Abstract
Serum-free light chain (SFLC) levels are useful for diagnosing nonsecretory myeloma and monitoring response in light-chain–only disease, especially in the presence of renal failure. As part of a tandem autotransplantation trial for newly diagnosed multiple myeloma, SFLC levels were measured at baseline, within 7 days of starting the first cycle, and before both the second induction cycle and the first transplantation. SFLC baseline levels higher than 75 mg/dL (top tertile) identified 33% of 301 patients with higher near-complete response rate (n-CR) to induction therapy (37% vs 20%,
P
= .002) yet inferior 24-month overall survival (OS: 76% vs 91%,
P
< .001) and event-free survival (EFS: 73% vs 90%,
P
< .001), retaining independent prognostic significance for both EFS (HR = 2.40,
P
= .008) and OS (HR = 2.43,
P
= .016). Baseline SFLC higher than 75 mg/dL was associated with light-chain–only secretion (
P
< .001), creatinine level 176.8 μM (2 mg/dL) or higher (
P
< .001), beta-2-microglobulin 297.5 nM/L (3.5 mg/L) or higher (
P
< .001), lactate dehydrogenase 190 U/L or higher (
P
< .001), and bone marrow plasmacytosis higher than 30% (
P
= .003). Additional independent adverse implications were conferred by top-tertile SFLC reductions before cycle 2 (OS: HR = 2.97,
P
= .003; EFS: HR = 2.56,
P
= .003) and before transplantation (OS: HR = 3.31,
P
= .001; EFS: HR = 2.65,
P
= .003). Unlike baseline and follow-up analyses of serum and urine M-proteins, high SFLC levels at baseline—reflecting more aggressive disease—and steeper reductions after therapy identified patients with inferior survival.