Multiple Myeloma and Related Serum Protein Disorders: An Electrophoretic Guide
This monoclonal gammopathy occurs in younger patients. Affected patients have only one tumor, with no other bone lesions and no urine or serum abnormalities. Affected patients have hyperviscosity and hypercellular bone marrow with extensive infiltration by lymphoplasma cells. Multiple myeloma: recognition and management. Am Fam Physician ; In some patients with a plasma cell dyscrasia, serum protein electrophoresis may be normal because the complete monoclonal immunoglobulin is absent or is present at a very low level.
The remainder had hypogammaglobulinemia or a normal-appearing pattern. Consequently, urine protein electrophoresis is recommended in all patients suspected of having a plasma cell dyscrasia. An additional point to consider is the size of the M-protein spike.
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Although this spike is usually greater than 3 g per dL in patients with multiple myeloma, up to one fifth of patients with this tumor may have an M-protein spike of less than 1 g per dL. If multiple myeloma still is considered clinically in a patient who does not have an M-protein spike on serum protein electrophoresis, urine protein electrophoresis should be performed. Monoclonal gammopathy is present in up to 8 percent of healthy geriatric patients.
Patients with monoclonal gammopathy of undetermined significance require close follow-up because about 1 percent per year develop multiple myeloma or another malignant monoclonal gammopathy. Suggested algorithm for follow-up of a monoclonal gammopathy. If the serum M-protein spike is 1.
If these examinations are normal, serum protein electrophoresis should be repeated in three to six months; if that examination is normal, serum protein electrophoresis should be repeated annually. If the repeat examination is abnormal or future patterns are abnormal, the next step is to refer the patient to a hematologist-oncologist. An M-protein spike of greater than 2. In addition, a beta 2 microglobulin test, a CRP test, and a hour urine collection for electrophoresis and immunofixation should be performed.
Abnormalities in any of these tests should result in a referral to a hematologist-oncologist. If all tests are normal, the pattern of follow-up in Figure 3 6 can be undertaken. If serum protein electrophoresis is abnormal at any time during the follow-up, a referral should be made. Already a member or subscriber? Log in. Family Medicine Residency Program. Address correspondence to Theodore X.
Reprints are not available from the authors. The authors indicate that they do not have any conflicts of interest. Sources of funding: none reported. Molecular diagnostic methods in cancer genetics. In: Abeloff MD, et al. Clinical oncology. New York: Churchill Livingstone, — Hoffman R, et al. Hematology: basic principles and practice.
New York: Churchill Livingstone, —70,,—9. Ravel R. Clinical laboratory medicine: clinical application of laboratory data. Louis: Mosby, —6, Bigos SJ, et al. Acute low back problems in adults. Rockville, Md. Kyle RA. The monoclonal gammopathies. Clin Chem. Sequence of testing for monoclonal gammopathies. Arch Pathol Lab Med. George ED, Sadovsky R.
Am Fam Physician. Retrospective cohort study of patients with polyclonal gammopathy.
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Mayo Clin Proc. Wallach JB. Interpretation of diagnostic tests. Differential diagnosis of monoclonal gammopathies. Review of patients with newly diagnosed multiple myeloma. Mayo Clinic Proc. Boccadoro M, Pileri A. Diagnosis, prognosis, and standard treatment of multiple myeloma. Hematol Oncol Clin North Am. A long-term study of prognosis in monoclonal gammopathy of undetermined significance. N Engl J Med. This content is owned by the AAFP. High levels are seen in type II hypercholesterolaemia , hypertriglyceridemia , and in the nephrotic syndrome. Transferrin and beta-lipoprotein LDL comprises the beta Increased beta-1 protein due to the increased level of free transferrin is typical of iron deficiency anemia , pregnancy , and oestrogen therapy.
Increased beta-1 protein due to LDL elevation occurs in hypercholesterolemia. Decreased beta-1 protein occurs in acute or chronic inflammation. Beta-2 comprises C3 complement protein 3.
It is raised in the acute phase response. Depression of C3 occurs in autoimmune disorders as the complement system is activated and the C3 becomes bound to immune complexes and removed from serum. Fibrinogen, a beta-2 protein, is found in normal plasma but absent in normal serum. Occasionally, blood drawn from heparinized patients does not fully clot, resulting in a visible fibrinogen band between the beta and gamma globulins. Fibrinogen from plasma samples will be seen in the beta gamma region.
The immunoglobulins or antibodies are generally the only proteins present in the normal gamma region. Of note, any protein migrating in the gamma region will be stained and appear on the gel, which may include protein contaminants, artifacts, or certain medications. Depending on whether an agarose or capillary method is used, interferences vary. A normal gamma zone should appear as a smooth 'blush', or smear, with no asymmetry or sharp peaks. Note that immunoglobulins may also be found in other zones; IgA typically migrates in the beta-gamma zone, and in particular, pathogenic immunoglobulins may migrate anywhere, including the alpha regions.
Hypogammaglobulinaemia is easily identifiable as a "slump" or decrease in the gamma zone. It is normal in infants.
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It is found in patients with X-linked agammaglobulinemia. IgA deficiency occurs in of the population, as is suggested by a pallor in the gamma zone. Of note, hypogammaglobulinema may be seen in the context of MGUS or multiple myeloma. If the gamma zone shows an increase the first step in interpretation is to establish if the region is narrow or wide. A broad "swell-like" manner wide indicates polyclonal immunoglobulin production. If it is elevated in an asymmetric manner or with one or more peaks or narrow "spikes" it could indicate clonal production of one or more immunoglobulins, .
Polyclonal gammopathy is indicated by a "swell-like" elevation in the gamma zone, which typically indicates a non-neoplastic condition although is not exclusive to non-neoplastic conditions. The most common causes of polyclonal hypergammaglobulinaemia detected by electrophoresis are severe infection , chronic liver disease, rheumatoid arthritis, systemic lupus erythematosus and other connective tissue diseases.
A narrow spike is suggestive of a monoclonal gammopathy, also known as a restricted band, or "M-spike". Lysozyme may be seen as a band cathodal to gamma in myelomonocytic leukaemia in which it is released from tumour cells. From Wikipedia, the free encyclopedia. Clinical Applications of Capillary Electrophoresis.
What Does It Mean If You Have M Proteins in Your Blood?
Methods in Molecular Medicine. Demos Medical. Clinical Chemistry. Retrieved 1 May Please submit your articles for these issues. Occurrence of double monoclonal bands on protein electrophoresis: An unusual finding. Indian J Hematol Blood Transfus ; Elkins BN. Clinical Chemistry: Theory, Analysis, Correlation. Missouri: Mosby Elsevier; New York: Demos Medical Publishing; Tripathy S.
The role of serum protein electrophoresis in the detection of multiple myeloma: An experience of a corporate hospital. J Clin Diagn Res ;