Patent Application
20150051839
The invention relates to an improved method of characterising a plasma cell disease in a patient and to apparatus and kits for carrying out the method.
The Applicants have for many years studied free light chains as a way of assaying for a wide-range of monoclonal gammopathies in patients. The use of such free light chains in diagnosis is reviewed in detail in the book “Serum Free Light Chain Analysis, Sixth Edition (2008) A.R. Bradwell, ISBN 9780704427969”. Polyclonal abnormalities, where there is decreased or increased production of polyclonal antibodies in patients is also known.
Antibodies comprise heavy chains and light chains. They usually have a two-fold symmetry and are composed of two identical heavy chains and two identical light chains, each containing variable and constant region domains. The variable domains of each light-chain/heavy-chain pair combine to form an antigen-binding site, so that both chains contribute to the antigen-binding specificity of the antibody molecule. Light chains are of two types, κ and λ and any given antibody molecule has either light chain but never both. There are approximately twice as many κ as λ molecules produced in humans, but this is different in some mammals. Usually the light chains are attached to heavy chains. However, some unattached “free light chains” (FLC) are detectable in the serum or urine of individuals. Free light chains may be specifically identified by raising antibodies against the surface of the free light chain that is normally hidden by the binding of the light chain to the heavy chain. In free light chains this surface is exposed, allowing it to be detected immunologically. Commercially available kits for the detection of κ or λ free light chains include, for example, “Freelite™”, manufactured by The Binding Site Limited, Birmingham, United Kingdom. The Applicants have previously identified that measuring the amount of free κ, free λ and/or free κ/free λ ratios, allows the detection of monoclonal gammopathies in patients. It has been used, for example, as an aid in the diagnosis of intact immunoglobulin multiple myeloma (MM), light chain MM, non-secretory MM, AL amyloidosis, light chain deposition disease, smouldering MM, plasmacytoma and MGUS (monoclonal gammopathies of undetermined significance). Detection of FLC has also been used, for example, as an aid to the diagnosis of other B-cell dyscrasia and indeed as an alternative to urinary Bence Jones protein analysis for the diagnosis of monoclonal gammopathies in general.
Conventionally, an increase in one of the λ or κ light chains is looked for. For example, multiple myeloma (MM) results from the monoclonal multiplication of a malignant plasma cell, resulting in an increase in a single type of cell producing a single type of immunoglobulin. This results in an increase in the amount of free light chain, either λ or κ, observed within an individual. This increase in concentration may be determined, and usually the ratio of the free κ to free λ is determined and compared with the normal range. This aids in the diagnosis of monoclonal disease. Moreover, the free light chain assays may also be used for the following of treatment of the disease in patients. Prognosis of, for example, patients after treatment for AL amyloidosis may be carried out.
Katzmann et al (Clin. Chem. (2002); 48(9): 1437-1944) discuss serum reference intervals and diagnostic ranges for free κ and free λ immunoglobulins in the diagnosis of monoclonal gammopathies. Individuals from 21-90 years of age were studied by immunoassay and compared to results obtained by immunofixation to optimise the immunoassay for the detection of monoclonal free light chains in individuals with B-cell dyscrasia.
The amount of κ and λ FLC and the κ/λ ratios were recorded allowing a reference interval to be determined for the detection of B-cell dyscrasias.
The Applicants have also previously identified that assaying for FLC can be used to predict long-term survival of individuals, even when the individual is an apparently healthy subject. (WO 2011/021041). They found that total FLC concentration is statistically, significantly linked to long-term survival. Moreover, this link appears to be similar or better than the link for existing long-term survival prognostic markers such as cholesterol, creatinine, cystatin C and C-reactive protein. Assays for total FLC measurement are disclosed in the document. Assays measuring total FLC are available from The Binding Site, Birmingham, United Kingdom under the trademark “Combylite”.
The measurement of heavy chain class to light chain type bound specific (HLC) immunoglobulins such as IgAλ, IgAκ, IgGκ, IgGλ, IgMκ or IgMλ, also has been found to assist in characterising monoclonal gammopathies. Heavy chain class-light chain type specific antibodies and their use are disclosed in WO 2006/079816. Such antibodies are commercially available from The Binding Site, Birmingham, United Kingdom under the trademark “Hevylite”.
Diseases associated with polyclonal abnormalities, where more than one specific antibody has increased or decreased production are generally known. For example, this may be characterised by a general increase in antibody production or by two or more monoclonal antibodies, from two separate tumour sources, being present. Chronic infections, autoimmune diseases and many tumours cause increases in polyclonal immunoglobulins. Skin, pulmonary and gut diseases are more likely to cause increases in IgA concentrations, whilst systemic infections will increase all immunoglobulins, but especially IgG.
Serum protein electrophoresis (SPE) involves scanning agarose electrophoretic gels after serum proteins have been separated and the gel has been stained. Immunofixation electrophoresis (IFE) detects the presence of serum proteins using antibodies binding to the proteins within electrophoretic gels to produce visible precipitation bands. There are a number of limitations associated with such methods. Since 2001, serum FLC assays have been available to identify free λ or free κ light chains (FLC) in serum. The combined use of FLC, SPE and/or IFE assays is recommended in international guidelines. The separate results of each test are interpreted separately, though the combined results together may or may not support one another, see for example Dispenzieri A. et. al, Leukaemia 23-2 (2009), 215-24.
More recently the HLC assays using Hevylite™ antibodies have been developed by the Applicants. Such HLC assays allow a quantifiable ratio between involved monoclonal proteins from tumours that can otherwise be measured by SPE and the uninvolved polyclonal levels of the same heavy chain class but bound to the opposite light chain to be measured. This ratio can be used in place of SPE and IFE for the determination of type and concentration of monoclonal proteins in the serum.
The interpretation of results from the various assays that are available can be difficult and require some skill and expertise. The Applicant has identified that the FLC and HLC results, optionally together with the total FLC and/or total HLC can be weighted to produce a score for the indication of monoclonal gammopathies. This can be used, not only to show an indication of the abnormality, but also a degree of confidence of this indication. Analytical errors in one or more of the results can also be more readily identified. This is expected to allow the distinction and degree of confidence in monoclonal gammopathies and the distinction between:
a) Monoclonal protein production (be this intact immunoglobulins, free light chains or indeed production of both). With or without an associated polyclonal suppression of non-involved immunoglobulins.
b) Elevation of polyclonal production with no monoclonal production—hypergammaglobulineamia.
c) Suppression of polyclonal production with no monoclonal production—hypogammaglobulineamia.
d) Normal polyclonal production with no monoclonal production.
e) Production of kappa light chains or lambda light chains bound to a class of heavy chain and/or production of a kappa light chain or lambda light chain without monoclonal protein production.
The invention provides a method for characterising a plasma cell associated disease in a patient comprising:
(i) providing at least one sample from the patient;
(ii) determining in the sample(s) two or more of,
An indication of an abnormal FLC κ:λ ratio or HLC κ:HLC λ ratio, elevated clonal concentration and suppression of uninvolved immunoglobulins, for example, gives a high level of certainty of the presence of a monoclonal plasma-cell associated disease.
Typically the κ:λ FLC ratio and the HLCκ:HLCλ ratio are determined.
Determining the total FLC and total HLC in the samples may also be used to provide scores.
Elevated levels of kappa FLC or lambda FLC with FLC κ:λ ratio within the normal range highlights potential abnormality and warrants further investigation. Similarly elevated HLCκ or HLCλ with HLCκ:HLCλ ratio within the normal range also highlights a potential abnormality and warrants further investigation.
The sample may be a urine sample, though serum, blood or plasma is preferred.
The scoring system allows the characterisation of the plasma-cell associated disease and assists in simplifying the characterisation, allowing assays to be carried out by less skilled practitioners and allowing a degree of confidence in the results to be determined.
The plasma cell associated disease may be a monoclonal gammopathy. It may be B-cell associated diseases such as myeloma, (such as intact immunoglobulin myeloma, light chain myeloma, non-secretory myeloma), an MGUS, AL amyloidosis, Waldenstrom's macroglobulinaemia, Hodgkin's lymphoma, follicular centre cell lymphoma, chronic lymphocytic leukaemia, mantle cell lymphoma, pre-B cell leukaemia or acute lymphoblastic leukaemia.
The plasma cell associated disease may also be a polyclonal associated disease such as hypergammaglobulineamia or hypogammaglobulineamia.
The method may be computer implemented, for example step (iii) may be implemented. The scores may be displayed on an output such as a computer display. Alternatively, the score may be used to produce an output of the likely diagnosis of the type of disease.
One or more samples may be taken from the patient at substantially the same time. The amounts may be assayed on a single sample or separate samples.
The scores may be used to indicate the type of plasma cell disease and/or include a confidence level for the characterisation of the plasma cell disease.
For example, a high or medium FLC κ:λ ratio would indicate a kappa monoclonal gammopathy. However, a lower confidence of monoclonal production would be indicated where a lower abnormal κ:λ FLC ratio was identified on its own. If the HLC ratio for one of the heavy chain classes (such as IgAκ:IgAλ) also indicates the abnormal ratio, for the ratio and light chain type, this confirms the finding of monoclonal production.
The summation of the total FLC and/or total HLC for a specific class, can be used to show abnormal levels of immunoglobulin production or for example suppression of one or more classes of immunoglobulins such as IgM or IgA.
Typically the FLC κ:λ ratio is determined and compared to a normal range for FLC κ:λ ratio. The normal range may be the typical range of κ:λ for apparently healthy individuals which, depending on the population being assessed is typically 0.26-1.65.
If the FLC κ:λ ratio is above or below that normal range it may be given a score. The score may be, for example, high, medium or low; 1, 2, 3 or 4; or +, ++, +++ or ++++ for the indication of clonality. A “normal ratio” may also be scored as, for example, zero. A ratio of above the predetermined range, such as above 1.65 indicates kappa monoclonality, so the kappa value would be given a score of, for example, high, medium or low; or 4 for very high, 3 for less high, 2 for lower, 1 just above the normal range. Where the ratio is below the normal range (below 0.26 for example) indicates λ monoclonality and again can be scored in a similar way.
For example the following ratios may be used to score the results.
Alternative scoring systems such as 1 to 4 or + to ++++ may also be used.
If the FLC κ:λ ratio is normal, then the total amount of FLC (κ+λ) may be determined and scored to indicate increased or decreased polyclonal FLC production. A normal total of FLC is typically 27 mg/ml in serum. Again scores of high, medium, low; −4 to +4 (where +4 indicates very high total FLC and −4 very low production) or −−−−, −−−, −−, −, 0 (normal), +, ++, +++, ++++ may be used. For example:
The amount of λ FLC in the sample may be compared to the amount of κ FLC in the sample (or the amount of HLC κ compared to HLC λ) to produce a clonality score or an indication of the production or suppression of the FLCs or HLCs. Typically the production or suppression levels are indicated for normal FLC or HLC ratios.
Normal ratios (e.g. between 0.26-1.65) can also be broken down.
For example FLC κ+FLC λ>45.7 mg/L—FLC production
Alternatively total FLC production can be split into three bands, high production, normal or suppression production.
The ratio of κ light chain type bound to a particular heavy chain class:λ light chain bound to the same heavy chain class (HLC κ:λ) ratio may compared to a normal range for that heavy chain class. The heavy chain class may be IgA, IgM, IgD or IgE. More typically IgG, IgA or IgM as these are more likely to be associated with such diseases. One or more of the classes may be assayed. Hence the ratios may be IgA:IgAλ, IgGκ:IgGλ, IgMκ:IgMλ, IgDκ:IgDλ and/or IgEκ:IgEλ.
Typical normal ratios are:
These HLC ratios may be scored in a similar manner to FLC.
Where the HLCκ:HLCλ ratio is within the normal range, the total HLC for that class (HLCκ+HLCλ) may be determined and scored to give an indication of elevation or suppression of heavy chain class production. That is, for example, IgGκ:IgGλ (the same class) is then determined.
Where the FLCκ:FLCλ and the HLCκ:HLCλ are within the normal range, elevated levels of FLCκ or FLCλ and/or HLCκ or HLCλ may indicated disease and highlight that further investigations are required. Elevation may be defined by levels above the normal range.
Typical normal ranges are:
Instead of or additionally the HLCκ:HLCλ ratio may be subclass specific. This gives more specific data. IgG for example has four subclasses (IgG1, IgG2, IgG3 and IgG4). IgA has two subclasses (IgA1 and IgA2). Hence the HLC ratio may be, for example, IgG2κ:IgG2λ ratio.
Examples of typical scoring systems are:
Polyclonality can be similarly scored.
Again, a score of “zero” may be given for a normal ratio. Suppression and production can also be indicated as three bands, high production, normal and suppressed.
Clonality may also be scored in a similar manner to FLC ratios for IgG and indeed similarly for other heavy chains.
For example a moderate IgAλ with some polyclonal M suppression and analytical error on the IgGκ (low weighting and disagreement) could be expressed as IgGκ low, IgAλ medium, IgM total medium suppression.
The FLC results (κ:λ FLC and/or total FLC) can be compared with the HLC results (HLCκ:HLCλ and/or total HLC) to identify errors or areas of agreement.
An IgA lambda with high λ FLC, polyclonally suppressed IgM and analytical error on IgG would be expressed as:
κ:λ FLC λ high, IgAλ high, IgGλ low, IgM total low suppression.
The alternative ways of scoring described above can be used as follows.
For example, do the FLC (β) results indicate clonality kappa [A] or lambda [B] or a polyclonal abnormality [C]. [A] or [B] can be scored on a level of 1 to 4 (+, ++, +++ or ++++). [C] can be suppression or elevation and so be scored on a measure of −4 to +4 (−−−, −−, −, 0, +, ++, +++ or ++++). This means that the FLC result will be one of the following:
For example a strong FLC lambda result the FLC measure (β) would be:
The HLC results for G (γ), A (α) or M (μ) can be depicted in the same manner, i.e. do they indicate clonality (kappa [A] or lambda [B] or a polyclonal abnormality [C]. Once again, clonality [A] or [B] can be scored on a level of 1 to 4 (+, ++, +++ or ++++) and for [C] suppression or elevation can occur and so be scored on a measure of −4 to +4 (−−−−, −−−, −−, −, 0, +, ++, +++, ++++).
For example an moderate IgA lambda with some polyclonal M suppression and analytical error on the IgG kappa (low weighting and disagreement) could be expressed as follows.
The FLC result (β) can then be combined with the HLC G (γ), A (α) and M (μ) results. The example of an IgA lambda with high lambda FLC levels, a polyclonally suppressed IgM results and an analytical error on the IgG would be expressed as follows:
The clonal identity is shown by the agreement between the FLC (β) result and the HLC (γ, α or μ) result, in this case β & α. β and α shows that this is a lambda sample, the disagreement of γ shows that the γ result is an error and the μ result provides the additional information that there is polyclonal suppression, that there is polyclonal suppression.
The second outcome from the algorithm is the degree of confidence in the result and this can be calculated from the items of agreement:
The measurements of the FLC and HLC in the sample(s) may be determined using methods generally known in the art.
Antibodies, or fragments of antibodies, specific for κ or λ FLC are generally know and are commercially available under the trade name Freelite™.
Heavy chain class—light chain type—specific antibodies (for example anti-IgAκ antibodies) are also generally known the art (see WO 2006/079816) and are commercially available under the trade name Hevylite™ from The Binding Site, Birmingham, UK. Alternatively the light chains bound to heavy chains can be determined via, for example, a sandwich assay using anti-light chain type antibodies and anti-heavy chain class antibodies as described in WO 2006/079816.
Typically the FLC or HLC, such as κ:λ FLC ratio, total FLC, HLCκ:HLCλ and/or total HLC is determined by immunoassay, such as ELISA assays or utilising fluorescently labeled beads, such as Luminix™ beads.
ELISA, for example uses antibodies to detect specific antigens. One or more of the antibodies used in the assay may be labeled with an enzyme capable of converting a substrate into a detectable analyte. Such enzymes include horseradish peroxidase, alkaline phosphatase and other enzymes known in the art. Alternatively other detectable tags or labels may be used instead of, or together with, the enzymes. These include radioisotopes, a wide range of coloured and fluorescent labels known in the art including fluorescein, Alexa fluor, Oregon Green, BODIPY, rhodamine red, Cascade Blue, Marina Blue, Pacific Blue, Cascade Yellow, gold; and conjugates such as biotin (available from, for example, Invitrogen Ltd, United Kingdom). Dye sols, metallic sols, chemiluminescent labels or coloured latex may also be used. one or more of these labels may be used in the ELISA assays according to the various inventions described therein, or alternatively in the other assays, labeled antibodies or kits described herein.
The construction of ELISA-type assays is itself well known in the art. For example, a “binding antibody” specific for the FLC is immobilised on a substrate. The “binding antibody” may be immobilised onto the substrate by methods which are well known in the art. FLC in the sample are bound by the “binding antibody” which binds the FLC or HLC to the substrate via the “binding antibody”.
Unbound immunoglobulins may be washed away.
In ELISA assays the presence of bound immunoglobulins may be determined by using a labeled “detecting antibody” specific to a different part of the FLC of interest than the binding antibody.
Flow cytometry may be used to detect the binding of the FLC or HLC of interest. This technique is well known in the art for, for example, cell sorting. However, it can also be used to detect labeled particles, such as beads and to measure their size. Numerous text books describe flow cytometry, such as Practical Flow Cytometry, 3rd Ed. (1994), H. Shapiro, Alan R. Liss, New York, and Flow Cytometry, First Principles (2nd Ed.) 2001, A. L. Given, Wiley Liss.
One of the binding antibodies, such as the antibody specific for FLC, is bound to a bead, such as a polystyrene or latex bead. the beads are mixed with the sample and the second detecting antibody. The detecting antibody is preferably labeled with a detectable label, which binds the FLC to be detected in the sample. This results in a labeled bead when the FLC to be assayed is present.
Other antibodies specific for other analytes described herein may also be used to allow the detection of those analytes.
Labeled beads may then be detected via flow cytometry. Different labels, such as different fluorescent labels may be used for, for example, the anti-free λ and anti-free κ antibodies. Other antibodies specific for other analytes described herein may also be used in this or other assays described herein to allow the detection of those analytes. This allows the amount of each type of FLC bound to be determined simultaneously or the presence of other analytes to be determined.
Alternatively, or additionally, different sized beads may be used for different antibodies, for example for different marker specific antibodies. Flow cytometry can distinguish between different sized beads and hence can rapidly determine the amount of each FLC or other analyte in a sample.
An alternative method uses the antibodies bound to, for example, fluorescently labeled beads such as commercially available Luminex™ beads. Different beads are used with different antibodies. Different beads are labeled with different fluorophore mixtures, thus allowing different analytes to be determined by the fluorescent wavelength. Luminex beads are available from Luminex Corporation, Austin, Tex., United States of America.
Preferably the assay used is a nephelometric or turbidimetric method.
Apparatus configured to carry out the method of the invention are also provided. They may comprise a computer processor and memory configured to carry out the method. They may comprise an output, such as display screen, to display the score(s) and/or result.
The apparatus may comprise a detector for measuring the κ:λ FLC ratio, HLCκ:HLCλ ratios and optionally the total FLC and/or total HLC.
The apparatus may be a flow cytometer, nephelometer or turbidometer.
Kits comprising
The kit may additionally comprise antibodies or fragments to measure the total FLC and/or HLC in the sample.
Such detecting antibodies or fragments may be mixed together, for example, in a multiplex kit, using different dyes or other labels for each different detecting antibody. The labels may, for example, be different Luminex™ beads.
The application may be described by may of example only.
κ:λ FLC ratios, total FLC, HLCκ:HLCλ ratios and/or total HLC may be carried out using techniques generally known in the art.
Typically Freelite™ kits, Hevylite™ kits and Combylite™ kits (available from The Binding Site Ltd, Birmingham, UK) are used according to manufacturers instructions to measure samples of serum from patients.
Results are scored as, for example, shown in Tables 1 to 6 above, and as described above.
Table 7 below shows the interpretation of some of the results that might be expected, based on the types of patients found previously by the applicants.
Non-clonal suggests that further investigation may be necessary.
Methods:
1515 patients referred to the Royal Wolverhampton Hospital were analysed. SPE and IFE were performed using a SEBIA Hydrasys 2, FLC and HLC assays were performed nephelometrically, and the results were analysed using an algorithm as described herein that incorporated:
(1) FLC and HLC ratios:
(2) the levels of isotype-match suppression;
(3) the levels of systemic immunoglobulin suppression; and
(4) FLC and HLC production.
The results from the algorithm and the historic SPE and IFE gels were compared with patient's clinical diagnosis.
Results:
At presentation, 156/1515 (10%) samples had an abnormal SPE; 101/156 which were positive by IFE. 52/101 of the IFE positive patients had confirmed haematological disorders, included:
At presentation, 175/1515 (11%) samples were identified by the FLC/HLC algorithm as having FLC and/or HLC abnormalities. The FLC/HLC algorithm identified 78 patients with haematological disorders, including all 52 patients identified by SPE/IFE, and a further 26 patients not detected by SPE/IFE, included:
An algorithm based on FLC and HLC assays provides a more sensitive method for detecting haematological disorders and identified 26 patients missed by a screening panel of SPE and sIFE.
| Number | Date | Country | Kind |
|---|---|---|---|
| 1203938.4 | Mar 2012 | GB | national |
| Filing Document | Filing Date | Country | Kind |
|---|---|---|---|
| PCT/GB2013/050540 | 3/6/2013 | WO | 00 |
