Freelite® & Hevylite®

Together Freelite & Hevylite provide optimal detection of monoclonal gammopathies

Index

• Introduction

- Monoclonal Gammopathy

- What is Freelite?

- What is Hevylite?

- Summary – How to use Freelite and Hevylite

• Diagnosis

- Freelite and Hevylite at diagnosis

- Detecting monoclonal gammopathies with Freelite

- IMWG guidelines for diagnosis of Multiple Myeloma

- Detecting Myeloma Kidney early

• Prognosis

- MGUS risk stratification

- AL amyloidosis

• Monitoring

- Use Freelite and Hevylite together

- Monitoring with Freelite

- Monitoring low levels of monoclonal protein

- Capture patients that are difficult to quantify

- Detect Light Chain Escape

- Identify patient clonal differences

- Capture clonal change

- Assessing Stringent Complete Response

- Capture residual disease

• Key Terminology

• Reference Ranges

• Interpretation

• Guidelines

• References

• Learn More

Monoclonal Gammopathy

Laboratory testing plays an importantrole at various patient management stages:

Diagnosis - to confirm disease state

Prognosis - to predict patient outcomes

Monitoring - to measure response to treatment

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

Kappa FLC

Intact ImmunoglobulinMultiple Myeloma~90% produce FLCs

Light ChainMultiple MyelomaOnly produce FLCs

FLCs = Free Light Chains

NonsecretoryMultiple Myeloma~70% produce FLCs

AL amyloidosis~80% produce FLCs

Lambda FLC

PEL = Protein Electrophoresis FLCs = Free Light Chains AL = AL amyloidosis IFE = Immunofixation Electrophoresis

Improve your accuracy in detecting monoclonal gammopathies

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.

Freelite

The International Myeloma Working Group Guidelines1

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)

...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.

““

Hevylite analysis allows improved management of Multiple Myeloma patients

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.

Hevylite

The Hevylite assay works by targeting epitopes between the heavy chain and light chain constant regions.

SPE = Serum Protein Electrophoresis MGUS = Monoclonal Gammopathy of Undetermined Significance MM = Mutiple MyelomaWM = 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

Freelite and Hevylite in Monoclonal Gammopathy testing

Diagnosis

Prognosis

Monitoring

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

Freelite + Hevylite• Provides risk stratification for MGUS and AL amyloidosis• Are prognostic indicators in Myeloma,1, 2 AL amyloidosis,1 WM,3, 4 SMM5

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• Residual disease• Clonal differences

SPE = Serum Protein Electrophoresis CZE = Capillary Zone Electrophoresis IFE = Immunofixation Electrophoresis

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.

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

Positive Negative

Establish baseline with relevant/appropriate

Hevylite pair

Establish Freelite baseline

Suspect AL amyloidosis, 24hr urine

SPE/CZE and Freelite ratioAt Diagnosis

Diagnosis

SPE = Serum Protein Electrophoresis IFE = Immunofixation Electrophoresis FLCs = Free Light Chains n.d. = no dataCZE = Capillary Zone Electrophoresis LCMM = Light Chain Multiple Myeloma NSMM = Nonsecretory Multiple Myeloma

Detect more monoclonal gammopathies with Freelite

A combination of SPE/CZE and Freelite is a clinically sensitive strategy for diagnosis of monoclonal gammopathies.

Optimising your Diagnostic Approach for Monoclonal Gammopathy Testing

Protocols

% of Paraproteins detected*Myeloma7 AL amyloidosis7 LCMM8,9,10 NSMM11

SPE alone 88 66 40 - 57 0 Serum IFE 94 74 n.d. 0 SPE, serum IFE, urine IFE 100 94 n.d. 0 SPE/CZE and Freelite 100 96 100 68 SPE/CZE, Freelite and serum IFE 100 97 100 68

* Myeloma is inclusive of 467 patients with MM (451), NSMM (4), Plasma cell leukaemia (4), Osteosclerotic MM (1), and Indolent Myeloma (7).

sFLC = serum Free Light Chain IMWG = International Myeloma Working Group MM = Multiple MyelomaMRI = Magnetic Resonance Imaging

Freelite now forms part of the IMWG diagnostic criteria for MM. It is recommended that patients meeting these criteria be treated for myeloma

2014 IMWG Guidelines for Diagnosis of Multiple Myeloma

Evidence of end-organ damage that can be attributed to the underlying plasma cell proliferative disorder:• Hypercalcaemia• Renal insufficiency• Anaemia• Bone lesions

} CRABfeatures

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

New IMWG Criteria for MM diagnosis12

Clonal bone marrow plasma cells ≥10% or biopsy-proven bony or extramedullary plasmacytoma

PLUS a myeloma defining event:

Detect Myeloma Kidney early to increase the chance of renal recovery

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

New AKI

Exclude myeloma kidney Assessment for FLC clone*

Alternative monoclonalFLC pathology

FLC clone

Clonal FLC <500 mg/L

Incidental MGUS

Either

No FLC clone

AKI of another cause

• Requires renal biopsy• Consider hematology work-up

Probable FLC tubular interstitial pathology

Clonal FLC ≥500 mg/L

• Requires hematology work-up• Initiation of disease-specific

treatment to reduce serumFLC levels *To exclude the presence of an intact monoclonal immunoglobin,

serum FLC assays should be combined with serum proteinelectrophoresis.

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.

Smouldering Multiple MyelomaSMM patients with a serum involved/uninvolved free light chain ratio ≥816 (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

MGUS risk stratification improves patient management

MGUS group Criteria Recommended follow-up

Low riskNo risk factors present

6 months initially & if stable, follow up every 2-3 years or when symptoms suggest a plasma cell malignancy

Low-intermediate risk

Any one risk factor present 6 months initially, then

annually and upon any change in the patient’s clinical condition

High-intermediate risk

Any two risk factors present

High riskAll three risk factors present

To optimise counselling and follow-up, 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

Prognosis

Risk factors:• Abnormal FLC ratio • Serum monoclonal protein >15g/L • IgA or IgM monoclonal protein type

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

Freelite is an independent prognostic marker for overall survival in AL amyloidosis, alongside cardiac biomarkers.17

AL amyloidosis

Incorporation of serum FLC-diff [dFLC] into the current staging system improves risk stratification for patients with AL amyloidosis and will help develop risk-adapted therapies for AL amyloidosis17

Kaplan-Meier curves for overall survival (OS) based on the new staging system incorporating 3 risk factors.

““

Risk factors:cTnT ≥ 0.025 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 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 ChainsdFLC = involved Free Light Chain minus uninvolved Free Light Chain

Use Freelite and Hevylite together

Monitor with Freelite dFLC plus Hevylite/SPE/CZE

Monitor with Hevylite and Freelite dFLC

Measure Freelite ratio Measure Hevylite ratio

Monitor with Freelite dFLC

>10g/L <10g/L

Monoclonal protein obvious

Monoclonal protein difficult to measure

Free Light Chains only Abnormal Freelite ratio

At Complete Response (CR)

To define a stringent CR

Residual Disease detection

Monitoring

IMWG = International Myeloma Working Group NSMM = Nonsecretory Multiple Myeloma LCMM = Light Chain Multiple MyelomaVDD = 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

dFLC is recommended to monitor response to treatment. The κ/λ FLC ratio alone is not recommended due to fluctuations in the uFLC 1

IMWG guidelines recommend the polyclonal Freelite test for quantitative monitoring of AL amyloidosis, NSMM and Oligosecretory Multiple Myeloma.1

Freelite has greater sensitivity than urine protein electrophoresis and overcomes the issue of patient non-compliance for providing urine samples.

Monitoring with Freelite

Rapid response to therapyA rapid decrease in λ sFLCs gives an earlier indication of response than intact immunoglobulin SPE measurements in a patient with IgGλ IIMM.

FLC half-life is 2-6 hours compared to IgG half-life (up to 21 days) providing earlier indication of response to treatment.

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

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 techniques.1, 18

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

SPE = Serum Protein Electrophoresis

Use Hevylite when electrophoresis is inaccurate

Capture Multiple Myeloma patients that are difficult to quantify

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.

IgA monoclonal proteins may co-migrate with other serum proteins

SPE is not linear and dye saturation leads to underestimation of responses

Monitor with Freelite to ensure that Light Chain Escape is not missed

λ

MM = Multiple Myeloma

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

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.

Courtesy of Christie Hospital, Manchester, UK.

Used together, Freelite and Hevylite can identify clonal differencesR/POD = Relapse/Progression of Disease FLCs = Free Light Chains CR = Complete Response

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.30

1. Light chain only patients showed no change2. 60% of patients with both intact immunoglobulins and

FLCs changed their monoclonal protein type3. 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 ( ).

1 2 3

This study of an MM patient with IgAκ monoclonal proteins plus κ 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.

κFLC = Kappa Free Light Chain

Use Freelite and Hevylite to capture clonal change

Freelite and Hevylite measure two independent biomarkers in Multiple Myeloma.

• Freelite measures kappa(κ) and lambda(λ) 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.

Freelite is essential for assessing sCR in all myeloma patientsSPE = Serum Protein Electrophoresis IFE = Immunofixation Electrophoresis CR = Complete Response sCR = stringent Complete Response ASCT = Autologous Stem Cell Transplant IHC = Immunohistochemistry

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.

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.

Definition of sCR19, 32

• 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

More information for better patient care decisionsIF = Immunofixation Electrophoresis SPE = Serum Protein Electrophoresis HLC = Heavy / Light Chain

Use Hevylite to capture more residual disease

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

A B C D E SPE positive SPE positive SPE negative SPE negative SPE negative

Using Hevylite and Freelite together improves sensitivity when detecting intact immunoglobulin monoclonal proteins and free light chains in residual disease.2

LCMM = Light Chain Multiple Myeloma MM = Multiple Myeloma

Key Terminology

Term Definition Description Example in a Lambda LCMM patient

FLC Free Light ChainiFLC Involved FLC The FLC type produced by the tumour λ

uFLC Uninvolved FLC The alternate light chain type to the iFLC κ

κ/λ sFLC ratio κ/λ A ratio of the concentration of κ to λ sFLC (indicates monoclonality) κ/λ

dFLC iFLC – uFLC The difference in the concentration between the iFLC and uFLC λ-κ

Involved/ Uninvolved sFLC ratio

iFLC/uFLC A ratio of the concentration of involved to uninvolved sFLC – could be κ/λ or λ/κ λ/κ

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 IgGκ

uHLC Uninvolved HLC The same heavy chain isotype but alternate light chain type to the iHLC IgGλ

HLC ratio e.g. IgAκ/IgAλA ratio of the concentration of κ to λ HLC (indicates monoclonality) IgGκ/IgGλ

dHLC iHLC – uHLCFor a particular immunoglobulin isotype, the difference in concentration between the iHLC and uHLC

IgGκ-IgGλ

HLC-pair suppression

When the concentration of the uHLC is below the normal reference interval

The ratio must be abnormal Suppression of IgGλ

Hevylite

Freelite

Reference ranges

Normal adult serum 95 percentile range

κ FLC 3.30 - 19.40 (mg/L)

λ FLC 5.71 - 26.30 (mg/L)

κ / λ FLC ratio100 percentile range

0.26 - 1.65

Renal reference range 100 percentile range

κ / λ FLC ratio 0.37 - 3.1

HevyliteFreeliteNormal adult

serum

95 percentile range

for SPAPLUS®

IgG Kappa

IgG Lambda

IgGκ/IgGλ Ratio

3.84 - 12.07 (g/L)

1.91 - 6.74 (g/L)

1.12 - 3.21IgA Kappa

IgA Lambda

IgAκ/IgAλ Ratio

0.57 - 2.08 (g/L)

0.44 - 2.04 (g/L)

0.78 - 1.94

IgM Kappa

IgM Lambda

IgMκ/IgMλ Ratio

0.19 - 1.63 (g/L)

0.12 - 1.01 (g/L)

1.18 - 2.74

An abnormal κ/λ FLC ratio is a highly sensitive indicator of monoclonal κ or λ 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 κ/λ FLC ratio: 0.37-3.1 for these patients.33

The renal reference range improves specificity whilst maintaining diagnostic sensitivity in patients with renal impairment.

MG = Monoclonal Gammopathy pIg = Polyclonal Immunoglobulin sFLC = serum Free Light Chain SPE = Serum Protein Electrophoresis HLC = Heavy / Light Chain FLC = Free Light Chains

Interpretation

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 κ/λ ratios. Possible monoclonal gammopathy - needs further investigation. Borderline elevated κ/λ ratios occur with renal impairment and may require appropriate renal function tests

• Low concentrations of κ, λ or both indicate bone marrow suppression

• Elevated concentrations of both κ and λ with a normal κ/λ 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 κ and λ with an abnormal κ/λ 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

Freelite and Hevylite should be used in conjunction with other laboratory tests and clinical evaluations.

Quality Assurance

Request your Freelite &Hevylite book7th Edition, fully revised for 2015

Follow us on Twitter:@BindingSiteHaem

Access our online, free, educational resource with up to date information on Freelite and Hevylite:

www.wikilite.com

Contact us

Learn More

The Binding Site Group Ltd, Birmingham UK

The Binding Site Inc,San Diego, USA

The Binding Site GmbH Schwetzingen

The Binding Site France,Grenoble

The Binding Site Spain, Barcelona

The Binding Site s.r.o. Prague

The Binding Site BeNeLux,Antwerp

The Binding Site Italy,Bergamo

FDA = Food and Drugs Administration (USA)

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.

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; 28:981-992

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; 30:4541-4549

Consensus recommendations for the uniform reporting of clinical trials: report of the International Myeloma Workshop Consensus Panel 1. Rajkumar SV, et al. Blood 2011; 117:4691-4695

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; 24:1121-1127

International Myeloma Working Group guidelines for serum-free light chain analysis in multiple myeloma and related disorders. Dispenzieri A, et al. Leukemia 2009; 23:215-224

International uniform response criteria for multiple myeloma. Durie BGM, et al. Leukemia 2006; 20:1467-1473

Freelite, Hevylite and SPAPLUS are registered trademarks of The Binding Site Group Ltd (Birmingham, UK) in certain countries.

EBK020March 2016

BROCHURE NOT FOR USE IN USA

References

1. Dispenzieri A, et al. International Myeloma Working Group guidelines for serum-free lightchain analysis in multiple myeloma and related disorders. Leukemia 2009: 23:215-224

2. Ludwig H, et al. Immunoglobulin heavy/light chain ratios improve paraprotein detection andmonitoring, identify residual disease and correlate with survival in multiple myeloma patients.Leukemia 2013, 27:213-219

3. Itzykson R, et al. Serum-free light chain elevation is associated with a shorter time to treatment in Waldenström’s Macroglobulinemia. haematologica 2008;93: 793-794

4. Leleu X, et al. Novel M-Component Based Biomarkers in Waldenström’s Macroglobulinemia.CLML 2011;11: 164-167

5. Bhutani M, et al. Serum Heavy-Light Chains (HLC) and Free Light Chains (FLC) As PredictorsFor Early CR In Newly Diagnosed Myeloma Patients Treated With Carfilzomib, Lenalidomide, andDexamethasone (CRd) 2013: Blood 122(21); 762a

6. Katzmann JA. Screening panels for monoclonal gammopathies: time to change. Clin BiochemRev 2009; 30:105-11

7. Katzmann JA, et al. Screening Panels for Detection of Monoclonal Gammopathies. Clin Chem 2009; 55:1517-1522

8. Bradwell AR, et al. Serum test for assessment of patients with Bence Jones myeloma. Lancet2003; 361:489-491

9. Wolff F, et al. Assessment of the analytical performance and the sensitivity of serum free lightchains immunoassay in patients with monoclonal gammopathy. Clin Biochem 2007; 40:351-4

10. Abraham RS, et al. Correlation of Serum Immunoglobulin Free Light Chain Quantificationwith Urinary Bence Jones Protein in Light Chain Myeloma. Clin Chem 2002; 48:655-657

11. Drayson M. et al. Serum free light-chain measurements for identifying and monitoringpatients with nonsecretory multiple myeloma. Blood 2001;97:2900-2902

12. Rajkumar SV, et al. International Myeloma Working Group updated criteria for the diagnosisof multiple myeloma. Lancet Oncology 2014; 15:e538-e548

13. Hutchison CA, et al. The pathogenesis and diagnosis of acute kidney injury in multiplemyeloma. Nat Rev Neph 2011; 8:43-51

14. Kyle RA, et al. Monoclonal gammopathy of undetermined significance (MGUS) andsmoldering (asymptomatic) multiple myeloma: IMWG consensus perspectives risk factors forprogression and guidelines for monitoring and management. Leukemia 2010: 24:1121-1127

15. Katzmann J, et al. Suppression of uninvolved immunoglobulins defined by heavy/light chainpair suppression is a risk factor for progression of MGUS. Leukemia 2013; 27:208–212

16. Dispenzieri A, et al. Immunoglobulin free light chain ratio is an independent risk factor forprogression of smoldering (asymptomatic) multiple myeloma. Blood 2008; 111:785-789

17. Kumar S, et al. Revised prognostic staging system for light chain amyloidosis incorporatingcardiac biomarkers and serum free light chain measurements. J Clin Oncol 2012;30:989-995

18. Ludwig H, et al. International Myeloma Working Group recommendations for globalmyeloma care. Leukemia 2013; 28:981-992

19. Durie BGM, et al. International uniform response criteria for multiple myeloma. Leukemia2006; 20:1467-1473

20. Larsen D, et al. Prevalence and Monitoring of Oligosecretory Myeloma. N Engl J Med 2012;367: 580-581.

21. Boyle E, et al. IgA Kappa/IgA Lambda Heavy/Light Chain Assessment in the Management ofPatients with IgA Myeloma. Cancer 2014;120:3952-3957

22. Ludwig H, et al. Immunoglobulin heavy/light chain ratios improve paraprotein detection andmonitoring, identify residual disease and correlate with survival in multiple myeloma patients.Leukemia 2013; 27:213-219

23. 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 forMonitoring Monoclonal Gammopathies. Clin Chem 2011, 57: 1687-1692

24. Eckold J, et al. Analytical performance and diagnostic potential of immunoassaysdetermining Intact Immunoglobulin κ/λ ratios in monoclonal gammopathies. Clin Lab 2014;60:1491-1500

25. Katzmann, J et al. Monitoring IgA Multiple Myeloma: Immunoglobulin Heavy/Light ChainAssays. Clin Chem 2015; 61:360-367

26. Katzmann and Kyle. Manual of molecular and Clinical laboratory Immunology. 7th ed, ASMpress, Washington DC

27. Brioli A, et al. Serum free immunoglobulin light chain evaluation as a marker of impact fromintraclonal heterogeneity on myeloma outcome. Blood 2014; 123:3414-3419

28. Kuhnemund A, et al. ‘Light-chain escape-multiple myeloma’ – an escape phenomenon fromplateau phase: report of the largest patient series using LC-monitoring. J Cancer Res Clin Oncol2009; 135:477-484

29. Ayliffe M, et al. Demonstration of changes in plasma cell subsets in multiple myeloma.haematologica 2007; 92:1135-1138

30. Zamarin D, et al. Patterns of relapse and progression in multiple myeloma patientsafter auto-SCT: implications for patients’ monitoring after transplantation. Bone MarrowTransplantation 2013; 48:419–424

31. Kapoor P, et al. Importance of Achieving Stringent Complete Response After AutologousStem-Cell Transplantation in Multiple Myeloma. Journal of Clinical Oncology 2013; 31:4529-35

32. Rajkumar SV, et al. Consensus recommendations for the uniform reporting of clinical trials:report of the International Myeloma Workshop Consensus Panel 1. Blood 2011; 117:4691-5

33. Hutchison CA, et al. Serum free light chain measurement aids the diagnosis of myeloma inpatients with severe renal failure. BMC Nephrol 2008;9:11