Underweight as a risk factor of mortality in patients with newly diagnosed multiple myeloma

The relationship between LDH and GLIM criteria for cancer cachexia: Systematic review and meta-analysis

INTRODUCTION

Cancer cachexia is a clinical condition characterized by recognizable "sickness behaviors" accompanied by loss of lean body tissue. The Global Leadership on Malnutrition (GLIM) has proposed phenotypic (unintentional weight loss, low body mass index and low muscle mass) and aetiologic (reduced food intake and inflammation or disease burden) diagnostic criteria. Recent work has suggested serum lactate dehydrogenase (LDH) might represent a 3rd aetiologic criteria. Little is known of its relationship with GLIM. A systematic review and meta-analysis of their comparative prognostic value and association was performed.

METHODS

A search of electronic databases (PubMed, Medline, Ovid, Cochrane) up to February 2023 was used to identify studies that compared the prognostic value of LDH and components of the GLIM criteria in cancer. An analysis of the relationship between LDH and the components of GLIM was undertaken where this data was available. RevMan 5.4.1 was used to perform a meta-analysis for each diagnostic criteria that had 3 or more studies which reported hazard ratios with a 95 per cent confidence interval for overall survival (OS).

RESULTS

A total of 119 studies were reviewed. Advanced lung cancer was the most studied population. Included in the meta-analysis were 6 studies (n=2165) on LDH and weight loss, 17 studies (n=7540) on LDH and low BMI, 5 studies (n=758) on LDH and low muscle mass, 0 studies on LDH and food intake and 93 studies (n=32,190) on LDH and inflammation. There was a significant association between elevated serum LDH and each of low BMI (OR 1.39, 1.09 - 1.77; p=0.008), elevated NLR (OR 2.04, 1.57 - 2.65; p<0.00001) and elevated CRP (OR 2.58, 1.81 - 3.67; p<0.00001). There was no association between elevated serum LDH and low muscle mass. Only one study presented data on the association between LDH and unintentional weight loss. Elevated LDH showed a comparative OS (HR 1.86, 1.57 - 2.07; p<0.00001) to unintentional weight loss (HR 1.57, 1.23 - 1.99; p=0.0002) and had a similar OS (HR 2.00, 1.70 - 2.34; p<0.00001) to low BMI (HR 1.57, 1.29-2.90; p<0.0001). LDH also showed an OS (HR 2.25, 1.76 - 2.87; p<0.00001) congruous with low muscle mass (HR 1.93, 1.14 - 3.27; p=0.01) and again, LDH conferred as poor an OS (HR 1.77, 1.64-1.90; p<0.00001) as elevated NLR (HR 1.61, 1.48 - 1.77; p<0.00001) or CRP (HR 1.55, 1.43 - 1.69; p<0.00001).

CONCLUSION

Current literature suggests elevated serum LDH is associated with inflammation in cancer (an aetiologic GLIM criterion), however more work is required to establish the relationship between LDH and the phenotypic components of GLIM. Additionally, elevated serum LDH appears to be a comparative prognosticator of overall survival in cancer when compared to the GLIM criteria.

Cystatin C and eGFRCKD-EPI-CysC: novel biomarkers for renal impairment diagnosis and two-year progression-free survival in multiple myeloma

To evaluate cystatin C (CysC) and estimation of glomerular filtration rate (GFR) calculated using the formula, CKD-EPI-CysC (eGFRCKD-EPI-CysC) for renal impairment diagnosis and predicting the prognosis of patients with multiple myeloma (MM). One hundred-fourteen patients with MM and 38 healthy individuals were recruited for the study. Data on clinical characteristics and renal function-related biochemical indicators were collected and analyzed. Patients with MM had increased levels of CysC (1.25 (0.97-2.31) vs. 0.84 (0.80-0.92), respectively, p < 0.001) and decreased levels of eGFRCKD-EPI-CysC (53.0 (24.4-81.1) vs. 97.2 (87.0-104.5), respectively, p < 0.001), compared with healthy individuals. There were significantly more patients with elevated CysC levels than with elevated sCr levels (64.9% vs. 41.2%, respectively, p < 0.001). The CKD-EPI-CysC formula detected more patients with eGFR < 60 ml/(min × 1.73 m2) than the CKD-EPI-sCr formula (52.63% vs. 37.72%, respectively, p < 0.001). Correlation analysis found that only CysC, eGFRCKD-EPI-CysC, and eGFRCKD-EPI-sCr-CysC strongly correlated with β2-microglobulin in group ISS-I. Logistic regression analysis was used to screen CysC (OR = 1.495, 95% CI = 1.097-2.038, p = 0.011) and eGFRCKD-EPI-CysC (OR = 0.980, 95% CI = 0.967-0.993, p = 0.003) as independent prognostic indicators for 2-year-progression-free survival (PFS) of patients with MM. Receiver operating characteristic curve analysis found that CysC values >1.70 mg/L had 67.6% sensitivity and 65.2% specificity and eGFRCKD-EPI-CysC values <38.62 ml/(min × 1.73 m2) had 65.2% sensitivity and 67.6% specificity for 2-year PFS of patients with MM. In summary, CysC and eGFRCKD-EPI-CysC were more sensitive than sCr and eGFRCKD-EPI-sCr for predicting renal impairment in patients newly diagnosed with MM. Increased CysC and decreased eGFRCKD-EPI-CysC levels were effective predictors of 2-year PFS of patients with MM.

Contribution of the Tumor Microenvironment to Metabolic Changes Triggering Resistance of Multiple Myeloma to Proteasome Inhibitors

Virtually all patients with multiple myeloma become unresponsive to treatment with proteasome inhibitors over time. Relapsed/refractory multiple myeloma is accompanied by the clonal evolution of myeloma cells with heterogeneous genomic aberrations, diverse proteomic and metabolic alterations, and profound changes of the bone marrow microenvironment. However, the molecular mechanisms that drive resistance to proteasome inhibitors within the context of the bone marrow microenvironment remain elusive. In this review article, we summarize the latest knowledge about the complex interaction of malignant plasma cells with its surrounding microenvironment. We discuss the pivotal role of metabolic reprograming of malignant plasma cells within the tumor microenvironment with a subsequent focus on metabolic rewiring in plasma cells upon treatment with proteasome inhibitors, driving multiple ways of adaptation to the treatment. At the same time, mutual interaction of plasma cells with the surrounding tumor microenvironment drives multiple metabolic alterations in the bone marrow. This provides a tumor-promoting environment, but at the same time may offer novel therapeutic options for the treatment of relapsed/refractory myeloma patients.