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Sanchorawala V. Systemic Light Chain Amyloidosis. N Engl J Med 2024; 390:2295-2307. [PMID: 38924733 DOI: 10.1056/nejmra2304088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Affiliation(s)
- Vaishali Sanchorawala
- From the Amyloidosis Center, Boston University Chobanian and Avedisian School of Medicine, Boston Medical Center, Boston
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Edwards CV, Ferri GM, Villegas-Galaviz J, Ghosh S, Bawa PS, Wang F, Klimtchuk E, Ajayi TB, Morgan GJ, Prokaeva T, Staron A, Ruberg FL, Sanchorawala V, Giadone RM, Murphy GJ. Abnormal global longitudinal strain and reduced serum inflammatory markers in cardiac AL amyloidosis patients without significant amyloid fibril deposition. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.03.14.584987. [PMID: 38558967 PMCID: PMC10980073 DOI: 10.1101/2024.03.14.584987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Background Cardiac dysfunction in AL amyloidosis is thought to be partly related to the direct impact of AL LCs on cardiomyocyte function, with the degree of dysfunction at diagnosis as a major determinant of clinical outcomes. Nonetheless, mechanisms underlying LC-induced myocardial toxicity are not well understood. Methods We identified gene expression changes correlating with human cardiac cells exposed to a cardiomyopathy-associated κAL LC. We then sought to confirm these findings in a clinical dataset by focusing on clinical parameters associated with the pathways dysregulated at the gene expression level. Results Upon exposure to a cardiomyopathy-associated κAL LC, cardiac cells exhibited gene expression changes related to myocardial contractile function and inflammation, leading us to hypothesize that there could be clinically detectable changes in GLS on echocardiogram and serum inflammatory markers in patients. Thus, we identified 29 patients with normal IVSd but abnormal cardiac biomarkers suggestive of LC-induced cardiac dysfunction. These patients display early cardiac biomarker staging, abnormal GLS, and significantly reduced serum inflammatory markers compared to patients with clinically evident amyloid fibril deposition. Conclusion Collectively, our findings highlight early molecular and functional signatures of cardiac AL amyloidosis, with potential impact for developing improved patient biomarkers and novel therapeutics.
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Hughes MS, Lentzsch S. Safety and Efficacy of Subcutaneous Daratumumab in Systemic AL Amyloidosis. Ther Clin Risk Manag 2023; 19:1063-1074. [PMID: 38164204 PMCID: PMC10758190 DOI: 10.2147/tcrm.s325859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 12/04/2023] [Indexed: 01/03/2024] Open
Abstract
Introduction Systemic AL amyloidosis, a plasma cell dyscrasia, is characterized by the production of misfolded immunoglobulin light chain. These misfolded proteins aggregate into amyloid fibrils and deposit throughout the body, resulting in widespread organ dysfunction and ultimately death. Achieving rapid and maximal elimination of the plasma cell clone is crucial to long-term survival. Daratumumab, an anti-CD38 monoclonal antibody delivered intravenously, has been swiftly incorporated into standard first-line treatment regimens. A novel formulation of daratumumab has been developed that can be injected subcutaneously. Areas Covered As a retrospective qualitative review of prior publications involving daratumumab, this work briefly summarizes the existing data regarding the safety and efficacy of subcutaneous (SC) daratumumab, compared to intravenous (IV) daratumumab. SC daratumumab appears to deliver the same disease benefit as IV daratumumab to patients with decreased infusion-related reactions (IRRs), decreased time for administration, and similar rates of adverse events (AEs) intrinsically related to daratumumab. Expert Opinion SC daratumumab is preferred over IV daratumumab, but the clinical situation ultimately should determine route of administration. Further investigation into cost-effectiveness benefit is warranted.
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Affiliation(s)
- Michael Sang Hughes
- Department of Hematology-Oncology, Columbia University Irving Medical Center, New York, NY, USA
| | - Suzanne Lentzsch
- Department of Hematology-Oncology, Columbia University Irving Medical Center, New York, NY, USA
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Abstract
Various types of systemic amyloidosis can wreak havoc on the architecture and functioning of the kidneys. Amyloidosis should be suspected in patients with worsening kidney function, proteinuria, and multisystem involvement, but isolated kidney involvement also is possible. Confirming the amyloidosis type and specific organ dysfunction is of paramount importance to select the appropriately tailored treatment and aim for better survival while avoiding treatment-associated toxicities. Amyloid renal staging in light chain amyloidosis amyloidosis helps inform prognosis and risk for end-stage kidney disease. Biomarker-based staging systems and response assessment guide the therapeutic strategy and allow the timely identification of refractory or relapsing disease so that patients can be switched to salvage therapy. Kidney transplantation is a viable option for selected patients with amyloidosis. Because of the complex nature of the pathophysiology and treatment of amyloidosis, a multidisciplinary team-based approach should be used in the care of these patients.
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Affiliation(s)
- Ralph Nader
- Renal, Electrolyte and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Avital Angel-Korman
- Nephrology and Hypertension Institute, Samson Assuta University Hospital, Ashdod, Israel; Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheba, Israel
| | - Andrea Havasi
- Amyloidosis Center, Boston University School of Medicine, Boston, MA; Clinical Research, Alnylam Pharmaceuticals, Cambridge, MA.
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He H, Lu J, Qiang W, Liu J, Liang A, Du J. The Landscape of Cytogenetic Aberrations in Light-Chain Amyloidosis with or without Coexistent Multiple Myeloma. J Clin Med 2023; 12:jcm12041624. [PMID: 36836158 PMCID: PMC9962902 DOI: 10.3390/jcm12041624] [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] [Received: 01/06/2023] [Revised: 01/28/2023] [Accepted: 02/10/2023] [Indexed: 02/22/2023] Open
Abstract
Interphase fluorescence in situ hybridization (iFISH) has been well established in the preliminary prognostic evaluation of multiple myeloma (MM). However, the chromosomal aberrations in patients with systemic light-chain amyloidosis, notably in patients with coexistent MM, have been rarely investigated. This study aimed to evaluate the effect of iFISH aberrations on the prognosis of systemic light-chain amyloidosis (AL) with and without concurrent MM. The iFISH results and clinical characteristics of 142 patients with systemic light-chain amyloidosis were analyzed, and survival analysis was conducted. Among the 142 patients, 80 patients had AL amyloidosis alone, and the other 62 patients had concurrent MM. The incidence rate of 13q deletion, t(4;14), was higher in AL amyloidosis patients with concurrent MM than that of primary AL amyloidosis patients (27.4% vs. 12.5%, and 12.9% vs. 5.0%, respectively), and the incidence rate of t(11;14) in primary AL amyloidosis patients was higher than that in AL amyloidosis patients with concurrent MM (15.0% vs. 9.7%). Moreover, the two groups had the similar incidence rates of 1q21 gain (53.8% and 56.5%, respectively). The result of the survival analysis suggested that patients with t(11;14) and 1q21 gain had a shorter median overall survival (OS) and progression-free survival (PFS), irrespective of the presence or absence of MM, and patients with AL amyloidosis and concurrent MM carrying t(11;14) had the poorest prognosis, with a median OS time of 8.1 months.
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Affiliation(s)
- Haiyan He
- Shanghai Tongji Hospital, School of Medicine, Tongji University, Shanghai 200092, China
- Department of Hematology, Myeloma & Lymphoma Center, Changzheng Hospital, Naval Medical University, Shanghai 200003, China
| | - Jing Lu
- Department of Hematology, Myeloma & Lymphoma Center, Changzheng Hospital, Naval Medical University, Shanghai 200003, China
| | - Wanting Qiang
- Department of Hematology, Myeloma & Lymphoma Center, Changzheng Hospital, Naval Medical University, Shanghai 200003, China
| | - Jin Liu
- Department of Hematology, Myeloma & Lymphoma Center, Changzheng Hospital, Naval Medical University, Shanghai 200003, China
| | - Aibin Liang
- Shanghai Tongji Hospital, School of Medicine, Tongji University, Shanghai 200092, China
- Correspondence: (A.L.); (J.D.)
| | - Juan Du
- Department of Hematology, Myeloma & Lymphoma Center, Changzheng Hospital, Naval Medical University, Shanghai 200003, China
- Correspondence: (A.L.); (J.D.)
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Diagnosis and Treatment of AL Amyloidosis. Drugs 2023; 83:203-216. [PMID: 36652193 DOI: 10.1007/s40265-022-01830-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2022] [Indexed: 01/19/2023]
Abstract
Systemic light chain (AL) amyloidosis is caused by an usually small B cell clone that produces a toxic light chain forming amyloid deposits in tissue. The heart and kidney are the major organs affected, but all others, with the exception of the CNS, can be involved. The disease is rapidly progressive, and it is still diagnosed late. Screening programs in patients followed by hematologists for plasma cell dyscrasias should be considered. The diagnosis requires demonstration in a tissue biopsy of amyloid deposits formed by immunoglobulin light chains. The workup of patients with AL amyloidosis requires adequate technology and expertise, and patients should be referred to specialized centers whenever possible. Stagings are based on cardiac and renal biomarkers and guides the choice of treatment. The combination of daratumumab, cyclophosphamide, bortezomib and dexamethasone (dara-CyBorD) is the current standard of care. Autologous stem cell transplant is performed in eligible patients, especially those who do not attain a satisfactory response to dara-CyBorD. Passive immunotherapy targeting the amyloid deposits combined with chemo-/immune-therapy targeting the amyloid clone is currently being tested in controlled clinical trials. Response to therapy is assessed based on validated criteria. Profound hematologic response is the early goal of treatment and should be accompanied over time by deepening organ response. Many relapsed/refractory patients are also treated with daratumumab combination, but novel regimens will be needed to rescue daratumumab-exposed subjects. Immunomodulatory drugs are the current cornerstone of rescue therapy, while immunotherapy targeting B-cell maturation antigen and inhibitors of Bcl-2 are promising alternatives.
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Palladini G, Milani P. Individualized Approach to Management of Light Chain Amyloidosis. J Natl Compr Canc Netw 2023; 21:91-98. [PMID: 36634608 DOI: 10.6004/jnccn.2022.7092] [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: 07/17/2022] [Accepted: 10/24/2022] [Indexed: 01/13/2023]
Abstract
Systemic light chain (AL) amyloidosis is caused by a B-cell (most commonly plasma cell) clone that produces a toxic light chain that forms amyloid fibrils in tissues and causes severe, progressive organ dysfunction. The clinical presentation is protean, and patients are usually extremely frail, thus requiring careful adaptation of the treatment approach. However, the severity of organ involvement can be accurately assessed with biomarkers that allow a sharp prognostic stratification and precise tailoring of the treatment strategy. Moreover, the availability of biomarker-based response criteria also allows adjustment of the treatment approach over time. The recent completion of 3 large randomized clinical trials has offered new evidence for designing appropriate treatments. All this information has recently been integrated in the joint guidelines of the International Society of Amyloidosis and the European Hematology Association for the treatment of AL amyloidosis. Other clinical trials are underway testing new agents directed against the amyloid clone and the amyloid deposits. Our understanding of the peculiarities of the amyloid clone, as well as our ability to detect residual clonal disease and improve organ dysfunction, are also being refined and will result in more precise personalization of the treatment approach.
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Affiliation(s)
- Giovanni Palladini
- Department of Molecular Medicine, University of Pavia, Italy.,Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Paolo Milani
- Department of Molecular Medicine, University of Pavia, Italy.,Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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Intérêt du daratumumab dans l’amylose AL réfractaire chez une patiente de 96 ans. Rev Med Interne 2022; 43:673-676. [DOI: 10.1016/j.revmed.2022.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 06/26/2022] [Accepted: 07/18/2022] [Indexed: 01/15/2023]
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Differences in the cytogenetic underpinnings of AL amyloidosis among African Americans and Caucasian Americans. Blood Cancer J 2022; 12:100. [PMID: 35787622 PMCID: PMC9253332 DOI: 10.1038/s41408-022-00697-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 06/13/2022] [Accepted: 06/15/2022] [Indexed: 11/08/2022] Open
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