6q deletion in Waldenström macroglobulinemia is associated with features of adverse prognosis.

Fluorescence in situ hybridisation (FISH) is an effective technique for the cytogenetic analysis of Waldenström macroglobulinemia (WM), but the potential impact of molecular cytogenetics on disease evolution and as a prognostic marker is still unknown. Deletion of the long arm of chromosome 6 (6q-) is the most frequent cytogenetic abnormality in WM. This study analysed the prevalence of this aberration in 102 WM patients, and correlated it with disease characteristics. The incidence of 6q21 deletion was 7% by conventional cytogenetics and 34% when analysed by FISH (54% when cytoplasmic immunoglobulin M-FISH was used). Patients with deletion of 6q displayed features of adverse prognosis, such as higher levels of beta2-microglobulin and monoclonal paraprotein and a greater tendency to display anaemia and hypoalbuminemia. Interestingly, there was a correlation between the presence of 6q deletion and the International Staging System prognostic index (incidence of 6q- among patients stratified in stages 1, 2 and 3 was 24%, 42% and 67% respectively). Those patients diagnosed with smouldering WM who displayed the abnormality showed a trend to an earlier requirement of treatment. Finally, the survival analysis did not show differences between the two groups of patients, probably due to the short follow up of our series.

Paraproteins: a regional South Australian experience.

We have performed a systematic review of all new serum and urinary paraproteins detected over a six year period in an immunodiagnostic laboratory serving a population of 400,000 people. Clinical diagnoses and associated laboratory features were ascertained from a computerized laboratory database or from clinical notes. Over the period of study, serum or urine paraproteins were detected in 613 new patients. These consisted of 568 patients with serum paraproteins and 45 patients with urinary monoclonal free light chain (in the absence of a serum paraprotein). These paraproteins occurred more commonly in males and the frequency increased with age. Approximately 30% of the serum paraproteins and 60% of urinary monoclonal free light chain were associated with B cell lymphoproliferative disorders (multiple myeloma, plasmacytoma, Waldenstrom's macroglobulinemia, non-Hodgkins lymphoma, chronic lymphocytic leukemia, etc) with the remainder being labeled as monoclonal gammopathies of uncertain significance (MGUS). At clinical presentation, patients with lymphoproliferative disorders tended to have higher levels of paraprotein, B2 microglobulin, the presence of free urinary light chain and demonstrated molecular size heterogeneity of the paraprotein but there was considerable overlap. A good correlation was noted between paraprotein concentration and viscosity in most patients. In conclusion paraproteins were most frequently encountered in the context of a gammopathy of uncertain significance. Features which suggested lymphoproliferative disorders included higher levels of serum paraprotein (> 15 g/l), elevated levels of B2-microglobulin and the presence of urinary free high chain. However, as much overlap was seen with patients with MGUS, regular monitoring of paraprotein level is considered mandatory in the management of these patients.

Preferential expression of human lambda-light-chain variable-region subgroups in multiple myeloma, AL amyloidosis, and Waldenström's macroglobulinemia.

We have compared the distribution of lambda-light-chain variable-region (V lambda) subgroups among Ig lambda molecules found in the serum of normal individuals with that of monoclonal Ig lambda components obtained from patients with plasma cell and related immunoproliferative disorders. A panel of monoclonal antibodies specific for each of the major human V lambda subgroups--V lambda I, V lambda II, V lambda III, V lambda IV, V lambda VI, and V lambda VIII--was used in a highly sensitive enzyme-linked immunosorbent assay (ELISA) to quantitate each of these populations. The mean distribution of Ig lambda I, Ig lambda II, Ig lambda III, Ig lambda IV, Ig lambda VI, and Ig lambda VIII molecules in serum specimens collected from 20 normal adults was approximately 40, 3, 43, 5, 5, and 3% of the total Ig lambda population, respectively. In contrast, that of monoclonal IgG, IgA, and IgD proteins and Bence Jones proteins obtained from patients with multiple myeloma and related gammopathies (n = 196) was approximately 27, 28, 39, 5, 0, and 1%, respectively. The percentage of monoclonal Ig lambda II components found in individuals with AL lambda amyloidosis (n = 41) was comparably increased to that seen in multiple myeloma and was even higher in patients with Waldenström's macroglobulinemia (n = 16), in whom 63% of the IgM lambda proteins were of the V lambda II subgroup. Also evidenced were differences in the distribution of other V lambda subgroups in the disease states: Most striking was the predominance (41%) of the V lambda VI subgroup among monoclonal lambda chains obtained from patients with AL amyloidosis and that this subgroup was found exclusively on amyloidosis-associated proteins. No Ig lambda VI-type myeloma- or macroglobulinemia-related proteins were identified. The observed alterations in V lambda subgroup distribution among "pathologic" monoclonal Igs were attributed to the particular disease and not related to the heavy-chain class. Our finding that certain V lambda subgroups are nonstochastically expressed in lambda-type multiple myeloma, AL amyloidosis, and Waldenström's macroglobulinemia provides evidence for abnormal VL gene usage in these disorders and, thus, furnishes new insight into their pathogenesis.

[Evaluation of the usefulness of measuring the serum and urine levels of light chain immunoglobulins in multiple myeloma and Waldenström's macroglobulinemia]. / Ocena przydatnosci oznaczania stezenia lekkich lancuchów immunoglobulinowych w surowicy krwi i moczu chorych na szpiczaka plazmocytowego i makroglobulinemie Waldenströma.

Quantitative determinations were carried out of light immunoglobulin chains by the method of ring precipitation in the serum and urine of 117 patients with plasmocytic myeloma and 16 with Waldenström's macroglobulinemia. The method was found useful for the identification of the light chain of the monoclonal proteins of IgG, and IgD classes. In the case of the lambda-type light chain disease the method is helpful in the identification of the M-component of the serum. Quantitative determination of light chains of immunoglobulins by ring precipitation is not essentially superior to other immunological and electrophoretic methods of protein analysis in monitoring treatment of cases of this myeloma.

Immuno-isotachophoretic determination of monoclonal immunoglobulin light chains produced by neoplastic B-cells: use in diagnosis, monitoring and detection of residual disease.

We suggest that countercurrent isotachophoresis performed on cellulose acetate membranes (ITP-CAM) should be used for detecting trace amounts of Bence-Jones protein (BJP) in urine of patients with chronic lymphocytic leukemia (CLL), non-Hodgkin's lymphoma (NHL) and related diseases. ITP-CAM allows simultaneous concentration and electrophoretic separation of proteins present in highly diluted solutions, as well as easy immunological detection of separated substances. BJP was found in 24 out of 42 patients with CLL, 33 of 56 with NHL and 3 of 3 with Waldenström macroglobulinemia. Twenty-three patients were followed during the course of chemo- or radiotherapy. In 19 cases the BJP findings correlated well with clinical status. In no case of partial or complete clinical response did BJP completely disappear from the urine.

Proteinuria in multiple myeloma and related diseases.

Proteinuria is frequently found in multiple myeloma and related disorders. Immunofixation electrophoresis is very helpful for the identification and characterization of the monoclonal component. In multiple myeloma, the presence of Bence-Jones (BJ) proteinuria is significantly associated with renal failure. The coexistence of BJ proteinuria and the nephrotic syndrome in myeloma patients should suggest AL amyloidosis or light chain deposition disease. In the latter, BJ proteinuria is absent in 30% of the cases and diagnosis is based on the demonstration of the monoclonal light chain deposits in tissues, predominantly in kidneys.

Renal impairment in myeloma: negative association with isoelectric point of excreted Bence-Jones protein.

The isoelectric point (pI) of the major form of Bence-Jones protein excreted by 62 patients with myeloma and six with macroglobulinaemia was measured by combining isoelectric focusing with immunoblotting techniques. The distribution of the pI values for both kappa and lambda type proteins was bimodal, most falling in the ranges 5.0-6.0 and 7.0-7.5. Plasma creatinine and creatinine clearance and the urine excretion of alpha-1-microglobulin and beta-2-microglobulin were measured in 24 of the patients. These patients, who were free of additional factors known to have an association with the development of renal impairment, were followed up for a mean period of 16 months (range three to 28 months). It was found that renal impairment was not related to the pI of the Bence-Jones protein excreted.

An unusual case of Waldenström macroglobulinemia with half molecules of IgG in serum and urine.

Immunochemical studies are described in an unusual case of Waldenström's macroglobulinemia. Two monoclonal Igs (whole IgG1/kappa and IgG1/kappa half molecules) occurred in the serum in addition to the IgM monoclonal protein. Protein electrophoresis of the serum showed a monoclonal component in the gamma region, and the immunoelectrophoresis allowed detection of a monoclonal IgM/kappa and another abnormality represented by a double precipitin line in serum and urine, observed when antiserum anti IgG was used. The abnormal proteins were purified and further analyzed. The IgG-related proteins were whole four chains IgG monoclonal molecules, 1/2 IgG monoclonal molecules, composed of one heavy and one light chain, and residual polyclonal IgG. The half molecules were antigenically deficient with respect to normal IgG. The idiotypic analysis showed that the three monoclonal proteins shared idiotypic determinants. This patient had clinical and morphological findings of Waldenström's macroglobulinemia and, as observed in other cases, the formation of half molecules was not associated with a distinct clinical syndrome.

Inhibitory effects of alkylated Bence-Jones protein, k-type light chain, from urine of a patient with macroglobulinemia on gastric juice secretion and ulceration in rats.

Bence-Jones protein (BJP) was isolate from the urine of a patient with macroglobulinemia by salting out the ammonium sulfate, followed by chromatography on DEAE-cellulose column and gel filtration. This native BJP was identified as k-type light chain by immunoelectrophoresis and the native light chain showed almost no activity of inhibiting the gastric ulceration in pylorus-ligated rats. In contrast, reduction of the disulfide bond by 2-mercaptoethanol and alkylation of the thiol by iodoacetate in this native light chain resulted in significant inhibition of the gastric ulceration. The alkylated light chain also showed a significant inhibition of gastric juice secretion in pylorus-ligated rats.

Urine B2-microglobulin in patients with macroglobulinemia Waldenström.

The level of B2-microglobulin in the urine was determined by a radioimmunoassay technique in six patients with Waldenström's macroglobulinemia. In 50% of the patients the B2-microglobulin in the urine was significantly increased. In none of the analyzed patients any glomerular malfunction, as measured by serum creatinine and creatinine clearance, was observed.

Emergence of immunoblastic sarcoma in Waldenstrom's macroglobulinemia.

A case involving a 65-year-old man with Waldenstrom's macroglobulinemia (WMG) which transformed into immunoblastic sarcoma is presented. Surface IgM (kappa) was demonstrated on the plasmacytoid lymphocytes of the bone marrow at presentation as well as on the less differentiated cells of the immunoblastic sarcoma. Serum IgM levels fell at the time that immunoblastic transformation occurred. This case illustrates the fact that a fall in serum paraprotein may herald a malignant transformation of WMG.

Giant kidneys in Waldenström's macroglobulinemia.

A patient with Waldenström's macroglubulinemia had the unique feature of having one kidney infiltrated with malignant cells to such an extent as to produce a large palpable abdominal mass. Other unusual aspects of this case include the destruction of renal tubules by the invading cells that resulted in interstitial fibrosis and was probably responsible for the appearance of whole IgM in the urine.

Distribution of heavy chain classes and light chain types in 757 cases of monoclonal gammapathies.

The distribution in heavy chain classes and light chain types of M components were studied in 757 cases of monoclonal gammapathies. These gammapathies were classified according to clinical and hematological data in 439 myeloma (MM), 165 Waldenström's macroglobulinemia (WM) and 152 monoclonal gammapathies occurring in other conditions. The IgG/IgA ratio differs in myeloma and in non-myelomatous gammapathies (64% IgG versus 33% IgA in myeloma and 95% IgG versus 5% in absence of myeloma). Presence of free light chains in patient's urines (Bence Jones proteinuria) was detected in about 72% of cases of MM, 48% of WM and only in 9% in others gammapathies. Concerning the sex of patients, an equal repartition between males and females is observed in MM, whereas males predominate in WM. The age distribution of the patients shows that 74% of myeloma and 79% of WM were above sixty. In addition to the 757 cases under study, 10 sera with two M Components were characterized.

Multiple myeloma and macrogammaglobulinemia. I. Urinary protein excretions and serum interrelationships.

Protein studies measuring selected serum and urinary biopolymers, representing activities of different organ systems, e.g., IgG, IgA, and C'3 complement (reticuloendothelial system), and albumin, transferrin, ceruloplasmin, and alpha-2 macroglobulin (liver) are compared and discussed. Mean normal excretions were 2.91 mg. per 24 hr. for IgG, 2.00 mg. per 24 hr. for IgA, and 20.39 mg. per 24 hr. for albumin. Renal function was estimated using creatinine clearance. The data suggest that concentration variations in certain of the proteins of the plasma pool are related to altered renal function. Such differences strayed below the normal but little, yet significant quantities of these proteins were found in urine. The identification and quantitation of abnormal urinary protein components in urine of patients who have myelomatosis and macrogammaglobulinemia may eventually be useful in medical management.