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Durot E, Roos-Weil D, Chauchet A, Decroocq J, Di Blasi R, Gastinne T, Bensaber H, Cheminant M, Jacquet C, Guidez S, Gros FX, Bachy E, Coste A, Cony-Makhoul P, Treon SP, Delmer A, Reshef R, Le Gouill S, Castillo JJ, Houot R. High efficacy of CD19 CAR T cells in patients with transformed Waldenström macroglobulinemia. Blood 2024; 143:2804-2807. [PMID: 38669635 DOI: 10.1182/blood.2024024452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 03/27/2024] [Accepted: 04/08/2024] [Indexed: 04/28/2024] Open
Abstract
ABSTRACT Histologic transformation of Waldenström macroglobulinemia (HT-WM) carries a poor prognosis with standard treatments. Here, we report the first series of HT-WM treated with chimeric antigen receptor T cells showing a high efficacy and no unexpected toxicity.
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Affiliation(s)
- Eric Durot
- Department of Hematology, University Hospital of Reims, Reims, France
| | - Damien Roos-Weil
- Sorbonne Université, Hematology, Pitié-Salpêtrière Hospital, Paris, France
| | - Adrien Chauchet
- Department of Hematology, University Hospital of Besançon, Besançon, France
| | | | | | - Thomas Gastinne
- Department of Hematology, University Hospital of Nantes, Nantes, France
| | - Hedi Bensaber
- Department of Hematology, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | | | - Caroline Jacquet
- Department of Hematology, University Hospital of Nancy, Nancy, France
| | - Stéphanie Guidez
- Department of Hematology, University Hospital of Poitiers, Poitiers, France
| | | | - Emmanuel Bachy
- Department of Hematology, Hospices Civils de Lyon, Pierre Bénite, Lyon, France
| | - Arthur Coste
- Department of Hematology, University Hospital of Reims, Reims, France
| | - Pascale Cony-Makhoul
- Medical and Scientific Department, Lymphoma Academic Research Organisation, Hôpital Lyon-Sud, Pierre-Bénite, France
| | - Steven P Treon
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Alain Delmer
- Department of Hematology, University Hospital of Reims, Reims, France
| | - Ran Reshef
- Division of Hematology/Oncology and Columbia Center for Translational Immunology, Columbia University Irving Medical Center, New York, NY
| | | | - Jorge J Castillo
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Roch Houot
- Department of Hematology, University Hospital of Rennes, Rennes, France
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2
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Negara I, Tomuleasa C, Buruiana S, Efremov DG. Molecular Subtypes and the Role of TP53 in Diffuse Large B-Cell Lymphoma and Richter Syndrome. Cancers (Basel) 2024; 16:2170. [PMID: 38927876 PMCID: PMC11201917 DOI: 10.3390/cancers16122170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 05/30/2024] [Accepted: 06/01/2024] [Indexed: 06/28/2024] Open
Abstract
Diffuse large B-cell lymphoma (DLBCL) is the most common lymphoid malignancy and a heterogeneous entity comprised of several biologically distinct subtypes. Recently, novel genetic classifications of DLBCL have been resolved based on common mutational patterns indicative of distinct pathways of transformation. However, the complicated and costly nature of the novel classifiers has precluded their inclusion into routine practice. In view of this, the status of the TP53 gene, which is mutated or deleted in 20-30% of the cases, has emerged as an important prognostic factor for DLBCL patients, setting itself apart from other predictors. TP53 genetic lesions are particularly enriched in a genetic subtype of DLBCL that shares genomic features with Richter Syndrome, highlighting the possibility of a subset of DLBCL arising from the transformation of an occult chronic lymphocytic leukemia-like malignancy, such as monoclonal B-cell lymphocytosis. Patients with TP53-mutated DLBCL, including those with Richter Syndrome, have a particularly poor prognosis and display inferior responses to standard chemoimmunotherapy regimens. The data presented in this manuscript argue for the need for improved and more practical risk-stratification models for patients with DLBCL and show the potential for the use of TP53 mutational status for prognostication and, in prospect, treatment stratification in DLBCL.
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Affiliation(s)
- Ivan Negara
- Molecular Hematology Unit, International Centre for Genetic Engineering and Biotechnology, 34149 Trieste, Italy
- Department of Internal Medicine, Hematology, “Nicolae Testemitanu” State University of Medicine and Pharmacy, 2004 Chisinau, Moldova;
| | - Ciprian Tomuleasa
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, 400347 Cluj-Napoca, Romania;
| | - Sanda Buruiana
- Department of Internal Medicine, Hematology, “Nicolae Testemitanu” State University of Medicine and Pharmacy, 2004 Chisinau, Moldova;
| | - Dimitar G. Efremov
- Molecular Hematology Unit, International Centre for Genetic Engineering and Biotechnology, 34149 Trieste, Italy
- Macedonian Academy of Sciences and Arts, 1000 Skopje, North Macedonia
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3
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Chen H, Zhao D, Wang Z, Zhang W, Wang W. Clonally related transformation from Waldenström macroglobulinemia to diffuse large B-cell lymphoma with central nervous system involvement at diagnosis: a case report and literature review. Clin Exp Med 2023; 23:5473-5476. [PMID: 37921873 DOI: 10.1007/s10238-023-01245-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 10/26/2023] [Indexed: 11/05/2023]
Abstract
Histological transformation to diffuse large B-cell lymphoma (DLBCL) rarely occurs in patients with Waldenström macroglobulinemia (WM). The median time from WM diagnosis to DLBCL is 4-5 years. Extranodal involvement is common in transformed WM. However, central nervous system (CNS) involvement is relatively uncommon. Here, we report a case of a simultaneous diagnosis of WM and clonally related DLBCL, with the involvement of CNS demonstrated by dual enhancement in MRI. Nevertheless, it is unclear if CNS infiltration is caused by DLBCL or WM for the inaccessibility of brain biopsy. Intensified chemotherapy and Bruton tyrosine kinase inhibitor were administrated, and a good response was achieved.Please check the edit made in the article title.we have checked it.
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Affiliation(s)
- Hongyun Chen
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Danqing Zhao
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Zi Wang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Wei Zhang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Wei Wang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
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4
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Parry EM, Roulland S, Okosun J. DLBCL arising from indolent lymphomas: How are they different? Semin Hematol 2023; 60:277-284. [PMID: 38072721 DOI: 10.1053/j.seminhematol.2023.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 11/10/2023] [Accepted: 11/16/2023] [Indexed: 03/12/2024]
Abstract
Transformation to diffuse large B-cell lymphoma (DLBCL) is a recognized, but unpredictable, clinical inflection point in the natural history of indolent lymphomas. Large retrospective studies highlight a wide variability in the incidence of transformation across the indolent lymphomas and the adverse outcomes associated with transformed lymphomas. Opportunities to dissect the biology of transformed indolent lymphomas have arisen with evolving technologies and unique tissue collections enabling a growing appreciation, particularly, of their genetic basis, how they relate to the preceding indolent lymphomas and the comparative biology with de novo DLBCL. This review summarizes our current understanding of both the clinical and biological aspects of transformed lymphomas and the outstanding questions that remain.
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Affiliation(s)
- Erin M Parry
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; Harvard Medical School, Boston, MA; Broad Institute of MIT and Harvard, Cambridge, MA
| | - Sandrine Roulland
- Aix-Marseille University, CNRS, INSERM, Centre d'Immunologie de Marseille-Luminy, Marseille, France
| | - Jessica Okosun
- Centre for Haemato-Oncology, Barts Cancer Institute, Queen Mary University of London, London, UK; Department of Haemato-Oncology, St Bartholomew's Hospital, London, UK.
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5
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Berendsen MR, van Bladel DA, Hesius E, Berganza Irusquieta C, Rijntjes J, van Spriel AB, van der Spek E, Pruijt JF, Kroeze LI, Hebeda KM, Croockewit S, Stevens WB, van Krieken JHJ, Groenen PJ, van den Brand M, Scheijen B. Clonal Relationship and Mutation Analysis in Lymphoplasmacytic Lymphoma/Waldenström Macroglobulinemia Associated With Diffuse Large B-cell Lymphoma. Hemasphere 2023; 7:e976. [PMID: 37928625 PMCID: PMC10621888 DOI: 10.1097/hs9.0000000000000976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 09/21/2023] [Indexed: 11/07/2023] Open
Abstract
Patients with lymphoplasmacytic lymphoma/Waldenström macroglobulinemia (LPL/WM) occasionally develop diffuse large B-cell lymphoma (DLBCL). This mostly results from LPL/WM transformation, although clonally unrelated DLBCL can also arise. LPL/WM is characterized by activating MYD88L265P (>95%) and CXCR4 mutations (~30%), but the genetic drivers of transformation remain to be identified. Here, in thirteen LPL/WM patients who developed DLBCL, the clonal relationship of LPL and DLBCL together with mutations contributing to transformation were investigated. In 2 LPL/WM patients (15%), high-throughput sequencing of immunoglobulin gene rearrangements showed evidence of >1 clonal B-cell population in LPL tissue biopsies. In the majority of LPL/WM patients, DLBCL presentations were clonally related to the dominant clone in LPL, providing evidence of transformation. However, in 3 patients (23%), DLBCL was clonally unrelated to the major malignant B-cell clone in LPL, of which 2 patients developed de novo DLBCL. In this study cohort, LPL displayed MYD88L265P mutation in 8 out of eleven patients analyzed (73%), while CXCR4 mutations were observed in 6 cases (55%). MYD88WT LPL biopsies present in 3 patients (27%) were characterized by CD79B and TNFAIP3 mutations. Upon transformation, DLBCL acquired novel mutations targeting BTG1, BTG2, CD79B, CARD11, TP53, and PIM1. Together, we demonstrate variable clonal B-cell dynamics in LPL/WM patients developing DLBCL, and the occurrence of clonally unrelated DLBCL in about one-quarter of LPL/WM patients. Moreover, we identified commonly mutated genes upon DLBCL transformation, which together with preserved mutations already present in LPL characterize the mutational landscape of DLBCL occurrences in LPL/WM patients.
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Affiliation(s)
| | - Diede A.G. van Bladel
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Eva Hesius
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Jos Rijntjes
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Annemiek B. van Spriel
- Department of Medical BioSciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Johannes F.M. Pruijt
- Department of Hematology, Jeroen Bosch Hospital, ‘s-Hertogenbosch, The Netherlands
| | - Leonie I. Kroeze
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Konnie M. Hebeda
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sandra Croockewit
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Wendy B.C. Stevens
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | | | | | - Blanca Scheijen
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
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6
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Zanwar S, Abeykoon JP, Ansell SM, Gertz MA, Mauermann M, Witzig TE, Johnston P, Kyle RA, King RL, Habermann TM, Kumar S, Kapoor P. Central nervous system involvement (Bing-Neel Syndrome) in patients with Waldenström macroglobulinemia. Leuk Lymphoma 2023; 64:1490-1493. [PMID: 37300306 DOI: 10.1080/10428194.2023.2214026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 03/15/2023] [Accepted: 03/21/2023] [Indexed: 06/12/2023]
Affiliation(s)
- Saurabh Zanwar
- Division of Hematology, Department of Internal Medicine, Rochester, MN, USA
| | - Jithma P Abeykoon
- Division of Hematology, Department of Internal Medicine, Rochester, MN, USA
| | - Stephen M Ansell
- Division of Hematology, Department of Internal Medicine, Rochester, MN, USA
| | - Morie A Gertz
- Division of Hematology, Department of Internal Medicine, Rochester, MN, USA
| | | | - Thomas E Witzig
- Division of Hematology, Department of Internal Medicine, Rochester, MN, USA
| | - Patrick Johnston
- Division of Hematology, Department of Internal Medicine, Rochester, MN, USA
| | - Robert A Kyle
- Division of Hematology, Department of Internal Medicine, Rochester, MN, USA
| | - Rebecca L King
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Thomas M Habermann
- Division of Hematology, Department of Internal Medicine, Rochester, MN, USA
| | - Shaji Kumar
- Division of Hematology, Department of Internal Medicine, Rochester, MN, USA
| | - Prashant Kapoor
- Division of Hematology, Department of Internal Medicine, Rochester, MN, USA
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7
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Talaulikar D, Tomowiak C, Toussaint E, Morel P, Kapoor P, Castillo JJ, Delmer A, Durot E. Evaluation and Management of Disease Transformation in Waldenström Macroglobulinemia. Hematol Oncol Clin North Am 2023:S0889-8588(23)00043-6. [PMID: 37246087 DOI: 10.1016/j.hoc.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Histologic transformation (HT) to diffuse large B-cell lymphoma occurs rarely in Waldenström macroglobulinemia, with higher incidence in MYD88 wild-type patients. HT is suspected clinically when rapidly enlarging lymph nodes, elevated lactate dehydrogenase levels, or extranodal disease occur. Histologic assessment is required for diagnosis. HT carries a worse prognosis compared with nontransformed Waldenström macroglobulinemia. A validated prognostic score based on three adverse risk factors stratifies three risk groups. The most common frontline treatment is chemoimmunotherapy, such as R-CHOP. Central nervous system prophylaxis should be considered if feasible and consolidation with autologous transplant should be discussed in fit patients responding to chemoimmunotherapy.
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Affiliation(s)
- Dipti Talaulikar
- Department of Hematology, Canberra Health Services, Canberra, Australian Capital Territory, Australia; College of Health and Medicine, Australian National University, Canberra, Australian Capital Territory, Australia.
| | - Cécile Tomowiak
- Hematology Department and Centre d'Investigations Cliniques (CIC) 1082 INSERM, University Hospital, Poitiers, France
| | - Elise Toussaint
- Department of Hematology, Institut de Cancérologie Strasbourg Europe (ICANS), Strasbourg, France
| | - Pierre Morel
- Department of Hematology, University Hospital of Amiens, Amiens, France
| | - Prashant Kapoor
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jorge J Castillo
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Alain Delmer
- Department of Hematology, University Hospital of Reims and UFR Médecine, Reims, France
| | - Eric Durot
- Department of Hematology, University Hospital of Reims and UFR Médecine, Reims, France
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8
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Cook JR, Amador C, Czader M, Duffield A, Goodlad J, Ott G, Xiao W, Dave S, Thakkar D, Thacker E, Dogan A, Wasik M, Nejati R. Transformations of marginal zone lymphomas and lymphoplasmacytic lymphomas: Report from the 2021 SH/EAHP Workshop. Am J Clin Pathol 2023:7143713. [PMID: 37186259 DOI: 10.1093/ajcp/aqad034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 03/10/2023] [Indexed: 05/17/2023] Open
Abstract
OBJECTIVES To summarize the conclusions of the 2021 Society for Hematopathology/European Association for Haematopathology workshop regarding transformations of marginal zone lymphoma (MZL) and lymphoplasmacytic lymphoma (LPL). METHODS Nineteen cases were submitted to this portion of the workshop. Additional studies were performed in cases with sufficient material. RESULTS Cases included splenic MZL (n = 4), splenic diffuse red pulp small B-cell lymphoma (n = 2), nodal MZL (n = 4), extranodal MZL (n = 1), and LPL (n = 8). The most common transformation was to diffuse large B-cell lymphoma (DLBCL), but others included classic Hodgkin lymphoma, high-grade B-cell lymphomas with MYC and BCL6 rearrangements, plasmablastic lymphoma, and plasma cell leukemia. Two splenic MZLs with transformation to DLBCL contained t(14;19)(q32;q13.3) IGH::BCL3 rearrangements in both samples. Paired sequencing studies in 5 MZLs with transformation to clonally related DLBCL identified a variety of mutations and gene fusions at the time of transformation, including CARD11, IGH::MYC, NOTCH2, P2RY8, TBLX1X1, and IGH::CD274. CONCLUSIONS Marginal zone lymphoma and LPL may undergo a variety of transformation events, most commonly to DLBCL, which is usually, although not always, directly clonally related to the underlying low-grade lymphoma. Multiparameter analysis including broad-based sequencing studies can assist in the diagnosis and classification of these uncommon cases.
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Affiliation(s)
- James R Cook
- Department of Laboratory Medicine, Robert J. Tomisch Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, US
| | - Catalina Amador
- Department of Pathology and Laboratory Medicine, University of Miami Miller School of Medicine, Miami, FL, US
| | - Magdalena Czader
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, US
| | - Amy Duffield
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Medical Center, New York, NY, US
| | - John Goodlad
- Department of Pathology, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - German Ott
- Department of Clinical Pathology, Robert-Borsch-Krankenhaus, and Dr. Margarete Fischer-Bosch Institute for Clinical Pharmacology, Stuttgart, Germany
| | - Wenbin Xiao
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Medical Center, New York, NY, US
| | - Sandeep Dave
- Duke University School of Medicine, Durham, NC, US
| | | | | | - Ahmet Dogan
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Medical Center, New York, NY, US
| | - Mariusz Wasik
- Department of Pathology, Fox Chase Cancer Center, Philadelphia, PA, US
| | - Reza Nejati
- Department of Pathology, Fox Chase Cancer Center, Philadelphia, PA, US
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9
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Zhu J, Zhu X, Xie F, Ding Y, Lu H, Dong Y, Li P, Fu J, Liang A, Zeng Y, Xiu B. Case report: Circulating tumor DNA technology displays temporal and spatial heterogeneity in Waldenström macroglobulinemia during treatment with BTK inhibitors. Pathol Oncol Res 2023; 29:1611070. [PMID: 37151353 PMCID: PMC10154527 DOI: 10.3389/pore.2023.1611070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 04/06/2023] [Indexed: 05/09/2023]
Abstract
Background: Waldenström macroglobulinemia (WM) is a rare subtype of B-cell lymphoma. Rituximab-based combination therapy and Bruton's tyrosine kinase (BTK) inhibitors have greatly improved the prognosis of WM. Despite the high response rate and good tolerance of BTK inhibitors in treatment of WM, a proportion of patients still experience disease progression. Case presentation: We report a 55-year-old man with relapsed WM. The patient achieved partial remission after six courses of CHOP chemotherapy and multiple plasma exchanges in initial treatment. He was admitted to the hospital with abdominal distension, and was diagnosed with relapsed WM and subsequently started on zanubrutinib. Disease progression and histological transformation occurred during treatment. We performed liquid biopsies on transformed plasma, tumor tissue and ascites at the same time and found high consistency between ascites and tissues. Moreover, we detected resistance mutations of BTK inhibitors (BTK, PLCG2) in ascites that were not detected in plasma or tissue. Eventually, the patient died during the 15-month follow-up after relapse. Conclusion: We describe a rare case of WM transformation to DLCBCL treated with chemoimmunotherapy and BTK inhibition. We analyzed tumor DNA obtained at different anatomic sites and circulating tumor DNA (ctDNA) derived from plasma and ascites specimens, with apparent significant temporal and spatial heterogeneity. The case specifically highlights the clinical value of ctDNA of ascites supernatant from WM patients, which is a more convenient and relatively noninvasive method compared with traditional invasive tissue biopsy.
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Affiliation(s)
- Jingjing Zhu
- Department of Hematology, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xinyu Zhu
- Department of Hematology, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Fengyang Xie
- Department of Hematology, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yi Ding
- Department of Hematology, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Huina Lu
- Department of Hematology, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yan Dong
- Department of Hematology, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ping Li
- Department of Hematology, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jianfei Fu
- Department of Hematology, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Aibin Liang
- Department of Hematology, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yu Zeng
- Department of Pathology, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
- *Correspondence: Yu Zeng, ; Bing Xiu,
| | - Bing Xiu
- Department of Hematology, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
- *Correspondence: Yu Zeng, ; Bing Xiu,
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10
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Muacevic A, Adler JR, Wojkiewicz S, Khandpur B, Downes E, Pathare P, Frank R. Transformed Waldenström Macroglobulinemia Responsive to Tafasitamab Plus Lenalidomide: A Case Report. Cureus 2022; 14:e32403. [PMID: 36636536 PMCID: PMC9831276 DOI: 10.7759/cureus.32403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2022] [Indexed: 12/14/2022] Open
Abstract
The histologic transformation (HT) of Waldenström macroglobulinemia (WM) into diffuse large-cell lymphoma is an uncommon but poor-prognostic event for which there is no standard therapy. Knowledge of this entity is mainly derived from largely retrospective studies, which report abysmal average survival rates even with the utilization of first-line chemoimmunotherapy and especially in patients who meet the high-risk criteria based on prognostic indices used for WM. We present the case of a 75-year-old man with high-risk, transformed WM who was ineligible for standard chemoimmunotherapy (due to pancytopenia and multiple comorbidities) and was consequently treated with tafasitabmab, an anti-CD19 monoclonal antibody plus lenalidomide. Tafasitamab plus lenalidomide (TAF/LEN) is a recently approved therapy for relapsed or refractory de novo diffuse large-cell lymphoma (DLCL) but has not been previously studied in transformed low-grade lymphomas or WM. We show that TAF/LEN resulted in a complete and durable response of the DLCL by PET/CT and a complete bone marrow response of lymphoplasmacytoid cells, including the normalization of complex cytogenetic abnormalities. The extraordinary response of our patient to TAF/LEN suggests that this combination may be an effective and tolerable therapy for transformed WM as well as relapsed or refractory non-transformed WM. Clinical trials of TAF/LN for the treatment of Waldenström macroglobulinemia are recommended.
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11
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Transformed Waldenström Macroglobulinemia: Update on Diagnosis, Prognosis and Treatment. HEMATO 2022. [DOI: 10.3390/hemato3040044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Histological transformation (HT) to an aggressive lymphoma results from a rare evolution of Waldenström macroglobulinemia (WM). A higher incidence of transformation events has been reported in MYD88 wild-type WM patients. HT in WM can be histologically heterogeneous, although the diffuse large B-cell lymphoma of activated B-cell subtype is the predominant pathologic entity. The pathophysiology of HT is largely unknown. The clinical suspicion of HT is based on physical deterioration and the rapid enlargement of the lymph nodes in WM patients. Most transformed WM patients present with elevated serum lactate dehydrogenase (LDH) and extranodal disease. A histologic confirmation regarding the transformation to a higher-grade lymphoma is mandatory for the diagnosis of HT, and the choice of the biopsy site may be dictated by the findings of the 18fluorodeoxyglucose-positron emission tomography/computed tomography. The prognosis of HT in WM is unfavorable, with a significantly inferior outcome compared to WM patients without HT. A validated prognostic score based on 3 adverse risk factors (elevated LDH, platelet count < 100 × 109/L and any previous treatment for WM) stratifies patients into 3 risk groups. The most common initial treatment used is a chemo-immunotherapy (CIT), such as R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone). The response duration is short and central nervous system relapses are frequent. Whether autologous stem cell transplantation could benefit fit patients responding to CIT remains to be studied.
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12
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Huang WY, Weng ZY. Occurrence of MYD88L265P and CD79B mutations in diffuse large b cell lymphoma with bone marrow infiltration: A case report. World J Clin Cases 2022; 10:7994-8002. [PMID: 36158496 PMCID: PMC9372833 DOI: 10.12998/wjcc.v10.i22.7994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 05/18/2022] [Accepted: 06/26/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Over the past 20 years, we have gained a deep understanding of the biological heterogeneity of diffuse large B cell lymphoma (DLBCL) and have developed a range of new treatment programs based on the characteristics of the disease, bringing us to the era of immune-chemotherapy. However, the effectiveness and molecular mechanisms of targeted-immunotherapy remain unclear in DLBCL. Targeted-immunotherapy may be beneficial for specific subgroups of patients, thus requiring biomarker assessment.
CASE SUMMARY Here, we report a case of MCD subtype DLBCL with MYD88L265P and CD79B mutations, considered in the initial stage as lymphoplasmic lymphoma (LPL) or Waldenstrom macroglobulinemia (WM). Flow cytometry supported this view; however, the immunohistochemical results of the lymph nodes overturned the above diagnosis, and the patient was eventually diagnosed with MCD subtype DLBCL. The presence of a monoclonal IgM component in the serum and infiltration of small lymphocytes with a phenotype compatible with WM into the bone marrow led us to propose a hypothesis that the case we report may have transformed from LPL/WM.
CONCLUSION This highlights the possible transformation from WM to DLBCL, CD79B mutation may be a potential biomarker for predicting this conversion.
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Affiliation(s)
- Wen-Ye Huang
- Department of Hematology, The Affiliated Yueqing Hospital of Wenzhou Medical University, Yueqing 325600, Zhejiang Province, China
| | - Zhi-Yun Weng
- Department of Hematology, The Affiliated Yueqing Hospital of Wenzhou Medical University, Yueqing 325600, Zhejiang Province, China
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13
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Kline KAF, Lee ST, Law JY, Kallen M. Waldenstrom macroglobulinemia and simultaneous intravascular large B-cell lymphoma: Rare transformation or unhappy coincidence? CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:e788-e791. [PMID: 35525836 DOI: 10.1016/j.clml.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 04/07/2022] [Indexed: 06/14/2023]
Affiliation(s)
- Kathryn A F Kline
- University of Maryland Greenebaum Comprehensive Cancer Center, 22 S. Greene Street, S9D10, Baltimore, MD 21201-1995, USA.
| | - Seung Tae Lee
- University of Maryland Greenebaum Comprehensive Cancer Center, 22 S. Greene Street, S9D10, Baltimore, MD 21201-1995, USA; Division of Hematology/Oncology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jennie Y Law
- University of Maryland Greenebaum Comprehensive Cancer Center, 22 S. Greene Street, S9D10, Baltimore, MD 21201-1995, USA; Division of Hematology/Oncology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Michael Kallen
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
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14
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Zanwar S, Abeykoon JP. Treatment paradigm in Waldenström macroglobulinemia: frontline therapy and beyond. Ther Adv Hematol 2022; 13:20406207221093962. [PMID: 35510210 PMCID: PMC9058343 DOI: 10.1177/20406207221093962] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 03/28/2022] [Indexed: 01/11/2023] Open
Abstract
Waldenström macroglobulinemia (WM) is an indolent lymphoplasmacytic lymphoma. Recent strides made in the genomic profiling of patients with WM have led to the identification of many novel therapeutic targets. Patients with WM can present with asymptomatic disease and not all patients require treatment. When criteria for initiating systemic therapy are met, the choice of therapy depends on the tumor genotype (MYD88 and CXCR4 mutation status), patient preference (fixed versus continuous duration therapy, oral versus intravenous route, cost), associated medical comorbidities, and adverse effect profile of the treatment. In the absence of head-to-head comparison between chemoimmunotherapy and Bruton’s tyrosine kinase inhibitors in otherwise fit patients with a MYD88L265P mutation, our preference is fixed duration therapy with four to six cycles of chemoimmunotherapy with bendamustine–rituximab. In this review, we discuss the role of MYD88 and CXCR4 mutation in treatment selection, and current data for frontline and salvage treatment options in patients with WM.
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15
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Elessa D, Debureaux PE, Villesuzanne C, Davi F, Bravetti C, Harel S, Talbot A, Oksenhendler E, Malphettes M, Thieblemont C, Moatti H, Maarek O, Arnulf B, Royer B. Inflammatory Waldenström's macroglobulinaemia: A French monocentric retrospective study of 67 patients. Br J Haematol 2022; 197:728-735. [PMID: 35393650 DOI: 10.1111/bjh.18157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 02/23/2022] [Accepted: 03/11/2022] [Indexed: 11/30/2022]
Abstract
Waldenström's macroglobulinaemia (WM) is a B-cell neoplasm resulting from bone marrow lymphoplasmacytic infiltration and monoclonal IgM secretion. Some patients present concomitant inflammatory syndrome attributed to the disease activity; we named this syndrome inflammatory WM (IWM). We retrospectively analysed all WM patients seen in a single tertiary referral centre from January 2007 to May 2021, and after excluding aetiologies for the inflammatory syndrome using a pertinent blood workup, including C-reactive protein (CRP), and imaging, we identified 67 (28%) IWM, 166 (68%) non-IWM, and nine (4%) WM with inflammatory syndrome of unknown origin. At treatment initiation, IWM patients had more severe anaemia (median Hb 90 vs 99 g/l; p < 0.01), higher platelet count (median 245 vs 196 × 109/l; p < 0.01) and comparable serum IgM level (median 24.9 vs 23.0 g/l; p = 0.28). A positive correlation was found between inflammatory and haematological responses (minimal response or better) (odds ratio 32.08; 95% confidence interval 8.80-98.03; p < 0.001). Overall survivals (OS) were similar (median OS: 17 vs 20 years; p = 0.11) but time to next treatment (TNT) was significantly shorter for IWM (TNT1: 1.6 vs 4.8 years, p < 0.0001). IWM mostly shared the same presentation and outcome as WM without inflammatory syndrome.
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Affiliation(s)
- Dikelele Elessa
- Department of Immuno Haematology, Hopital Saint-Louis, Assistance Publique Hôpitaux de Paris, Paris, France.,University of Paris, Paris, France
| | - Pierre-Edouard Debureaux
- Department of Immuno Haematology, Hopital Saint-Louis, Assistance Publique Hôpitaux de Paris, Paris, France.,University of Paris, Paris, France
| | - Camille Villesuzanne
- Department of Immuno Haematology, Hopital Saint-Louis, Assistance Publique Hôpitaux de Paris, Paris, France.,University of Paris, Paris, France
| | - Frederic Davi
- Laboratory of Haematology, Hopital Pitie-Salpetriere, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Clotilde Bravetti
- Laboratory of Haematology, Hopital Pitie-Salpetriere, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Stephanie Harel
- Department of Immuno Haematology, Hopital Saint-Louis, Assistance Publique Hôpitaux de Paris, Paris, France.,University of Paris, Paris, France
| | - Alexis Talbot
- Department of Immuno Haematology, Hopital Saint-Louis, Assistance Publique Hôpitaux de Paris, Paris, France.,University of Paris, Paris, France
| | - Eric Oksenhendler
- University of Paris, Paris, France.,Department of Clinical Immunology, Hopital Saint-Louis, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Marion Malphettes
- University of Paris, Paris, France.,Department of Clinical Immunology, Hopital Saint-Louis, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Catherine Thieblemont
- University of Paris, Paris, France.,Department of Haemato-Oncology, Hopital Saint-Louis, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Hannah Moatti
- University of Paris, Paris, France.,Department of Haemato-Oncology, Hopital Saint-Louis, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Odile Maarek
- University of Paris, Paris, France.,Laboratory of Haematology, Hopital Saint-Louis, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Bertrand Arnulf
- Department of Immuno Haematology, Hopital Saint-Louis, Assistance Publique Hôpitaux de Paris, Paris, France.,University of Paris, Paris, France
| | - Bruno Royer
- Department of Immuno Haematology, Hopital Saint-Louis, Assistance Publique Hôpitaux de Paris, Paris, France.,University of Paris, Paris, France
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16
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Pratt G, El-Sharkawi D, Kothari J, D'Sa S, Auer R, McCarthy H, Krishna R, Miles O, Kyriakou C, Owen R. Diagnosis and management of Waldenström macroglobulinaemia-A British Society for Haematology guideline. Br J Haematol 2022; 197:171-187. [PMID: 35020191 DOI: 10.1111/bjh.18036] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 12/23/2021] [Accepted: 12/27/2021] [Indexed: 12/14/2022]
Abstract
SCOPE The objective of this guideline is to provide healthcare professionals with clear guidance on the management of patients with Waldenström macroglobulinaemia. In individual patients, circumstances may dictate an alternative approach. METHODOLOGY This guideline was compiled according to the British Society for Haematology (BSH) process at http://www.b-s-h.org.uk/guidelines/proposing-and-writing-a-new-bsh-guideline/. Recommendations are based on a review of the literature using Medline, Pubmed, Embase, Central, Web of Science searches from beginning of 2013 (since the publication of the previous guidelines) up to November 2021. The following search terms were used: Waldenström('s) macroglobulin(a)emia OR lymphoplasmacytic lymphoma, IgM(-related) neuropathy OR cold h(a)emagglutinin disease OR cold agglutinin disease OR cryoglobulin(a)emia AND (for group a only) cytogenetic OR molecular OR mutation OR MYD88 OR CXCR4, management OR treatment OR transfusion OR supportive care OR plasma exchange OR plasmapheresis OR chemotherapy OR bendamustine OR bortezomib OR ibrutinib OR fludarabine OR dexamethasone OR cyclophosphamide OR rituximab OR everolimus, bone marrow transplantation OR stem cell transplantation. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) nomenclature was used to evaluate levels of evidence and to assess the strength of recommendations. The GRADE criteria can be found at http://www.gradeworkinggroup.org. Review of the manuscript was performed by the British Society for Haematology (BSH) Guidelines Committee Haemato-Oncology Task Force, the BSH Guidelines Committee and the Haemato-Oncology sounding board of BSH. It was also on the members section of the BSH website for comment. It has also been reviewed by UK Charity WMUK; these organisations do not necessarily approve or endorse the contents.
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Affiliation(s)
- Guy Pratt
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Jaimal Kothari
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Shirley D'Sa
- University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Helen McCarthy
- University Hospitals Dorset NHS Foundation Trust, Dorset, UK
| | - Rajesh Krishna
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Oliver Miles
- Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | - Charalampia Kyriakou
- University College London Hospitals NHS Foundation Trust, London, UK
- London North West University Healthcare NHS Trust, London, UK
| | - Roger Owen
- The Leeds Teaching Hospitals NHS Trust, Leeds, UK
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17
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High frequency of central nervous system involvement in transformed Waldenström macroglobulinemia. Blood Adv 2022; 6:3655-3658. [PMID: 35290439 PMCID: PMC9631579 DOI: 10.1182/bloodadvances.2022007331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 02/26/2022] [Indexed: 11/20/2022] Open
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18
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Cingam S, Sidana S. Differential Diagnosis of Waldenström's Macroglobulinemia and Early Management: Perspectives from Clinical Practice. Blood Lymphat Cancer 2022; 12:107-117. [PMID: 36003901 PMCID: PMC9394652 DOI: 10.2147/blctt.s259860] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 07/28/2022] [Indexed: 11/23/2022]
Abstract
Waldenström's Macroglobulinemia (WM) is a clonal B-lymphocyte neoplasm characterized by the presence of IgM monoclonal protein and ≥10% bone marrow involvement with lymphoplasmacytic cells. Several mature B-cell and plasma cell disorders can potentially produce monoclonal IgM immunoglobulin and hence, careful consideration of the differential diagnosis is vital. Clinico-pathological features, immunophenotype, and MYD88 mutation status help distinguish WM from other plasma cell and lymphoproliferative disorders. Treatment is only indicated in patients symptomatic from adenopathy or organomegaly, neuropathy, hyper viscosity, cryoglobulinemia, cold agglutinin disease, cytopenia's or amyloidosis. Alkylators (cyclophosphamide, bendamustine) in combination with anti-CD20 antibodies and novel targeted agents including Bruton tyrosine kinase (BTK) inhibitors like ibrutinib are the mainstay of frontline treatment in symptomatic WM.
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Affiliation(s)
- Shashank Cingam
- Division of Hematology and Oncology, University of New Mexico Comprehensive Cancer Center, Albuquerque, NM, 87102, USA
| | - Surbhi Sidana
- Division of BMT and Cell Therapy, Stanford University School of Medicine, Stanford, CA, 94305, USA
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19
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Durot E, Kanagaratnam L, Zanwar S, Kastritis E, D'Sa S, Garcia-Sanz R, Tomowiak C, Hivert B, Toussaint E, Protin C, Abeykoon JP, Guerrero-Garcia T, Itchaki G, Vos JM, Michallet AS, Godet S, Dupuis J, Leprêtre S, Bomsztyk J, Morel P, Leblond V, Treon SP, Dimopoulos MA, Kapoor P, Delmer A, Castillo JJ. A prognostic index predicting survival in transformed Waldenström macroglobulinemia. Haematologica 2021; 106:2940-2946. [PMID: 33179472 PMCID: PMC8561274 DOI: 10.3324/haematol.2020.262899] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Indexed: 02/06/2023] Open
Abstract
Histological transformation into diffuse large B-cell lymphoma is a rare complication in patients with Waldenström macroglobulinemia (WM) and is usually associated with a poor prognosis. The objective of this study was to develop and validate a prognostic index for survival of patients with transformed WM. Through this multicenter, international collaborative effort, we developed a scoring system based on data from 133 patients with transformed WM who were evaluated between 1995 and 2016 (training cohort). Univariate and multivariate analyses were used to propose a prognostic index with 2-year survival after transformation as an endpoint. For external validation, a dataset of 67 patients was used to evaluate the performance of the model (validation cohort). By multivariate analysis, three adverse covariates were identified as independent predictors of 2-year survival after transformation: elevated serum lactate dehydrogenase (2 points), platelet count <100x109/L (1 point) and any previous treatment for WM (1 point). Three risk groups were defined: low-risk (0-1 point, 24% of patients), intermediate-risk (2-3 points, 59%; hazard ratio = 3.4) and high-risk (4 points, 17%; hazard ratio = 7.5). Two-year survival rates were 81%, 47%, and 21%, respectively (P<0.0001). This model appeared to be a better discriminant than either the International Prognostic Index or the revised International Prognostic Index. We validated this model in an independent cohort. This easy-to-compute scoring index is a robust tool that may allow identification of groups of transformed WM patients with different outcomes and could be used for improving the development of risk-adapted treatment strategies.
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Affiliation(s)
- Eric Durot
- Department of Hematology, University Hospital of Reims and UFR Médecine, Reims.
| | | | - Saurabh Zanwar
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens
| | - Shirley D'Sa
- University College London Hospitals (UCLH) NHS Foundation Trust, London
| | - Ramon Garcia-Sanz
- Department of Hematology, University Hospital of Salamanca, CIBERONC and Research Biomedical Institute of Salamanca (IBSAL), Salamanca
| | - Cécile Tomowiak
- Department of Hematology and CIC U1402, University Hospital of Poitiers, Poitiers
| | | | - Elise Toussaint
- Department of Hematology, University Hospital of Strasbourg, Strasbourg
| | | | - Jithma P Abeykoon
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | | | - Gilad Itchaki
- Institute of Hematology, Rabin Medical Center, Sackler Medical School, Tel-Aviv University, Israel
| | - Josephine M Vos
- Amsterdam University Medical Center (UMC) and LYMMCARE, Amsterdam
| | | | - Sophie Godet
- Department of Hematology, University Hospital of Reims and UFR Médecine, Reims
| | - Jehan Dupuis
- Lymphoid Malignancies Unit, Henri Mondor Hospital, Créteil
| | - Stéphane Leprêtre
- Inserm U1245 and Department of Hematology, Henri Becquerel Center and Normandie University UNIROUEN, Rouen
| | - Joshua Bomsztyk
- University College London Hospitals (UCLH) NHS Foundation Trust, London
| | - Pierre Morel
- Department of Hematology, University Hospital of Amiens, Amiens
| | - Véronique Leblond
- Department of Hematology, Pitié-Salpêtrière Hospital and Sorbonne University, UPMC Paris, GRECHY
| | - Steven P Treon
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Meletios A Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens
| | - Prashant Kapoor
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Alain Delmer
- Department of Hematology, University Hospital of Reims and UFR Médecine, Reims
| | - Jorge J Castillo
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
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20
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Castillo JJ, LaMacchia J, Flynn CA, Sarosiek S, Pozdnyakova O, Treon SP. Plasmablastic lymphoma transformation in a patient with Waldenström macroglobulinemia treated with ibrutinib. Br J Haematol 2021; 195:466-468. [PMID: 34355802 DOI: 10.1111/bjh.17759] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Jorge J Castillo
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - John LaMacchia
- Harvard Medical School, Boston, MA, USA.,Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA
| | - Catherine A Flynn
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Shayna Sarosiek
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Olga Pozdnyakova
- Harvard Medical School, Boston, MA, USA.,Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA
| | - Steven P Treon
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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21
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Levy A, Guidez S, Debiais C, Princet I, Bouyer S, Dindinaud E, Delwail V, Systchenko T, Moya N, Gruchet C, Sabirou F, Bobin A, Gardeney H, Nsiala L, Cailly L, Olivier G, Motard C, Fleck E, Corby A, Roul C, Denis G, Dieval C, Leleu X, Tomowiak C. Waldenström macroglobulinemia and relationship to immune deficiency. Leuk Lymphoma 2021; 62:2665-2670. [PMID: 34085595 DOI: 10.1080/10428194.2021.1907379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Primary or secondary immune deficiency (ID) is a risk factor, although rare, to develop Waldenström macroglobulinemia (WM). We aimed to better understand the incidence of this occurrence in the real-life and the outcome of either entity. We conducted a review of 194 WM in the Poitou-Charentes registry and identified 7 (3.6%) with a prior history of ID. Across the 7 WM with ID, 4 progressed to active WM disease and required treatment for WM with a median time between WM diagnosis and the first treatment of 1.5 years (range 0-3). The median time from ID to WM occurrence was 8 years (1-18). WM could develop from ID, although a rare event. Our first action was to systematically decrease immunosuppression with long-term control of ID. Half of indolent WM remained indolent despite ID and for remaining WM none appeared of poor risk WM.
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Affiliation(s)
- Anthony Levy
- Service d'Hématologie et Thérapie Cellulaire, CHU and Inserm, Poitiers, France
| | - Stéphanie Guidez
- Service d'Hématologie et Thérapie Cellulaire, CHU and Inserm, Poitiers, France
| | - Céline Debiais
- Laboratoire d'Anatomie Pathologie, CHU, Poitiers, France
| | | | | | | | - Vincent Delwail
- Service d'Hématologie et Thérapie Cellulaire, CHU and Inserm, Poitiers, France
| | - Thomas Systchenko
- Service d'Hématologie et Thérapie Cellulaire, CHU and Inserm, Poitiers, France
| | - Niels Moya
- Service d'Hématologie et Thérapie Cellulaire, CHU and Inserm, Poitiers, France
| | - Cécile Gruchet
- Service d'Hématologie et Thérapie Cellulaire, CHU and Inserm, Poitiers, France
| | - Florence Sabirou
- Service d'Hématologie et Thérapie Cellulaire, CHU and Inserm, Poitiers, France
| | - Arthur Bobin
- Service d'Hématologie et Thérapie Cellulaire, CHU and Inserm, Poitiers, France
| | - Hélène Gardeney
- Service d'Hématologie et Thérapie Cellulaire, CHU and Inserm, Poitiers, France
| | - Laly Nsiala
- Service d'Hématologie et Thérapie Cellulaire, CHU and Inserm, Poitiers, France
| | - Laura Cailly
- Service d'Hématologie et Thérapie Cellulaire, CHU and Inserm, Poitiers, France
| | | | | | | | - Anne Corby
- Service d'Onco-Hématologie, La Rochelle, France
| | | | | | | | - Xavier Leleu
- Service d'Hématologie et Thérapie Cellulaire, CHU and Inserm, Poitiers, France
| | - Cécile Tomowiak
- Service d'Hématologie et Thérapie Cellulaire, CHU and Inserm, Poitiers, France
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22
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Kobayashi H, Asada N, Egusa Y, Ikeda T, Sakamoto M, Abe M, Ennishi D, Sakata M, Takaki A, Kawahara S, Meguri Y, Nishimori H, Fujii N, Matsuoka KI, Sato Y, Yoshino T, Maeda Y. Transformation to diffuse large B-cell lymphoma with germinal center B-cell like subtype and discordant light chain expression in a patient with Waldenström macroglobulinemia/lymphoplasmacytic lymphoma. Int J Hematol 2021; 114:401-407. [PMID: 33907976 DOI: 10.1007/s12185-021-03157-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 04/19/2021] [Accepted: 04/22/2021] [Indexed: 01/09/2023]
Abstract
Waldenström macroglobulinemia (WM)/lymphoplasmacytic lymphoma (LPL) is a rare indolent B-cell neoplasm, and a gain-of-function mutation in the myeloid differentiation primary response 88 (MYD88), L265P, is a commonly recurring mutation in patients with WM/LPL. Histological transformation of WM/LPL to an aggressive lymphoma such as diffuse large B-cell lymphoma (DLBCL) is rare, and transformed DLBCL has a worse prognosis than de novo DLBCL, partly because transformed DLBCL is mostly classified as non-germinal center B-cell-like (non-GCB) subtype. We herein describe a 75-year-old man with DLBCL with a history of WM/LPL. DLBCL in this patient showed the GCB subtype, and the light chain restriction of DLBCL was different from that of the antecedent WM/LPL, indicating that the two types of lymphoma cells had distinctive origins. However, DLBCL in this patient harbored the MYD88 L265P mutation, and polymerase chain reaction and Sanger sequencing of the DLBCL and WM/LPL for immunoglobulin heavy chain gene rearrangement suggested a clonal relationship between the two lymphomas. Since the outcome of transformed DLBCL is worse than for de novo DLBCL, it is important to evaluate the clonal relationship between primary WM/LPL and the corresponding transformed DLBCL, even if the DLBCL expresses a GCB subtype or discordant light chain restriction.
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Affiliation(s)
- Hiroki Kobayashi
- Department of Hematology and Oncology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, Okayama, 700-8558, Japan
| | - Noboru Asada
- Department of Hematology and Oncology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, Okayama, 700-8558, Japan.
| | - Yuria Egusa
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Okayama, Japan
| | - Tomoka Ikeda
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Okayama, Japan
| | - Misa Sakamoto
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Okayama, Japan
| | - Masaya Abe
- Department of Hematology and Oncology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, Okayama, 700-8558, Japan
| | - Daisuke Ennishi
- Department of Hematology and Oncology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, Okayama, 700-8558, Japan
| | - Masahiro Sakata
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Okayama, Japan
| | - Akinobu Takaki
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Okayama, Japan
| | - Soichiro Kawahara
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Okayama, Japan
| | - Yusuke Meguri
- Department of Hematology and Oncology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, Okayama, 700-8558, Japan
| | - Hisakazu Nishimori
- Department of Hematology and Oncology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, Okayama, 700-8558, Japan
| | - Nobuharu Fujii
- Department of Transfusion Medicine, Okayama University Hospital, Okayama, Okayama, Japan
| | - Ken-Ichi Matsuoka
- Department of Hematology and Oncology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, Okayama, 700-8558, Japan
| | - Yasuharu Sato
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Okayama, Japan
| | - Tadashi Yoshino
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Okayama, Japan
| | - Yoshinobu Maeda
- Department of Hematology and Oncology, Okayama University Hospital, 2-5-1 Shikata-cho, Kita-ku, Okayama, Okayama, 700-8558, Japan
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23
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The dangers of déjà vu: memory B cells as the cells of origin of ABC-DLBCLs. Blood 2021; 136:2263-2274. [PMID: 32932517 DOI: 10.1182/blood.2020005857] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 08/27/2020] [Indexed: 02/06/2023] Open
Abstract
Activated B-cell (ABC)-diffuse large B-cell lymphomas (DLBCLs) are clinically aggressive and phenotypically complex malignancies, whose transformation mechanisms remain unclear. Partially differentiated antigen-secreting cells (plasmablasts) have long been regarded as cells-of-origin for these tumors, despite lack of definitive experimental evidence. Recent DLBCL reclassification based on mutational landscapes identified MCD/C5 tumors as specific ABC-DLBCLs with unfavorable clinical outcome, activating mutations in the signaling adaptors MYD88 and CD79B, and immune evasion through mutation of antigen-presenting genes. MCD/C5s manifest prominent extranodal dissemination and similarities with primary extranodal lymphomas (PENLs). In this regard, recent studies on TBL1XR1, a gene recurrently mutated in MCD/C5s and PENLs, suggest that aberrant memory B cells (MBs), and not plasmablasts, are the true cells-of-origin for these tumors. Moreover, transcriptional and phenotypic profiling suggests that MCD/C5s, as a class, represent bona fide MB tumors. Based on emerging findings we propose herein a generalized stepwise model for MCD/C5 and PENLs pathogenesis, whereby acquisition of founder mutations in activated B cells favors the development of aberrant MBs prone to avoid plasmacytic differentiation on recall and undergo systemic dissemination. Cyclic reactivation of these MBs through persistent antigen exposure favors their clonal expansion and accumulation of mutations, which further facilitate their activation. As a result, MB-like clonal precursors become trapped in an oscillatory state of semipermanent activation and phenotypic sway that facilitates ulterior transformation and accounts for the extranodal clinical presentation and biology of these tumors. In addition, we discuss diagnostic and therapeutic implications of a MB cell-of-origin for these lymphomas.
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García-Sanz R, Jiménez C. Time to Move to the Single-Cell Level: Applications of Single-Cell Multi-Omics to Hematological Malignancies and Waldenström's Macroglobulinemia-A Particularly Heterogeneous Lymphoma. Cancers (Basel) 2021; 13:1541. [PMID: 33810569 PMCID: PMC8037673 DOI: 10.3390/cancers13071541] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 03/19/2021] [Accepted: 03/24/2021] [Indexed: 02/07/2023] Open
Abstract
Single-cell sequencing techniques have become a powerful tool for characterizing intra-tumor heterogeneity, which has been reflected in the increasing number of studies carried out and reported. We have rigorously reviewed and compiled the information about these techniques inasmuch as they are relative to the area of hematology to provide a practical view of their potential applications. Studies show how single-cell multi-omics can overcome the limitations of bulk sequencing and be applied at all stages of tumor development, giving insights into the origin and pathogenesis of the tumors, the clonal architecture and evolution, or the mechanisms of therapy resistance. Information at the single-cell level may help resolve questions related to intra-tumor heterogeneity that have not been previously explained by other techniques. With that in mind, we review the existing knowledge about a heterogeneous lymphoma called Waldenström's macroglobulinemia and discuss how single-cell studies may help elucidate the underlying causes of this heterogeneity.
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Affiliation(s)
- Ramón García-Sanz
- Hematology Department, University Hospital of Salamanca (HUS/IBSAL), CIBERONC and Cancer Research Institute of Salamanca-IBMCC (USAL-CSIC), 37007 Salamanca, Spain;
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Elimimian EB, Bilani N, Diacovo MJ, Sirvaitis S, Fu CL. Histologic Transformation in an Untreated Waldenstrom's Macroglobulinemia After 14 Years: Case Report and Review of the Literature. J Hematol 2021; 10:25-29. [PMID: 33643507 PMCID: PMC7891909 DOI: 10.14740/jh767] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 11/14/2020] [Indexed: 11/11/2022] Open
Abstract
Waldenstrom's macroglobulinemia (WM) is an indolent B-cell non-Hodgkin lymphoma characterized by lymphoplasmacytic histology in the bone marrow with monoclonal IgM. Median survival can be in excess of 10 years. The 5-year cumulative incidence of death is low at about 10%. One-third of all-cause specific mortality is due to the lymphoma for which histologic transformation (HT) is rare. Here we present a case of a 60-year-old man with longstanding untreated WM, presenting with minimally symptomatic transformation to diffuse large B-cell lymphoma (DLBCL), with an accompanying review of the literature. Transformed WM, diagnosed greater than 5 years, has a reported survival period of 8 - 9 months. This case highlights that after a decade of continued stability in WM, not requiring treatment, an acute change in laboratory data with minimally progressive IgM levels, in the absence of B symptoms and clinical findings, may be the harbinger of transformation and at the time of diagnosis can have a rapidly deteriorating clinical course. In this case, the tripling of the lactate dehydrogenase (LDH) as the primary drastic change demonstrates the importance of the rapid increase in LDH as a singly reliable marker for HT. Late transformation has been borne out as a negative variable as the generally indolent course of WM is curtailed with the poor outcome in HT. Although MYD88 wildtype is a possible predictive factor for transformation, it is unclear if late transformation is clonally or non-clonally related and further molecular investigation is needed.
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Affiliation(s)
- Elizabeth B Elimimian
- Department of Hematology-Oncology, Maroone Cancer Center, Cleveland Clinic, Florida 2950 Cleveland Clinic Blvd, Weston, FL 33331, USA
| | - Nadeem Bilani
- Department of Hematology-Oncology, Maroone Cancer Center, Cleveland Clinic, Florida 2950 Cleveland Clinic Blvd, Weston, FL 33331, USA
| | - Maria J Diacovo
- Department of Hematology-Oncology, Maroone Cancer Center, Cleveland Clinic, Florida 2950 Cleveland Clinic Blvd, Weston, FL 33331, USA
| | | | - Chieh Lin Fu
- Department of Hematology-Oncology, Maroone Cancer Center, Cleveland Clinic, Florida 2950 Cleveland Clinic Blvd, Weston, FL 33331, USA
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Kaiser LM, Hunter ZR, Treon SP, Buske C. CXCR4 in Waldenström's Macroglobulinema: chances and challenges. Leukemia 2021; 35:333-345. [PMID: 33273682 PMCID: PMC7862063 DOI: 10.1038/s41375-020-01102-3] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 10/09/2020] [Accepted: 11/17/2020] [Indexed: 02/06/2023]
Abstract
It is one of the major aims in cancer research to improve our understanding of the underlying mechanisms which initiate and maintain tumor growth and to translate these findings into novel clinical diagnostic and therapeutic concepts with the ultimate goal to improve patient care. One of the greater success stories in this respect has been Waldenström's Macroglobulinemia (WM), which is an incurable B-cell neoplasm characterized by serum monoclonal immunoglobulin M (IgM) and clonal lymphoplasmacytic cells infiltrating the bone marrow. Recent years have succeeded to describe the molecular landscape of WM in detail, highlighting two recurrently mutated genes, the MYD88 and the CXCR4 genes: MYD88 with an almost constant and recurrent point mutation present in over 90% of patients and CXCR4 with over 40 different mutations in the coding region affecting up to 40% of patients. Intriguingly, both mutations are activating mutations leading in the case of CXCR4 to an indelible activation and perpetual signaling of the chemokine receptor. These data have shed light on the essential role of CXCR4 in this disease and have paved the way to use these findings for predicting treatment response to the Bruton tyrosine kinase (BTK) inhibitor ibrutinib and novel therapeutic approaches in WM, which might be transferable to other related CXCR4 positive diseases. Well known for its central role in cancer progression and distribution, CXCR4 is highlighted in this review with regard to its biology, prognostic and predictive relevance and therapeutic implications in WM.
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Affiliation(s)
- Lisa Marie Kaiser
- Institute of Experimental Cancer Research, CCC and University Hospital Ulm, Germany, 89081, Ulm, Germany
| | - Zachary R Hunter
- Bing Center for Waldenström's Macroglobulinemia, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Steven P Treon
- Bing Center for Waldenström's Macroglobulinemia, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Christian Buske
- Institute of Experimental Cancer Research, CCC and University Hospital Ulm, Germany, 89081, Ulm, Germany.
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Xia Y, Zhu HY, Wang L, Chen RZ, Chen W, Ding CY, Xu W, Li JY. [Clonal-related transformation from Waldenström macroglobulinemia to diffuse large B cell lymphoma during the treatment of ibrutinib: a case report and literature review]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 41:770-772. [PMID: 33113611 PMCID: PMC7595864 DOI: 10.3760/cma.j.issn.0253-2727.2020.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Y Xia
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Key Laboratory of Hematology of Nanjing Medical University, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing 210029, China
| | - H Y Zhu
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Key Laboratory of Hematology of Nanjing Medical University, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing 210029, China
| | - L Wang
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Key Laboratory of Hematology of Nanjing Medical University, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing 210029, China
| | - R Z Chen
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Key Laboratory of Hematology of Nanjing Medical University, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing 210029, China
| | - W Chen
- Department of Pathology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing 210029, China
| | - C Y Ding
- Department of Nuclear Medicine, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing 210029, China
| | - W Xu
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Key Laboratory of Hematology of Nanjing Medical University, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing 210029, China
| | - J Y Li
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Key Laboratory of Hematology of Nanjing Medical University, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing 210029, China
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Human MYD88L265P is insufficient by itself to drive neoplastic transformation in mature mouse B cells. Blood Adv 2020; 3:3360-3374. [PMID: 31698464 DOI: 10.1182/bloodadvances.2019000588] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 08/20/2019] [Indexed: 12/16/2022] Open
Abstract
MYD88 L265P is the most common mutation in lymphoplasmacytic lymphoma/Waldenström macroglobulinemia (LPL/WM) and one of the most frequent in poor-prognosis subtypes of diffuse large B-cell lymphoma (DLBCL). Although inhibition of the mutated MYD88 pathway has an adverse impact on LPL/WM and DLBCL cell survival, its role in lymphoma initiation remains to be clarified. We show that in mice, human MYD88L265P promotes development of a non-clonal, low-grade B-cell lymphoproliferative disorder with several clinicopathologic features that resemble human LPL/WM, including expansion of lymphoplasmacytoid cells, increased serum immunoglobulin M (IgM) concentration, rouleaux formation, increased number of mast cells in the bone marrow, and proinflammatory signaling that progresses sporadically to clonal, high-grade DLBCL. Murine findings regarding differences in the pattern of MYD88 staining and immune infiltrates in the bone marrows of MYD88 wild-type (MYD88WT) and MYD88L265P mice are recapitulated in the human setting, which provides insight into LPL/WM pathogenesis. Furthermore, histologic transformation to DLBCL is associated with acquisition of secondary genetic lesions frequently seen in de novo human DLBCL as well as LPL/WM-transformed cases. These findings indicate that, although the MYD88L265P mutation might be indispensable for the LPL/WM phenotype, it is insufficient by itself to drive malignant transformation in B cells and relies on other, potentially targetable cooperating genetic events for full development of lymphoma.
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Hirji SH, Maeng MM, Tooley AA, Soderquist C, Annunziata J, Kazim M. Orbital marginal cell lymphoma and mantle cell lymphoma subclone in patient with monoclonal gammopathy of unknown significance. Orbit 2020; 40:247-251. [PMID: 32363993 DOI: 10.1080/01676830.2020.1760312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Indolent lymphomas have the potential to transform into more aggressive phenotypes. This phenomenon is best exemplified by the transformation of chronic lymphocytic leukemia/small lymphocytic lymphoma into diffuse large B-cell lymphoma. However, it is less common to find multiple small cell lymphomas in the orbit, particularly mantle cell lymphoma. We present a case of an extranodal marginal zone lymphoma arising in the orbit that acquired a subclonal t(11;14) (q13;32) CCND1-IGH translocation, giving rise to a subclone of mantle cell lymphoma. The management of this tumor was targeted towards the more aggressive mantle cell subclone. The tumor exhibited an incomplete response to rituximab alone. To the best of the authors' knowledge, this represents the first such case to be described irrespective of site of origin.
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Affiliation(s)
- Sitara H Hirji
- Columbia University, Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Michelle M Maeng
- Edward S. Harkness Eye Institute, Columbia University Medical Center, New York, NY, USA
| | - Andrea A Tooley
- Edward S. Harkness Eye Institute, Columbia University Medical Center, New York, NY, USA
| | - Craig Soderquist
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY, USA
| | - Joseph Annunziata
- Department of Pathology & Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Michael Kazim
- Edward S. Harkness Eye Institute, Columbia University Medical Center, New York, NY, USA
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Zanwar S, Abeykoon JP, Durot E, King R, Perez Burbano GE, Kumar S, Gertz MA, Quinquenel A, Delmer A, Gonsalves W, Cornillet‐Lefebvre P, He R, Warsame R, Buadi FK, Novak AJ, Greipp PT, Inwards D, Habermann TM, Micallef I, Go R, Muchtar E, Kourelis T, Dispenzieri A, Lacy MQ, Dingli D, Nowakowski G, Thompson CA, Johnston P, Thanarajasingam G, Bennani NN, Witzig TE, Villasboas J, Leung N, Lin Y, Kyle RA, Rajkumar SV, Ansell SM, Le‐Rademacher JG, Kapoor P. Impact of MYD88 L265P mutation status on histological transformation of Waldenström Macroglobulinemia. Am J Hematol 2020; 95:274-281. [PMID: 31814157 DOI: 10.1002/ajh.25697] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 12/01/2019] [Accepted: 12/04/2019] [Indexed: 12/28/2022]
Abstract
Histological transformation in Waldenström macroglobulinemia (WM) is an uncommon complication, with limited data, particularly regarding the impact of MYD88 L265P mutation on transformation. We examined risk factors and outcomes associated with transformation in WM, highlighting the role of MYD88 L265P mutation. Patients with WM seen at Mayo Clinic, Rochester, USA and University Hospital of Reims, France, between 01/01/1996 and December 31, 2017 were included; 50 (4.3%) of 1147 patients transformed to a high-grade lymphoma, with median time-to-transformation of 4.5 (range 0-21) years in the transformed cohort. The MYD88 L265P mutation status was known in 435/1147 (38%) patients (406 with non-transformed WM and 29 patients in transformed cohort). On multivariate analysis, MYD88 WT status alone was an independent predictor of transformation (odds ratio, 7[95%CI: 2.1-23]; P = .003). Additionally, the MYD88 WT status was independently associated with shorter time-to-transformation (HR 7.9 [95%CI: 2.3-27; P = .001]), with a 5-year transformation rate of 16% for MYD88 WT vs 2.8% with MYD88 L265P mutated patients. Patients with transformation demonstrated a significant increase in risk of death compared to patients who did not transform (HR 5.075; 95%CI: 3.8-6.8; P < .001). In conclusion, the MYD88 WT status is an independent predictor of transformation and associated with a shorter time-to-transformation. Additionally, transformation conferred an inferior overall survival in patients with WM.
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Affiliation(s)
- Saurabh Zanwar
- Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Jithma P. Abeykoon
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Eric Durot
- Department of HematologyUniversity Hospital of Reims and UFR Médecine Reims France
| | - Rebecca King
- Department of Laboratory Medicine and PathologyMayo Clinic Rochester Minnesota
| | - Gabriela E. Perez Burbano
- Division of Biomedical Statistics and Informatics, Department of Health Sciences ResearchMayo Clinic Rochester Minnesota
| | - Shaji Kumar
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Morie A. Gertz
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Anne Quinquenel
- Department of HematologyUniversity Hospital of Reims and UFR Médecine Reims France
| | - Alain Delmer
- Department of HematologyUniversity Hospital of Reims and UFR Médecine Reims France
| | - Wilson Gonsalves
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | | | - Rong He
- Department of Laboratory Medicine and PathologyMayo Clinic Rochester Minnesota
| | - Rahma Warsame
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Francis K. Buadi
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Anne J. Novak
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | | | - David Inwards
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Thomas M. Habermann
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Ivana Micallef
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Ronald Go
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Eli Muchtar
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Taxiarchis Kourelis
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Angela Dispenzieri
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Martha Q. Lacy
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - David Dingli
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Grzegorz Nowakowski
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Carrie A. Thompson
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Patrick Johnston
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Gita Thanarajasingam
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - N. Nora Bennani
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Thomas E. Witzig
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Jose Villasboas
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Nelson Leung
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Yi Lin
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Robert A. Kyle
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - S. Vincent Rajkumar
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Stephen M. Ansell
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Jennifer G. Le‐Rademacher
- Division of Biomedical Statistics and Informatics, Department of Health Sciences ResearchMayo Clinic Rochester Minnesota
| | - Prashant Kapoor
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
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Dvorak P, Hoffmann P, Simkovic M, Jandura J, Nova M. Is percutaneous computed tomography-guided biopsy sufficient to establish indolent lymphoma transformation? Arch Med Sci 2019; 15:1443-1453. [PMID: 31749872 PMCID: PMC6855164 DOI: 10.5114/aoms.2018.79573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 09/20/2018] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The aim of the study was to retrospectively evaluate the technical features, efficacy, accuracy, and relevant complications of computed tomography-guided biopsies in various anatomical localizations when diagnosing indolent lymphoma transformations, relapses, duplicate malignant diseases or benign processes. MATERIAL AND METHODS From December 2007 to December 2017, 81 percutaneous biopsy procedures in 72 patients for tumors, sizes 17-232 mm in diameter (median length: 39 mm), were performed in patients with known indolent lymphomas in their clinical history. The patients were men in 41 cases and women in 31 cases, aged 36 to 86 years. RESULTS In 79 cases (97.5%; 95% CI: 91.3-99.7) results were true positive or true negative; only 2 interventions (2.5%; 95% CI: 0.3-8.6) were histologically false negative. Transformation was verified in 29 cases (35.8%; 95% CI: 25.4-47.2), relapses in 30 cases (37%; 95% CI: 26.6-48.5), duplicate malignancy in 15 cases (18.5%; 95% CI: 10.8-28.7) and benign processes in 7 cases (8.7%; 95% CI: 3.5-17.0). Eight complications in total were revealed, 7 of which were in consequence of thoracic cavity biopsy. A statistically significant relationship between the complication incidence and anatomical localization in the thoracic cavity was identified (p = 0.0104). CONCLUSIONS Percutaneous CT guided biopsy performed in patients with a history of indolent lymphoma had high accuracy in establishing the correct diagnosis regarding transformation, relapse, duplicate malignancy or a benign process. Simultaneously, the complication rate was low.
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Affiliation(s)
- Petr Dvorak
- Department of Radiology, University Hospital, Hradec Kralove, Czech Republic
| | - Petr Hoffmann
- Department of Radiology, University Hospital, Hradec Kralove, Czech Republic
| | - Martin Simkovic
- 4 Department of Internal Medicine – Hematology, University Hospital, Hradec Kralove, Czech Republic
| | - Jiri Jandura
- Department of Radiology, University Hospital, Hradec Kralove, Czech Republic
| | - Marketa Nova
- The Fingerland Department of Pathology, University Hospital, Hradec Kralove, Czech Republic
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Bansal R, Jurcic JG, Sawas A, Mapara MY, Reshef R. Chimeric antigen receptor T cells for treatment of transformed Waldenström macroglobulinemia. Leuk Lymphoma 2019; 61:465-468. [PMID: 31544563 DOI: 10.1080/10428194.2019.1665668] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Rajat Bansal
- Division of Hematology & Oncology, Columbia University Irving Medical Center, New York, NY, USA
| | - Joseph G Jurcic
- Division of Hematology & Oncology, Columbia University Irving Medical Center, New York, NY, USA
| | - Ahmed Sawas
- Division of Hematology & Oncology, Columbia University Irving Medical Center, New York, NY, USA
| | - Markus Y Mapara
- Division of Hematology & Oncology, Columbia University Irving Medical Center, New York, NY, USA
| | - Ran Reshef
- Division of Hematology & Oncology, Columbia University Irving Medical Center, New York, NY, USA
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Alessandrino F, DiPiro PJ, Jagannathan JP, Babina G, Krajewski KM, Ramaiya NH, Giardino AA. Multimodality imaging of indolent B cell lymphoma from diagnosis to transformation: what every radiologist should know. Insights Imaging 2019; 10:25. [PMID: 30796644 PMCID: PMC6386758 DOI: 10.1186/s13244-019-0705-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 11/14/2018] [Indexed: 12/28/2022] Open
Abstract
Indolent B cell lymphomas are a group of lymphoid malignancies characterized by their potential to undergo histologic transformation to aggressive lymphomas. While different subtypes of indolent B cell lymphomas demonstrate specific clinical and imaging features, histologic transformation can be suspected on cross-sectional imaging when disproportionate lymph node enlargement or new focal lesions in extranodal organs are seen. On PET/CT, transformed indolent lymphoma may show new or increased nodal FDG avidity or new FDG-avid lesions in different organs. In this article, we will (1) review the imaging features of different subtypes of indolent B cell lymphomas, (2) discuss the imaging features of histologic transformation, and (3) propose a diagnostic algorithm for transformed indolent lymphoma. The purpose of this review is to familiarize radiologists with the spectrum of clinical and imaging features of indolent B cell lymphomas and to define the role of imaging in raising concern for transformation and in guiding biopsy for confirmation.
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Affiliation(s)
- Francesco Alessandrino
- Department of Imaging, Dana Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA, 02215, USA.
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
| | - Pamela J DiPiro
- Department of Imaging, Dana Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA, 02215, USA
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Jyothi P Jagannathan
- Department of Imaging, Dana Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA, 02215, USA
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Gosangi Babina
- Department of Imaging, Dana Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA, 02215, USA
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Katherine M Krajewski
- Department of Imaging, Dana Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA, 02215, USA
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Nikhil H Ramaiya
- Department of Imaging, Dana Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA, 02215, USA
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
- Department of Radiology, UH Cleveland Medical Center, Case Western Reserve University, 11100 Euclid Ave, Cleveland, OH, 44106, USA
| | - Angela A Giardino
- Department of Imaging, Dana Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Boston, MA, 02215, USA
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
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Gavriatopoulou M, Fotiou D, Ntanasis-Stathopoulos I, Kastritis E, Terpos E, Dimopoulos MA. How I treat elderly patients with plasma cell dyscrasias. Aging (Albany NY) 2018; 10:4248-4268. [PMID: 30568029 PMCID: PMC6326666 DOI: 10.18632/aging.101707] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 12/04/2018] [Indexed: 01/01/2023]
Abstract
Plasma cell dyscrasias are a rare heterogeneous group of hematological disorders which are more prevalent in the older part of the population. The introduction of novel agents, improved understanding of disease biology and better supportive management have improved outcomes considerably and in the era of the aging population the question of how to best manage older patients with plasma cell dyscrasias has never been more relevant. Data on how to treat these patients comes mostly from subgroup analysis as they are underrepresented in clinical trials. This review will cover issues, available evidence and recommendations relevant to diagnosis and management of the older patients with Multiple Myeloma (MM), Waldenstrom Macroglobulinemia (WM) and systemic AL Amyloidosis. What will become increasingly evident is the need to develop and establish the use of disease-specific geriatric assessment (GA) tools. Frailty status assessment using GA tools and moving away from making decisions based merely on chronological age will allow setting clear treatment goals and consequently achieving an optimum balance between effectiveness and toxicity for this complex and heterogeneous group of patients.
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Affiliation(s)
- Maria Gavriatopoulou
- Alexandra Hospital, Oncology Department, Department of Therapeutics, National and Kapodistrian University of Athens, 11528 Athens, Greece
- Equal contribution
| | - Despoina Fotiou
- Alexandra Hospital, Oncology Department, Department of Therapeutics, National and Kapodistrian University of Athens, 11528 Athens, Greece
- Equal contribution
| | - Ioannis Ntanasis-Stathopoulos
- Alexandra Hospital, Oncology Department, Department of Therapeutics, National and Kapodistrian University of Athens, 11528 Athens, Greece
| | - Efstathios Kastritis
- Alexandra Hospital, Oncology Department, Department of Therapeutics, National and Kapodistrian University of Athens, 11528 Athens, Greece
| | - Evangelos Terpos
- Alexandra Hospital, Oncology Department, Department of Therapeutics, National and Kapodistrian University of Athens, 11528 Athens, Greece
| | - Meletios Athanasios Dimopoulos
- Alexandra Hospital, Oncology Department, Department of Therapeutics, National and Kapodistrian University of Athens, 11528 Athens, Greece
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Talaulikar D, Biscoe A, Lim JH, Gibson J, Arthur C, Mackinlay N, Saxena K, Cheng YY, Chen VM. Genetic analysis of Diffuse Large B‐cell Lymphoma occurring in cases with antecedent Waldenström Macroglobulinaemia reveals different patterns of clonal evolution. Br J Haematol 2018; 185:767-770. [DOI: 10.1111/bjh.15610] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Dipti Talaulikar
- Haematology Translational Research Unit Canberra Hospital Canberra Australia
- Australian National University Medical School Canberra Australia
| | - Amber Biscoe
- Haematology Concord Repatriation General Hospital Sydney Australia
| | - Jun H. Lim
- Australian National University Medical School Canberra Australia
| | - John Gibson
- Royal Prince Alfred Hospital Sydney Australia
| | | | | | - Kartik Saxena
- Haematology Translational Research Unit Canberra Hospital Canberra Australia
| | - Yuen Y. Cheng
- Asbestos Diseases Research Institute The University of Sydney Sydney Australia
| | - Vivien M. Chen
- Haematology Concord Repatriation General Hospital Sydney Australia
- ANZAC Research Institute Sydney Australia
- University of Sydney Sydney Australia
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36
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Kastritis E, Leblond V, Dimopoulos MA, Kimby E, Staber P, Kersten MJ, Tedeschi A, Buske C. Waldenström's macroglobulinaemia: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2018; 29:iv41-iv50. [PMID: 29982402 DOI: 10.1093/annonc/mdy146] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Affiliation(s)
- E Kastritis
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - V Leblond
- Department of Hematology, Pitié Salpêtrière Hospital, Pierre and Marie Curie University, UPMC GRC11-GRECHY, Paris, France
| | - M A Dimopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - E Kimby
- Division of Hematology, Department of Medicine at Huddinge, Karolinska Institute and University Hospital, Stockholm, Sweden
| | - P Staber
- Division of Hematology and Hemostaseology, Department of Internal Medicine I, Vienna General Hospital, Vienna, Austria
| | - M J Kersten
- Department of Hematology, Academic Medical Center
- LYMMCARE (Lymphoma and Myeloma Center Amsterdam), Amsterdam, The Netherlands
| | - A Tedeschi
- Department of Haematology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - C Buske
- Comprehensive Cancer Center Ulm, Institute of Experimental Cancer Research, University Hospital Ulm, Ulm, Germany
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37
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Castillo JJ, Treon SP. Initial Evaluation of the Patient with Waldenström Macroglobulinemia. Hematol Oncol Clin North Am 2018; 32:811-820. [PMID: 30190019 DOI: 10.1016/j.hoc.2018.05.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The initial evaluation of the patient with Waldenström macroglobulinemia can be challenging. Not only is it a rare disease, but the clinical features can vary greatly from patient to patient. In this article, we aim at providing concise and practical recommendations for the initial evaluation of patients with Waldenström macroglobulinemia, specifically regarding history taking, physical examination, laboratory testing, bone marrow aspiration, and biopsy evaluation and imaging studies. We then review the most common special clinical situations seen in patients with Waldenström macroglobulinemia, especially anemia, hyperviscosity, cryoglobulinemia, peripheral neuropathy, extramedullary disease, Bing-Neel syndrome, and amyloidosis.
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Affiliation(s)
- Jorge J Castillo
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Mayer 221, Boston, MA 02215, USA.
| | - Steven P Treon
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Harvard Medical School, 450 Brookline Avenue, Mayer 221, Boston, MA 02215, USA
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38
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Szablewski V, Costes-Martineau V, René C, Croci-Torti A, Joujoux JM. Composite cutaneous lymphoma of diffuse large B-cell lymphoma-leg type and subcutaneous panniculitis-like T-cell lymphoma. J Cutan Pathol 2018; 45:716-720. [PMID: 29851123 DOI: 10.1111/cup.13289] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Revised: 03/17/2018] [Accepted: 05/25/2018] [Indexed: 12/16/2022]
Abstract
Composite lymphoma (CL) is a rare disease defined by the occurrence of two distinct lymphomas within a single tissue at the same time. We present the case of an 89-year-old male with a clinical history of immunoglobulin M monoclonal gammopathy of undetermined significance. The patient presented cutaneous eruption of nodules on the right bottom and arm. An excisional biopsy revealed cutaneous infiltration composed of two components. The first one consisted of large B-cells with CD20+/MUM1+/BCL2+ phenotype whereas the second one involved the subcutaneous fat in a panniculitic manner, and was CD3+/CD8+/granzyme B+/TCRβF1+. The final diagnosis was CL of primary cutaneous large B-cell lymphoma-leg type (PCLBCL-leg type) and subcutaneous panniculitis-like T-cell lymphoma (SPTCL). We report and characterize for the first time coexistent PCLBCL-leg type and SPTCL in a patient.
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Affiliation(s)
| | | | - Céline René
- Département d'Immunologie, CHU Montpellier, Montpellier, France
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39
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Simon L, Baron M, Leblond V. How we manage patients with Waldenström macroglobulinaemia. Br J Haematol 2018; 181:737-751. [PMID: 29637541 DOI: 10.1111/bjh.15202] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Waldenström macroglobulinaemia (WM) is a rare, indolent B-cell lymphoproliferative disorder characterized by cellular involvement in bone marrow and monoclonal IgM production. Symptoms can be related to cytopenias, tumoural involvement, or IgM-related disorders. Somatic mutations in the MYD88 gene have been described in the majority of WM cases. The mutation is responsible for a gain-of-function and induces activation of nuclear factor-κB, for DNA transcription and cell survival. It seems that MYD88 mutation is associated with better prognosis and better response to some treatment. Treatments are started when WM is symptomatic, following systematic biological and morphological assessments. Therapeutic choice depends on age, frailty and urgent efficacy need. In first line, the majority of patients are treated with monoclonal anti-CD20 antibody-based regimens combined with cytotoxic chemotherapy. Rituximab, cyclophosphamide and dexamethasone remain the most commonly used regimen with good safety. Nevertheless, increasing numbers of new drugs are becoming available or are in development. Proteasome inhibitors, such as bortezomib or carfilzmib, showed good and rapid responses. Bruton tyrosine kinase (BTK) inhibitor demonstrated excellent results and is now available for relapse/refractory disease or as first line for some patients. This review highlights the diagnostic procedures and therapeutic approaches in WM.
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Affiliation(s)
- Laurence Simon
- Department of Haematology, APHP Hôpital Pitié-Salpétrière, Paris, France
| | - Marine Baron
- Department of Haematology, APHP Hôpital Pitié-Salpétrière, Paris, France
| | - Véronique Leblond
- Department of Haematology, APHP Hôpital Pitié-Salpétrière, Paris, France
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40
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Abeykoon JP, Paludo J, King RL, Ansell SM, Gertz MA, LaPlant BR, Halvorson AE, Gonsalves WI, Dingli D, Fang H, Rajkumar SV, Lacy MQ, He R, Kourelis T, Reeder CB, Novak AJ, McPhail ED, Viswanatha DS, Witzig TE, Go RS, Habermann TM, Buadi FK, Dispenzieri A, Leung N, Lin Y, Thompson CA, Hayman SR, Kyle RA, Kumar SK, Kapoor P. MYD88 mutation status does not impact overall survival in Waldenström macroglobulinemia. Am J Hematol 2018; 93:187-194. [PMID: 29080258 DOI: 10.1002/ajh.24955] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 10/25/2017] [Indexed: 12/22/2022]
Abstract
Waldenström macroglobulinemia (WM) is an immunoglobulin M-associated lymphoma, with majority of cases demonstrating MYD88 locus alteration, most commonly, MYD88L265P . Owing to low prevalence of the wild-type (WT) MYD88 genotype in WM, clinically relevant data in this patient population are sparse, with one study showing nearly a 10-fold increased risk of mortality in this subgroup compared to patients with MYD88L265P mutation. We studied a large cohort of patients with MYD88L265P and MYD88WT WM, evaluated at Mayo Clinic, Rochester, between 1995 and 2016, to specifically assess the impact of these genotypes on clinical course. Of 557 patients, MYD88L265P mutation status, as determined by allele-specific polymerase chain reaction, was known in 219, and 174 (79%) of those exhibited MYD88L265P , 157 of 174 patients had active disease. Of 45 (21%) patients with MYD88WT genotype, 44 had active disease. The estimated median follow-up was 7.0 years; median overall survival was 10.2 years (95% CI: 8.4-16.5) for MYD88L265P versus 13.9 years (95% CI: 6.4-29.3) for the MYD88WT (P = 0.86). The time-to-next therapy from frontline treatment and the presenting features were similar in the two patient populations. For patients with smoldering WM at diagnosis, the median time-to-progression to active disease was 2.8 years (95% CI: 2.2-3.8) in the MYD88L265P cohort and 1.9 years (95% CI: 0.7-3.1) in the MYD88WT cohort (P = 0.21). The frequency of transformation to high-grade lymphoma, or the development of therapy-elated myelodysplastic syndrome was higher in the MYD88WT cohort (16% versus 4% in the MYD88L265P , P = 0.009). In conclusion, MYD88L265P mutation does not appear to be a determinant of outcome, and its presence may not be a disease-defining feature in WM. Our findings warrant external validation, preferably through prospective studies.
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41
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Castillo JJ, Treon SP. Toward personalized treatment in Waldenström macroglobulinemia. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:365-370. [PMID: 29222280 PMCID: PMC6142554 DOI: 10.1182/asheducation-2017.1.365] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Waldenström macroglobulinemia (WM) is a rare lymphoma with 1000 to 1500 new patients diagnosed per year in the United States. Patients with WM can experience prolonged survival times, which seem to have increased in the last decade, but relapse is inevitable. The identification of recurrent mutations in the MYD88 and CXCR4 genes has opened avenues of research to better understand and treat patients with WM. These developments are giving way to personalized treatment approaches for these patients, focusing on increasing depth and duration of response alongside lower toxicity rates. In the present document, we review the diagnostic differential, the clinical manifestations, and the pathological and genomic features of patients with WM. We also discuss the safety and efficacy data of alkylating agents, proteasome inhibitors, monoclonal antibodies, and Bruton tyrosine kinase inhibitors in patients with WM. Finally, we propose a genomically driven algorithm for the treatment of WM. The future of therapies for WM appears bright and hopeful, but we should be mindful of the cost-effectiveness and long-term toxicity of novel agents.
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Affiliation(s)
- Jorge J Castillo
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Steven P Treon
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
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42
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Treon SP, Gustine J, Xu L, Manning RJ, Tsakmaklis N, Demos M, Meid K, Guerrera ML, Munshi M, Chan G, Chen J, Kofides A, Patterson CJ, Yang G, Liu X, Severns P, Dubeau T, Hunter ZR, Castillo JJ. MYD88
wild-type Waldenstrom Macroglobulinaemia: differential diagnosis, risk of histological transformation, and overall survival. Br J Haematol 2017; 180:374-380. [DOI: 10.1111/bjh.15049] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Accepted: 10/09/2017] [Indexed: 12/26/2022]
Affiliation(s)
- Steven P. Treon
- Bing Center for Waldenstrom's Macroglobulinemia; Dana Farber Cancer Institute; Boston MA USA
- Department of Medicine; Harvard Medical School; Boston MA USA
| | - Joshua Gustine
- Bing Center for Waldenstrom's Macroglobulinemia; Dana Farber Cancer Institute; Boston MA USA
- Department of Medicine; Harvard Medical School; Boston MA USA
| | - Lian Xu
- Bing Center for Waldenstrom's Macroglobulinemia; Dana Farber Cancer Institute; Boston MA USA
- Department of Medicine; Harvard Medical School; Boston MA USA
| | - Robert J. Manning
- Bing Center for Waldenstrom's Macroglobulinemia; Dana Farber Cancer Institute; Boston MA USA
- Department of Medicine; Harvard Medical School; Boston MA USA
| | - Nicholas Tsakmaklis
- Bing Center for Waldenstrom's Macroglobulinemia; Dana Farber Cancer Institute; Boston MA USA
- Department of Medicine; Harvard Medical School; Boston MA USA
| | - Maria Demos
- Bing Center for Waldenstrom's Macroglobulinemia; Dana Farber Cancer Institute; Boston MA USA
- Department of Medicine; Harvard Medical School; Boston MA USA
| | - Kirsten Meid
- Bing Center for Waldenstrom's Macroglobulinemia; Dana Farber Cancer Institute; Boston MA USA
- Department of Medicine; Harvard Medical School; Boston MA USA
| | - Maria L. Guerrera
- Bing Center for Waldenstrom's Macroglobulinemia; Dana Farber Cancer Institute; Boston MA USA
- Department of Medicine; Harvard Medical School; Boston MA USA
| | - Manit Munshi
- Bing Center for Waldenstrom's Macroglobulinemia; Dana Farber Cancer Institute; Boston MA USA
- Department of Medicine; Harvard Medical School; Boston MA USA
| | - Gloria Chan
- Bing Center for Waldenstrom's Macroglobulinemia; Dana Farber Cancer Institute; Boston MA USA
- Department of Medicine; Harvard Medical School; Boston MA USA
| | - Jiaji Chen
- Bing Center for Waldenstrom's Macroglobulinemia; Dana Farber Cancer Institute; Boston MA USA
- Department of Medicine; Harvard Medical School; Boston MA USA
| | - Amanda Kofides
- Bing Center for Waldenstrom's Macroglobulinemia; Dana Farber Cancer Institute; Boston MA USA
- Department of Medicine; Harvard Medical School; Boston MA USA
| | - Christopher J. Patterson
- Bing Center for Waldenstrom's Macroglobulinemia; Dana Farber Cancer Institute; Boston MA USA
- Department of Medicine; Harvard Medical School; Boston MA USA
| | - Guang Yang
- Bing Center for Waldenstrom's Macroglobulinemia; Dana Farber Cancer Institute; Boston MA USA
- Department of Medicine; Harvard Medical School; Boston MA USA
| | - Xia Liu
- Bing Center for Waldenstrom's Macroglobulinemia; Dana Farber Cancer Institute; Boston MA USA
- Department of Medicine; Harvard Medical School; Boston MA USA
| | - Patricia Severns
- Bing Center for Waldenstrom's Macroglobulinemia; Dana Farber Cancer Institute; Boston MA USA
- Department of Medicine; Harvard Medical School; Boston MA USA
| | - Toni Dubeau
- Bing Center for Waldenstrom's Macroglobulinemia; Dana Farber Cancer Institute; Boston MA USA
- Department of Medicine; Harvard Medical School; Boston MA USA
| | - Zachary R. Hunter
- Bing Center for Waldenstrom's Macroglobulinemia; Dana Farber Cancer Institute; Boston MA USA
- Department of Medicine; Harvard Medical School; Boston MA USA
| | - Jorge J. Castillo
- Bing Center for Waldenstrom's Macroglobulinemia; Dana Farber Cancer Institute; Boston MA USA
- Department of Medicine; Harvard Medical School; Boston MA USA
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43
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Hiemcke-Jiwa LS, Leguit RJ, Radersma-van Loon JH, Westerweel PE, Rood JJM, Doorduijn JK, Huibers MMH, Minnema MC. Efficacy of ibrutinib in a patient with transformed lymphoplasmacytic lymphoma and central nervous system involvement. Leuk Lymphoma 2017; 59:1256-1259. [DOI: 10.1080/10428194.2017.1369074] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Laura S. Hiemcke-Jiwa
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Roos J. Leguit
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Peter E. Westerweel
- Department of Internal Medicine, Albert Schweitzer hospital Dordrecht, Dordrecht, The Netherlands
| | - Johannes J. M. Rood
- Department of Pharmaceutical Sciences, Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht University, Faculty of Science, Utrecht, The Netherlands
| | - Jeanette K. Doorduijn
- Department of Hematology, Erasmus Cancer Institute Rotterdam, Rotterdam, The Netherlands
| | - Manon M. H. Huibers
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Monique C. Minnema
- Department of Hematology, University Medical Center Utrecht Cancer Center, Utrecht, The Netherlands
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44
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From Waldenström's macroglobulinemia to aggressive diffuse large B-cell lymphoma: a whole-exome analysis of abnormalities leading to transformation. Blood Cancer J 2017; 7:e591. [PMID: 28841204 PMCID: PMC5596383 DOI: 10.1038/bcj.2017.72] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 06/26/2017] [Accepted: 07/04/2017] [Indexed: 12/26/2022] Open
Abstract
Transformation of Waldenström’s macroglobulinemia (WM) to diffuse large B-cell lymphoma (DLBCL) occurs in up to 10% of patients and is associated with an adverse outcome. Here we performed the first whole-exome sequencing study of WM patients who evolved to DLBCL and report the genetic alterations that may drive this process. Our results demonstrate that transformation depends on the frequency and specificity of acquired variants, rather than on the duration of its evolution. We did not find a common pattern of mutations at diagnosis or transformation; however, there were certain abnormalities that were present in a high proportion of clonal tumor cells and conserved during this transition, suggesting that they have a key role as early drivers. In addition, recurrent mutations gained in some genes at transformation (for example, PIM1, FRYL and HNF1B) represent cooperating events in the selection of the clones responsible for disease progression. Detailed comparison reveals the gene abnormalities at diagnosis and transformation to be consistent with a branching model of evolution. Finally, the frequent mutation observed in the CD79B gene in this specific subset of patients implies that it is a potential biomarker predicting transformation in WM.
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45
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Okolo ON, Johnson AC, Yun S, Arnold SJ, Anwer F. Rare transformation to double hit lymphoma in Waldenstrom's macroglobulinemia. Immunotherapy 2017; 9:709-714. [PMID: 28771100 DOI: 10.2217/imt-2017-0027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Waldenström macroglobulinemia (WM) is a lymphoproliferative lymphoma that is characterized by monoclonal immunoglobulin M (IgM) protein and bone marrow infiltration. Its incidence is rare and rarer still is its ability to transform to a B-cell lymphoma, particularly the aggressive diffuse large B-cell lymphoma, which bodes a poor prognosis. When transformation includes mutations of MYC, BCL-2 and/or BCL-6, it is known as a 'double hit' or 'triple hit' lymphoma respectively. This paper presents a rare case of WM with mutations positive for MYC and BCL2, making it a case of double hit B-cell lymphoplasmacytic lymphoma with plasmatic differentiation without morphological transformation to aggressive histology like DLBCL. The paper also broadens to include discussions on current topics in the classification, diagnosis, possible causes of transformation, and treatment of WM, including transformation to double hit lymphoma. The significance of this case lies in that the presence of double hit lymphoma-like genetic mutations in WM have not been previously described in the literature and potentially such changes are harbinger of extra-nodal presentation, aggressive growth, and possibly poor prognosis, if data from other double-hit lymphoma are extrapolated.
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Affiliation(s)
- Onyemaechi N Okolo
- Department of Medicine, University of Arizona, 1501 N. Campbell Ave, Tucson, AZ 8572, USA
| | - Ariel C Johnson
- University of Arizona College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85721, USA
| | - Seongseok Yun
- Hematology & Oncology, H. Lee Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, Tampa, FL 33612, USA
| | - Stacy J Arnold
- Division of Pathology, Department of Medicine, University of Arizona, 1501 N Campbell Ave, Tucson, AZ 85721, USA
| | - Faiz Anwer
- Department of Medicine, University of Arizona, 1501 N. Campbell Ave, Tucson, AZ 8572, USA.,Division of Hematology, Oncology, Blood & Marrow Transplantation, Department of Medicine, University of Arizona, 1501 N Campbell Ave, Tucson, AZ 85721, USA
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46
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Durot E, Tomowiak C, Michallet AS, Dupuis J, Hivert B, Leprêtre S, Toussaint E, Godet S, Merabet F, Van Den Neste E, Ivanoff S, Roussel X, Zini JM, Regny C, Lemal R, Sutton L, Perrot A, Le Dû K, Kanagaratnam L, Morel P, Leblond V, Delmer A. Transformed Waldenström macroglobulinaemia: clinical presentation and outcome. A multi-institutional retrospective study of 77 cases from the French Innovative Leukemia Organization (FILO). Br J Haematol 2017; 179:439-448. [DOI: 10.1111/bjh.14881] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 06/20/2017] [Indexed: 01/11/2023]
Affiliation(s)
- Eric Durot
- Department of Haematology; University Hospital of Reims and UFR Médecine; Reims France
| | - Cécile Tomowiak
- Department of Haematology; University Hospital of Poitiers; Poitiers France
| | | | - Jehan Dupuis
- Lymphoid Malignancies Unit; Henri Mondor Hospital; Créteil France
| | | | | | - Elise Toussaint
- Department of Oncology and Haematology; University Hospital of Strasbourg; Strasbourg France
| | - Sophie Godet
- Department of Haematology; University Hospital of Reims and UFR Médecine; Reims France
| | - Fatiha Merabet
- Department of Haematology; André Mignot Hospital; Versailles France
| | - Eric Van Den Neste
- Department of Haematology; Saint-Luc Hospital; University Catholic of Leuven; Bruxelles Belgium
| | - Sarah Ivanoff
- Department of Haematology; University Hospital of Amiens; Amiens France
| | - Xavier Roussel
- Department of Haematology; University Hospital of Besançon; Besançon France
| | - Jean-Marc Zini
- Department of Haematology; Saint-Louis Hospital; Paris France
| | - Caroline Regny
- Department of Haematology; University Hospital of Grenoble; Grenoble France
| | - Richard Lemal
- Department of Haematology; University Hospital of Clermont-Ferrand; Clermont-Ferrand France
| | - Laurent Sutton
- Department of Haematology; Hospital of Argenteuil; Argenteuil France
| | - Aurore Perrot
- Department of Haematology; University Hospital of Nancy; Nancy France
| | - Katell Le Dû
- Department of Haematology; Clinique Victor Hugo; Le Mans France
| | - Lukshe Kanagaratnam
- Department of Research and Innovation; University Hospital of Reims; Reims France
| | - Pierre Morel
- Department of Haematology; University Hospital of Amiens; Amiens France
| | - Véronique Leblond
- Department of Haematology; Pitié-Salpêtrière Hospital; UPMC Paris; Grechy France
| | - Alain Delmer
- Department of Haematology; University Hospital of Reims and UFR Médecine; Reims France
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47
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de Leval L, Copie-Bergman C, Rosenwald A, Rimsza L, Pittaluga S, Bisig B, Dirnhofer S, Facchetti F, Pileri S, Fend F, Wotherspoon A. B-cell lymphomas with discordance between pathological features and clinical behavior. Virchows Arch 2017; 471:439-451. [PMID: 28573510 DOI: 10.1007/s00428-017-2152-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 05/02/2017] [Accepted: 05/12/2017] [Indexed: 12/22/2022]
Abstract
B-cell lymphomas encompass a large number of disease entities clinically ranging from indolent to aggressive. The defining pathological features usually predict clinical course, with small and large B-cell lymphomas correlating to low-grade vs high-grade features, but discordant situations may be encountered. Two sessions of the workshop of the XVIII meeting of the European Association for Haematopathology (EAHP) held in Basel in 2016 addressed this topic. One session illustrated various facets of "aggressiveness" in indolent lymphomas, either peculiar clinical manifestations, cytological variants, or unusual genetic features, as well as several examples of progression or transformation to a more aggressive disease. Another session exemplified large B-cell lymphomas with unexpected indolent behavior including cases arising in well-defined body compartments or in sanctuary sites. This paper describes the features of the cases presented in both groups, highlights the most salient points of discussion raised by the submitters and the panel, and summarizes current knowledge and recommendations relevant to diagnostic pathology practice.
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Affiliation(s)
- Laurence de Leval
- Institute of Pathology, University Hospital Lausanne (CHUV), 25 Rue du Bugnon, CH-1011, Lausanne, Switzerland.
| | - Christiane Copie-Bergman
- Department of Pathology, Hopital Henri Mondor, INSERM U955, Université Paris Est, Creteil, France
| | - Andreas Rosenwald
- Institute of Pathology, University of Würzburg and Comprehensive Cancer Center Mainfranken, Würzburg, Germany
| | - Lisa Rimsza
- Department of Laboratory Medicine and Pathology, the Mayo Clinic, Scottsdale, AZ, USA
| | - Stefania Pittaluga
- Laboratory of Pathology, Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - Bettina Bisig
- Institute of Pathology, University Hospital Lausanne (CHUV), 25 Rue du Bugnon, CH-1011, Lausanne, Switzerland
| | - Stefan Dirnhofer
- Institute of Pathology and Genetics, University Hospital Basel, Basel, Switzerland
| | - Fabio Facchetti
- Section of Pathology, Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Stefano Pileri
- Unit of Hematopathology, European Institute of Oncology, Milan, Italy
| | - Falko Fend
- Institute of Pathology and Neuropathology and Comprehensive Cancer Center, University Hospital Tübingen, Tubingen, Germany
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48
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Gavriatopoulou M, Terpos E, Kastritis E, Dimopoulos MA. Current treatment options and investigational drugs for Waldenstrom’s Macroglobulinemia. Expert Opin Investig Drugs 2017; 26:197-205. [DOI: 10.1080/13543784.2017.1275561] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Maria Gavriatopoulou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Alexandra General Hospital, Athens, Greece
| | - Evangelos Terpos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Alexandra General Hospital, Athens, Greece
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Alexandra General Hospital, Athens, Greece
| | - Meletios A. Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Alexandra General Hospital, Athens, Greece
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