Real world test characteristics of mass spectrometry monoclonal protein monitoring in multiple myeloma

Abstract

Abstract Introduction Matrix assisted laser desorption ionization time of flight mass spectrometry (MALDI-TOF MS, mass fix) represents a sensitive and specific alternative to electrophoresis and immunofixation for quantifying monoclonal antibodies in patients with multiple myeloma (MM). Here we report real world data utilizing mass fix and compare its test characteristics to a gold standard of minimal residual disease (MRD) quantification utilizing next generation sequencing (NGS). Results All patients who had obtained mass fix and MRD testing by NGS as part of routine clinical care at Mayo Clinic Arizona were screened for this study. In total, 343 pairs of mass fix and NGS testing within 50 days of each other representing 269 unique patients with secretory multiple myeloma were included. Cases of IgD myeloma and those secreting only free light chains were excluded. The threshold of MRD negativity was set at <1x10-6(less than one malignant cell in one million) and was assessed utilizing the clonoSEQ NGS assay. The median age of our cohort is 67, it is 44% female, and primarily Caucasian (88%) with a median follow-up of 7.3 months from testing date. FISH testing was performed in 96% of patients and at least one high risk cytogenetic abnormality (t(4;14), t(14;16), del(17p)) was found in 23% of patients. The t(11;14) translocation was found in 18%, +1q in 26%, and amp(1q) in 6% of evaluated patients. Notably, patients at all stages of treatment or disease status were included in our study. Induction treatment for newly diagnosed MM (NDMM, 133 patients) was mostly daratumumab-containing quadruplet (63%) or triplet drug regimens (36%). Autologous stem cell transplant (ASCT) was performed in 79% of NDMM and 80% of relapsed refractory MM patients (RRMM, 138 patients). Of the RRMM patients, 94% were triple class exposed and 41% were penta-exposed. Overall agreement between NGS and mass fix results was 65% (Kappa statistic: 0.31, 95% CI: 0.22 – 0.41). Most discordant cases were instances of mass fix negativity and NGS positivity (n = 89, 26% of all testing pairs). Only 7% of cases (n= 30) represented mass fix positivity with NGS negativity. Mass fix was able to define therapeutic monoclonal antibody by its unique mass spectrometric profile in 38 of the total test pairs that otherwise would have been considered disease associated. Of the 30 patients testing mass fix positive and NGS negative, 25 (83%) represent post-treatment evaluations. Thus, ongoing mass fix positivity represents monoclonal protein washout kinetics. All of these cases are noted to have declining mass fix levels at last follow up and 40% had undetectable monoclonal protein. The discordant mass fix negative and NGS positive cases were evenly distributed across NDMM and RRMM representing 32% and 20% of test pairs in each group, respectively. Amongst these 89 total test pairs, the median abundance of malignant clone by NGS was 10 cells per million (range 0.06 to 297,895). This is in contrast to 136 concordantly positive test pairs where the median was 2960 cells per million (range 0.353 to 1,017,360). The median monoclonal protein identified (in those with a quantifiable M-spike) was 0.30 g/dL. Receiver operating characteristic curves using NGS as gold standard found the optimal mass fix threshold to be 0.010g/dL (specificity 95%, sensitivity 51%) for NDMM patients and 0.046g/dL (specificity 84%, sensitivity 55%) in RRMM patients. Conclusions Development of a MRD assay based on peripheral blood sampling could greatly improve the ease and speed of obtaining these assessments. Our experience highlights both the great potential and need to identify appropriate clinical contexts for optimal use of mass fix MRD assessment. A significant limitation of our data is that low level monoclonal proteins without a previous reference above a threshold of 20mg/dL are not reported as positive and may account for a significant fraction of discordant cases reported here. All clonoSEQ NGS samples are referenced to a positive control greatly increasing specificity. The currently reported dataset is biased against mass fix as not all test pairs reported are known to have a positive reference. Further delineation of these cases is forthcoming. Previous reports have also noted that mass fix test characteristics can improve with time from treatment which will be assessed with future follow-up.