considered higher risk with poor prognosis. These patients should be monitored closely and may be considered candidates for early treatment intervention. SPE = Serum Protein Electrohoresis IFE = Immunofixation Electrophoresis FLC = Free Light Chain MGUS = Monoclonal Gammopathy of Undetermined Significance SMM = Smouldering Mutiple Myeloma IMWG = International Myeloma Working Group

11 AL amyloidosis Freelite is an independent prognostic marker for overall survival in AL amyloidosis, alongside cardiac biomarkers. 17 Incorporation of serum FLC-diff [dflc] into the current staging system improves risk stratification for patients with AL amyloidosis and will help develop risk adopted therapies for AL amyloidosis 17 Kaplan-Meier curves for overall survival (OS) based on the new staging system incorporating 3 risk factors. Risk factors: ctnt ng/ml NT-ProBNP 1800 pg/ml FLC-diff 180 mg/l Stages: Stage 1 = no risk factors Stage 2 = 1 risk factor Stage 3 = 2 risk factors Stage 4 = 3 risk factors IMWG guidelines recommend the use of Freelite in prognosis. 1 Use Freelite to predict outcomes and identify those AL amyloidosis patients who may benefit from closer monitoring or altered therapy IMWG = International Myeloma Working Group FLCs = Free Light Chains FLC-diff = dflc = involved Free Light Chain minus uninvolved Free Light Chain ctnt = cardiac Troponin-T NT-ProBNP = N-terminal pro B-type natriuretic peptide

12 Monitoring Use Freelite and Hevylite together Monoclonal protein obvious Monoclonal protein difficult to measure Free Light Chains only Abnormal Freelite ratio >10g/L <10g/L Monitor with Freelite dflc plus Hevylite/SPE/CZE Monitor with Hevylite and Freelite dflc Monitor with Freelite dflc At Complete Response (CR) Measure Freelite ratio Measure Hevylite ratio To define a stringent CR Minimal Residual Disease detection Use Freelite and Hevylite together: To quantitatively monitor patients with Multiple Myeloma When monoclonal protein cannot be measured accurately using electrophoresis To provide additional sensitivity for detection of residual disease SPE = Serum Protein Electrophoresis CZE = Capillary Zone Electrophoresis FLCs = Free Light Chains dflc = involved Free Light Chain minus uninvolved Free Light Chain

13 Monitoring with Freelite IMWG guidelines recommend the polyclonal Freelite test for quantitative monitoring of AL amyloidosis, NSMM and Oligosecretory Multiple Myeloma. 1 Rapid response to therapy A rapid decrease in λ sflcs gives an earlier indication of response than intact immunoglobulin SPE measurements in a patient with IgGλ IIMM. Freelite has greater sensitivity than urine protein electrophoresis and overcomes the issue of patient noncompliance for providing urine samples. FLC half-life is 2-6 hours compared to IgG half-life (up to 21 days) providing earlier indication of response to treatment. dflc is recommended to monitor response to treatment. The k/l FLC ratio alone is not recommended due to fluctuations in the uflc 1 IMWG = International Myeloma Working Group NSMM = Nonsecretory Multiple Myeloma LCMM = Light Chain Multiple Myeloma VDD = Velcade, doxorubicin and dexamethasone sflcs = serum Free Light Chains IIMM = Intact Immunoglobulin Multiple Myeloma dflc = involved Free Light Chain minus uninvolved Free Light Chain SPE = Serum Protein Electrophoresis

14 Monoclonal protein <10g/L Oligosecretory disease - Monitor with Hevylite and Freelite Freelite is recommended by IMWG guidelines for monitoring Oligosecretory Multiple Myeloma due to its high sensitivity compared to traditional 1, 18 techniques. This has enabled patients to access clinical trials from which they were previously excluded. 19 Freelite can be used to monitor 71% of IIMM with oligosecretory disease. 20 Hevylite may offer a much-needed alternative monitoring tool in these difficult to quantify oligosecretory MM patients. 21 In addition, changes in Hevylite ratio reflect response to therapy and relapse. 22 SPE has limited accuracy due to significant variation below 10g/L. 23 Freelite measures at mg/l levels and the Hevylite assay is linear below 10 g/l monoclonal protein. 24 Use Freelite and Hevylite to accurately monitor patients with low levels of monoclonal protein IMWG = International Myeloma Working Group MM = Multiple Myeloma IIMM = Intact Immunoglobulin Multiple Myeloma SPE = Serum Protein Electrophoresis

15 Capture Multiple Myeloma patients that are difficult to quantify IgA monoclonal proteins may co-migrate with other serum proteins SPE is not linear and dye saturation leads to underestimation of responses These 14 co-migrating samples were difficult to measure accurately but all had an abnormal Hevylite ratio. Around 40% of IgA monoclonal proteins cannot be quantified accurately by SPE. Using Hevylite overcomes this limitation and improves patient monitoring. 25 Monoclonal protein is 44.9g/L by SPE, however total IgG is 64.9g/L. 26 Underestimation by SPE makes it difficult to monitor patients. Hevylite provides an accurate numerical result. Use Hevylite when electrophoresis is inaccurate SPE = Serum Protein Electrophoresis

16 Detect Light Chain Escape to improve patient outcome Light Chain Escape (LCE) is an increase in monoclonal free light chains at relapse with no associated increase in intact immunoglobulin concentrations. Patients who relapse with any light chain involvement have poorer prognosis than those relapsing with intact immunoglobulins only. 27 Of relapsing IgA MM patients, 20% have LCE and of relapsing IgG patients ~7% have LCE. 27 By detecting LCE early, unnecessary complications such as renal impairment may be avoided. 28 λ Courtesy of Christie Hospital, Manchester, UK. This Intact Immunoglobulin MM patient was monitored following bortezomib treatment ( ). Both IgAλ and λ serum FLC levels decrease in response to treatment and remain stable for many months. Subsequent relapse with LCE was only detected by Freelite. Monitor with Freelite to ensure that Light Chain Escape is not missed MM = Multiple Myeloma

17 Identify patient clonal differences Different plasma cell clones can produce serum FLCs and intact monoclonal immunoglobulins in the same patient. 29 This is an example of intra-clonal heterogeneity, which is increasingly prevalent in myeloma. Clones detected at relapse and progression can be different to those seen at diagnosis Light chain only patients showed no change 2. 60% of patients with both intact immunoglobulins and FLCs changed their monoclonal protein type 3. 17% of patients with intact immunoglobulins changed their monoclonal protein type 44% of the total number of patients changed their monoclonal protein type at relapse ( ) Used together, Freelite and Hevylite can identify clonal differences R/POD = Relapse/Progression of Disease FLCs = Free Light Chains CR = Complete Response

18 Use Freelite and Hevylite to capture clonal change Freelite and Hevylite measure two independent biomarkers in Multiple Myeloma. Freelite measures kappa(k) and lambda(l) free light chains (mg/l) Hevylite measures intact monoclonal immunoglobulins (g/l) The patient presented with abnormal Hevylite and Freelite ratios. Following treatment both the Hevylite ratio and κflc concentrations normalise. After more treatment the Hevylite ratio did not normalise. Further relapse was seen at around 2000 days with both an increase in the Hevylite ratio and κflc concentration. By day 900 the patient relapsed with an increase in IgA Hevylite ratio but little change in the κflc levels. This study of an MM patient with IgAk monoclonal proteins plus k free light chains highlights why it is important to monitor patients with Hevylite and Freelite. Freelite and Hevylite are both quantitative and easy to use, combining accurate results with high sensitivity, enabling rapid identification of clonal change at relapse. kflc = Kappa Free Light Chain

19 Achieving Stringent Complete Response indicates better outcome following ASCT Patients who achieve a scr have a better outcome compared to those with a lower depth of response to treatment. 31 Patients with a scr after ASCT had a better overall survival than those who achieved a CR. 19, 32 Definition of scr Normal Freelite ratio Negative SPE and IFE Disappearance of soft tissue plasmacytomas Absence of clonal plasma cells by IHC/2-4 colour flow cytometry For measurable or immeasurable disease Where the scr was sustained for 6 months post transplant, a significantly better overall survival was achieved compared to when a scr was not sustained. Freelite is essential for assessing scr in all myeloma patients SPE = Serum Protein Electrophoresis IFE = Immunofixation Electrophoresis CR = Complete Response scr = stringent Complete Response ASCT = Autologous Stem Cell Transplant IHC = Immunohistochemistry

20 Use Hevylite to capture more residual disease A B C D E SPE positive SPE positive SPE negative SPE negative SPE negative The high sensitivity of Hevylite can indicate the presence of residual disease in patients classified as being in Complete Response by other methods (D). 2 The abnormal Hevylite ratio in B-D is produced by immunosuppression of the uninvolved immunoglobulin (IgAλ) rather than an increase in the involved IgAκ, highlighting the unique information provided by Hevylite. Red = abnormal Hevylite Using Hevylite and Freelite together improves sensitivity when detecting intact immunoglobulin monoclonal proteins and free light chains in residual disease. 2 More information for better patient care decisions IF = Immunofixation Electrophoresis SPE = Serum Protein Electrophoresis HLC = Heavy / Light Chain

21 Key Terminology Freelite Term Definition Description Example in a Lambda LCMM patient FLC Free Light Chain iflc Involved FLC The FLC type produced by the tumour l uflc Uninvolved FLC The alternate light chain type to the iflc k k/l sflc ratio k/l A ratio of the concentration of κ to λ sflc (indicates monoclonality) k/l dflc iflc uflc The difference in the concentration between the iflc and uflc l-k Involved/ Uninvolved sflc ratio iflc/uflc A ratio of the concentration of involved to uninvolved sflc could be κ/l or l/κ l/k Hevylite Term Definition Description Example in an IgGk MM patient HLC Heavy and light chain isotypes ihlc Involved HLC The HLC type produced by the tumour IgGk uhlc Uninvolved HLC The same heavy chain isotype but alternate light chain type to the ihlc IgGl HLC ratio e.g. IgAk/IgAl A ratio of the concentration of κ to λ HLC (indicates monoclonality) IgGk/IgGl dhlc ihlc uhlc For a particular immunoglobulin isotype, the difference in concentration between the ihlc and uhlc IgGk-IgGl HLC-pair suppression When the concentration of the uhlc is below the normal reference interval The ratio must be abnormal Suppression of IgGl LCMM = Light Chain Multiple Myeloma MM = Multiple Myeloma

22 Reference ranges Freelite Hevylite Normal adult serum 95 percentile range Normal adult 95 percentile range k FLC (mg/l) serum for SPAPLUS l FLC k / l FLC ratio (mg/l) 100 percentile range IgG Kappa IgG Lambda IgGk/IgGl Ratio IgA Kappa (g/l) (g/l) (g/l) An abnormal k/l FLC ratio is a highly sensitive indicator of monoclonal k or l FLC in serum. A study showed that patients with renal impairment had increased levels of FLC in serum and proposed an extended Freelite ratio reference range k/l FLC ratio: for these patients. 33 IgA Lambda IgAk/IgAl Ratio IgM Kappa IgM Lambda IgMk/IgMl Ratio (g/l) (g/l) (g/l) Renal reference range 100 percentile range k / l FLC ratio The renal reference range improves specificity whilst maintaining diagnostic sensitivity in patients with renal impairment.

23 Interpretation Freelite and Hevylite should be used in conjunction with other laboratory tests and clinical evaluations. Freelite results should be considered in the following categories: Normal samples. SPE + FLC results are normal - unlikely that the patient has a monoclonal gammopathy Abnormal k/l ratios. Possible monoclonal gammopathy - needs further investigation. Borderline elevated k/l ratios occur with renal impairment and may require appropriate renal function tests Low concentrations of k, l or both indicate bone marrow suppression Elevated concentrations of both k and l with a normal k/l ratio may be due to: - Renal impairment (common) - Over-production of polyclonal FLC from inflammatory conditions (common) - Biclonal gammopathies of different FLC types (rare) Elevated concentrations of both k and l with an abnormal k/l ratio: Possible combination of monoclonal gammopathy and renal impairment Hevylite for monitoring: Abnormal HLC ratio indicates monoclonality Abnormal HLC ratio + HLC pair suppression indicates poor prognosis MG = Monoclonal Gammopathy pig = Polyclonal Immunoglobulin sflc = serum Free Light Chain SPE = Serum Protein Electrophoresis HLC = Heavy / Light Chain FLC = Free Light Chains

24 Learn More Quality Assurance Our manufacturing site has quality systems approved to both ISO9001 and ISO13485 certification. These, together with strict adherence to rigorous internal quality control procedures, ensure customers can be confident in the quality of Binding Site products. Assays for in vitro diagnostic use have been FDA cleared for the USA and CE marked for Europe. Performance of our assays is regularly monitored by participation in a number of independent national and international quality assurance schemes. The Binding Site GmbH Schwetzingen Request your Freelite & Hevylite book 7th Edition, fully revised for 2015 The Binding Site France, Grenoble Follow us on Access our online, free, educational resource with up to date information on Freelite and Hevylite: The Binding Site Group Ltd, Birmingham UK Contact us The Binding Site Spain, Barcelona The Binding Site s.r.o. Prague The Binding Site BeNeLux, Antwerp The Binding Site Inc, San Diego, USA The Binding Site Italy, Bargamo FDA = Food and Drugs Administration (USA)

25 Guidelines International Myeloma Working Group updated criteria for the diagnosis of multiple myeloma. Rajkumar SV, et al. Lancet Oncology 2014; 15:e538-e548 International Myeloma Working Group recommendations for global myeloma care. Ludwig H, et al. Leukemia 2014; 28: New Criteria for Response to Treatment in Immunoglobulin Light Chain Amyloidosis Based on Free Light Chain Measurement and Cardiac Biomarkers: Impact on Survival Outcomes. Palladini, et al. J Clin Onc 2012; 30: Consensus recommendations for the uniform reporting of clinical trials: report of the International Myeloma Workshop Consensus Panel 1. Rajkumar SV, et al. Blood 2011; 117: Monoclonal gammopathy of undetermined significance (MGUS) and smoldering (asymptomatic) multiple myeloma: IMWG consensus perspectives risk factors for progression and guidelines for monitoring and management. Kyle RA, et al. Leukemia 2010; 24: International Myeloma Working Group guidelines for serum-free light chain analysis in multiple myeloma and related disorders. Dispenzieri A, et al. Leukemia 2009; 23: International uniform response criteria for multiple myeloma. Durie BGM, et al. Leukemia 2006; 20:

26 References 1. Dispenzieri A, et al. International Myeloma Working Group guidelines for serum-free light chain analysis in multiple myeloma and related disorders. Leukemia 2009: 23: Ludwig H, et al. Immunoglobulin heavy/light chain ratios improve paraprotein detection and monitoring, identify residual disease and correlate with survival in multiple myeloma patients. Leukemia 2013, 27: Itzykson R, et al. Serum-free light chain elevation is associated with a shorter time to treatment in Waldenström s Macroglobulinemia. haematologica 2008;93: Leleu X, et al. Novel M-Component Based Biomarkers in Waldenström s Macroglobulinemia. CLML 2011;11: Bhutani M, et al. Serum Heavy-Light Chains (HLC) and Free Light Chains (FLC) As Predictors For Early CR In Newly Diagnosed Myeloma Patients Treated With Carfilzomib, Lenalidomide, and Dexamethasone (CRd) 2013: Blood 122(21); 762a 6. Katzmann JA. Screening panels for monoclonal gammopathies: time to change. Clin Biochem Rev 2009; 30: Katzmann JA, et al. Screening Panels for Detection of Monoclonal Gammopathies. Clin Chem 2009; 55: Bradwell AR, et al. Serum test for assessment of patients with Bence Jones myeloma. Lancet 2003; 361: Wolff F, et al. Assessment of the analytical performance and the sensitivity of serum free light chains immunoassay in patients with monoclonal gammopathy. Clin Biochem 2007; 40: Abraham RS, et al. Correlation of Serum Immunoglobulin Free Light Chain Quantification with Urinary Bence Jones Protein in Light Chain Myeloma. Clin Chem 2002; 48: Drayson M. et al. Serum free light-chain measurements for identifying and monitoring patients with nonsecretory multiple myeloma. Blood 2001;97: Rajkumar SV, et al. International Myeloma Working Group updated criteria for the diagnosis of multiple myeloma. Lancet Oncology 2014; 15:e538-e Hutchison CA, et al. The pathogenesis and diagnosis of acute kidney injury in multiple myeloma. Nat Rev Neph 2011; 8: Kyle RA, et al. Monoclonal gammopathy of undetermined significance (MGUS) and smoldering (asymptomatic) multiple myeloma: IMWG consensus perspectives risk factors for progression and guidelines for monitoring and management. Leukemia 2010: 24: Katzmann J, et al. Suppression of uninvolved immunoglobulins defined by heavy/light chain pair suppression is a risk factor for progression of MGUS. Leukemia 2013; 27: Dispenzieri A, et al. Immunoglobulin free light chain ratio is an independent risk factor for progression of smoldering (asymptomatic) multiple myeloma. Blood 2008; 111: Kumar S, et al. Revised prognostic staging system for light chain amyloidosis incorporating cardiac biomarkers and serum free light chain measurements. J Clin Oncol 2012;30: Ludwig H, et al. International Myeloma Working Group recommendations for global myeloma care. Leukemia 2013; 28: Durie BGM, et al. International uniform response criteria for multiple myeloma. Leukemia 2006; 20: Larsen D, et al. Prevalence and Monitoring of Oligosecretory Myeloma. N Engl J Med 2012; 367: Boyle E, et al. IgA Kappa/IgA Lambda Heavy/Light Chain Assessment in the Management of Patients with IgA Myeloma. Cancer 2014;120: Ludwig H, et al. Immunoglobulin heavy/light chain ratios improve paraprotein detection and monitoring, identify residual disease and correlate with survival in multiple myeloma patients. Leukemia 2013; 27: Katzmann J, et al. Long-Term Biological Variation of Serum Protein Electrophoresis M-Spike, Urine M-Spike, and Monoclonal Serum Free Light Chain Quantification: Implications for Monitoring Monoclonal Gammopathies. Clin Chem 2011, 57: Eckold J, et al. Analytical performance and diagnostic potential of immunoassays determining Intact Immunoglobulin k/l ratios in monoclonal gammopathies. Clin Lab 2014; 60: Katzmann, J et al. Monitoring IgA Multiple Myeloma: Immunoglobulin Heavy/Light Chain Assays. Clin Chem 2015; 61: Katzmann and Kyle. Manual of molecular and Clinical laboratory Immunology. 7th ed, ASM press, Washington DC 27. Brioli A, et al. Serum free immunoglobulin light chain evaluation as a marker of impact from intraclonal heterogeneity on myeloma outcome. Blood 2014; 123: Kuhnemund A, et al. Light-chain escape-multiple myeloma an escape phenomenon from plateau phase: report of the largest patient series using LC-monitoring. J Cancer Res Clin Oncol 2009; 135: Ayliffe M, et al. Demonstration of changes in plasma cell subsets in multiple myeloma. haematologica 2007; 92: Zamarin D, et al. Patterns of relapse and progression in multiple myeloma patients after auto-sct: implications for patients monitoring after transplantation. Bone Marrow Transplantation 2013; 48: Kapoor P, et al. Importance of Achieving Stringent Complete Response After Autologous Stem-Cell Transplantation in Multiple Myeloma. Journal of Clinical Oncology 2013; 31: Rajkumar SV, et al. Consensus recommendations for the uniform reporting of clinical trials: report of the International Myeloma Workshop Consensus Panel 1. Blood 2011; 117: Hutchison CA, et al. Serum free light chain measurement aids the diagnosis of myeloma in patients with severe renal failure. BMC Nephrol 2008;9:11 BROCHURE NOT FOR USE IN USA Freelite, Hevylite and SPAPLUS are registered trademarks of The Binding Site Group Ltd (Birmingham, UK) in certain countries. EBK020