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Li Z, Yan C, Hu GX, Zhao R, Jin H, Yun H, Wei Z, Pan CZ, Shu XH, Zeng MS. Layer-specific strain in patients with cardiac amyloidosis using tissue tracking MR. FRONTIERS IN RADIOLOGY 2023; 3:1115527. [PMID: 37601532 PMCID: PMC10435886 DOI: 10.3389/fradi.2023.1115527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 07/04/2023] [Indexed: 08/22/2023]
Abstract
Background Cardiac infiltration is the major predictor of poor prognosis in patients with systemic amyloidosis, thus it becomes of great importance to evaluate cardiac involvement. Purpose We aimed to evaluate left ventricular myocardial deformation alteration in patients with cardiac amyloidosis (CA) using layer-specific tissue tracking MR. Material and Methods Thirty-nine patients with CA were enrolled. Thirty-nine normal controls were also recruited. Layer-specific tissue tracking analysis was done based on cine MR images. Results Compared with the control group, a significant reduction in LV whole layer strain values (GLS, GCS, and GRS) and layer-specific strain values was found in patients with CA (all P < 0.01). In addition, GRS and GLS, as well as subendocardial and subepicardial GLS, GRS, and GCS, were all diminished in patients with CA and reduced LVEF, when compared to those with preserved or mid-range LVEF (all P < 0.05). GCS showed the largest AUC (0.9952, P = 0.0001) with a sensitivity of 93.1% and specificity of 90% to predict reduced LVEF (<40%). Moreover, GCS was the only independent predictor of LV systolic dysfunction (Odds Ratio: 3.30, 95% CI:1.341-8.12, and P = 0.009). Conclusion Layer-specific tissue tracking MR could be a useful method to assess left ventricular myocardial deformation in patients with CA.
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Affiliation(s)
- Zheng Li
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Cardiovascular Disease, Shanghai, China
- Shanghai Institute of Medical Imaging, Shanghai, China
| | - Cheng Yan
- Shanghai Institute of Medical Imaging, Shanghai, China
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guo-Xiang Hu
- Shanghai Institute of Medical Imaging, Shanghai, China
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Rui Zhao
- Department of Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, United States
| | - Hang Jin
- Shanghai Institute of Medical Imaging, Shanghai, China
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Hong Yun
- Shanghai Institute of Medical Imaging, Shanghai, China
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zheng Wei
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Cui-Zhen Pan
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Cardiovascular Disease, Shanghai, China
- Shanghai Institute of Medical Imaging, Shanghai, China
| | - Xian-Hong Shu
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Cardiovascular Disease, Shanghai, China
- Shanghai Institute of Medical Imaging, Shanghai, China
| | - Meng-Su Zeng
- Shanghai Institute of Medical Imaging, Shanghai, China
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
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2
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Maroun BZ, Allam S, Chaulagain CP. Multidisciplinary supportive care in systemic light chain amyloidosis. Blood Res 2022; 57:106-116. [PMID: 35593003 PMCID: PMC9242830 DOI: 10.5045/br.2022.2021227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 04/30/2022] [Accepted: 05/04/2022] [Indexed: 11/17/2022] Open
Abstract
The immunoglobulin light-chain amyloidosis is a multisystemic disease which manifests by damage to the vital organs by light chain-derived amyloid fibril. Traditionally, the treatment has been directed to the underlying plasma cell clone with or without high dose chemotherapy followed by autologous stem cell transplantation using melphalan based conditioning. Now with the approval of highly tolerable anti-CD38 monoclonal antibody daratumumab based anti-plasma cell therapy in 2021, high rates of hematologic complete responses are possible even in patients who are otherwise deemed not a candidate for autologous stem cell transplantation. However, despite the progress, there remains a limitation in the strategies to improve symptoms particularly in patients with advanced cardiac involvement, those with nephrotic syndrome and autonomic dysfunction due to underlying systemic AL amyloidosis. The symptoms can be an ordeal for the patients and their caregivers and effective strategies are urgently needed to address them. The supportive care is aimed to counteract the symptoms of the disease and the effects of the treatment on involved organs’ function and preserve patients’ quality of life. Here we discuss multidisciplinary approach in a system-based fashion to address the symptom management in this dreadful disease. In addition to achieving excellent anti-plasma cell disease control, using treatment directed to remove amyloid from the vital organs can theoretically hasten recovery of the involved organs thereby improving symptoms at a faster pace. Ongoing phase III clinical trials of CAEL-101 and Birtamimab will address this question.
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Affiliation(s)
- Bou Zerdan Maroun
- Department of Hematology-Oncology, Myeloma and Amyloidosis Program, Maroone Cancer Center, Cleveland Clinic Florida, Weston FL, USA
| | - Sabine Allam
- Faculty of Medicine, University of Balamand, Beirut, Lebanon
| | - Chakra P Chaulagain
- Department of Hematology-Oncology, Myeloma and Amyloidosis Program, Maroone Cancer Center, Cleveland Clinic Florida, Weston FL, USA
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3
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Safety, tolerability, and response rates of daratumumab in relapsed AL amyloidosis: results of a phase 2 study. Blood 2020; 135:1541-1547. [PMID: 31978210 DOI: 10.1182/blood.2019004436] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 01/15/2020] [Indexed: 12/23/2022] Open
Abstract
Daratumumab, a monoclonal CD38 antibody, is approved in the treatment of myeloma, but its efficacy and safety in light-chain (AL) amyloidosis has not been formally studied. This prospective phase 2 trial of daratumumab monotherapy for the treatment of AL amyloidosis was designed to determine the safety, tolerability, and hematologic and clinical response. Daratumumab 16 mg/kg was administered by IV infusion once weekly for weeks 1 to 8, every 2 weeks for weeks 9 to 24, and every 4 weeks thereafter until progression or unacceptable toxicity, for up to 24 months. Twenty-two patients with previously treated AL amyloidosis were enrolled. The majority of the patients had received high-dose melphalan and stem cell transplantation and/or treatment with a proteasome inhibitor. The median time between prior therapy and trial enrollment was 9 months (range, 1-180 months). No grade 3-4 infusion-related reactions occurred. The most common grade ≥3 adverse events included respiratory infections (n = 4; 18%) and atrial fibrillation (n = 4, 18%). Hematologic complete and very-good-partial response occurred in 86% of patients. The median time to first and best hematologic response was 4 weeks and 3 months, respectively. Renal response occurred in 10 of 15 patients (67%) with renal involvement and cardiac response occurred in 7 of 14 patients (50%) with cardiac involvement. In summary, daratumumab is well tolerated in patients with relapsed AL amyloidosis and leads to rapid and deep hematologic responses and organ responses. This trial was registered at www.clinicaltrials.gov as #NCT02841033.
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4
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Schulman A, Connors LH, Weinberg J, Mendelson LM, Joshi T, Shelton AC, Sanchorawala V. Patient outcomes in light chain (AL) amyloidosis: The clock is ticking from symptoms to diagnosis. Eur J Haematol 2020; 105:495-501. [DOI: 10.1111/ejh.13472] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/11/2020] [Accepted: 06/13/2020] [Indexed: 12/19/2022]
Affiliation(s)
- Amanda Schulman
- Amyloidosis Center Boston Medical Center Boston University School of Medicine Boston Massachusetts USA
| | - Lawreen H Connors
- Amyloidosis Center Boston Medical Center Boston University School of Medicine Boston Massachusetts USA
| | - Janice Weinberg
- Department of Biostatistics Boston University School of Public Health Boston Massachusetts USA
| | - Lisa M Mendelson
- Amyloidosis Center Boston Medical Center Boston University School of Medicine Boston Massachusetts USA
| | - Tracy Joshi
- Amyloidosis Center Boston Medical Center Boston University School of Medicine Boston Massachusetts USA
| | - Anthony C Shelton
- Amyloidosis Center Boston Medical Center Boston University School of Medicine Boston Massachusetts USA
| | - Vaishali Sanchorawala
- Amyloidosis Center Boston Medical Center Boston University School of Medicine Boston Massachusetts USA
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5
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Jain A, Ramasamy K. Time to Redefine Risk-Stratification and Response Criteria in Immunoglobulin Light Chain Amyloidosis? CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 20:e769-e776. [PMID: 32653456 DOI: 10.1016/j.clml.2020.05.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/21/2020] [Accepted: 05/29/2020] [Indexed: 12/20/2022]
Abstract
Immunoglobulin light chain (AL) amyloidosis results from clonal plasma cell (PC)-derived immunoglobulin light chain-mediated end-organ dysfunction, the extent and severity of which predicts survival. Anti-PC therapies reduce clonal light chain burden, which usually results in improvement of organ function, and consequently overall survival. Response assessment is critical to gauge therapeutic efficacy, to report clinical trial outcomes, and to switch therapy in those without response. Response in AL amyloidosis is 2-fold: hematologic response and organ response (OR). Depth of hematologic response is graded on the basis of serum free light chain (sFLC) parameters, but assessment of OR is binary. The role of normal sFLC ratio or complete remission as a treatment end point has been challenged, thus highlighting the need to quantify involved FLC and residual PC beyond the normal sFLC ratio to possibly account for the ongoing organ damage seen in some patients with complete remission. Mass spectrometry and urinary exosome represent ultrasensitive strategies to estimate involved FLC below the detection threshold of current sFLC assays. The role of new sFLC parameters and minimal residual disease as potential prognostic parameters has been recognized. Brain natriuretic peptide (BNP) and 24-hour proteinuria:estimated glomerular filtration rate ratio were identified to overcome certain limitations of N-terminal-Pro-BNP, 24-hour proteinuria, and estimated glomerular filtration rate for cardiac and renal response assessment, respectively. Use of monoclonal antibodies targeting PC and amyloid deposits has expanded the therapeutic armamentarium of AL amyloidosis, and given their excellent efficacy, early ORs are reported. This review provides insights into recent advances in the risk-stratification and response assessment of patients with AL amyloidosis in light of the changing therapeutic paradigms. Incorporation of these advancements into formal consensus guidelines would require further validation.
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Affiliation(s)
- Ankur Jain
- Department of hematology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India.
| | - Karthik Ramasamy
- Department of Haematology, Oxford University Hospitals, NHS Foundation Trust; NIHR BRC Blood Theme, Oxford, England, UK; Oxford Myeloma Centre for Translational Research
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6
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Cohen OC, Sharpley F, Gillmore JD, Lachmann HJ, Sachchithanantham S, Mahmood S, Fontana M, Whelan CJ, Martinez-Naharro A, Kyriakou C, Rabin N, Popat R, Yong K, Cheesman S, Shah R, Hawkins PN, Wechalekar AD. Use of ixazomib, lenalidomide and dexamethasone in patients with relapsed amyloid light-chain amyloidosis. Br J Haematol 2020; 189:643-649. [PMID: 31984481 DOI: 10.1111/bjh.16401] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 11/25/2019] [Indexed: 02/06/2023]
Abstract
With improving outcomes in amyloid light-chain (AL) amyloidosis, there is a need to study novel agents in this setting. We report outcomes of 40 patients with relapsed AL amyloidosis treated with ixazomib + lenalidomide + dexamethasone (IRd). Haematological responses were assessed on an intention-to-treat basis at three months: complete response (CR) - 8 (20·5%), very good partial response (VGPR) - 8 (20·5%), partial response (PR) - 7 (17·9%) and no response (NR) - 16 (41·0%). One patient had missing data. Six patients subsequently improved response. Best responses were: CR - 10 (25·6%), VGPR - 8 (20·5%), PR - 7 (17·9%), NR - 14 (35·9%). Cardiac and renal organ responses occurred in 5·6% and 13·3% respectively. Median progession-free survival (PFS) was 17·0 months (95% CI 7·3-20·7 months), improving to 28·8 months (95% CI 20·6-37·0 months) in those achieving CR/VGPR. Median overall survival was 29·1 months (95% CI 24-33 months). Serious adverse events were seen in 14 (35·0%) patients inclusive of 15 admissions due to: infection (6/15, 40·0%), fluid overload (5/15, 33·3%), cardiac arrhythmia (2/15, 13·3%), renal dysfunction (1/15, 6·6%) and anaemia (1/15, 6·6%). In summary, IRd is an oral treatment option with a manageable toxicity profile leading to deep responses in 47% of patients with relapsed AL amyloidosis.
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Affiliation(s)
- Oliver C Cohen
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
| | - Faye Sharpley
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
| | - Julian D Gillmore
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
| | - Helen J Lachmann
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
| | - Sajitha Sachchithanantham
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK.,University College London Hospitals NHS Trust, London, UK
| | - Shameem Mahmood
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK.,University College London Hospitals NHS Trust, London, UK
| | - Marianna Fontana
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
| | - Carol J Whelan
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
| | - Ana Martinez-Naharro
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
| | | | - Neil Rabin
- University College London Hospitals NHS Trust, London, UK
| | - Rakesh Popat
- University College London Hospitals NHS Trust, London, UK
| | - Kwee Yong
- University College London Hospitals NHS Trust, London, UK
| | - Simon Cheesman
- University College London Hospitals NHS Trust, London, UK
| | - Raakhee Shah
- University College London Hospitals NHS Trust, London, UK
| | - Philip N Hawkins
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
| | - Ashutosh D Wechalekar
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK.,University College London Hospitals NHS Trust, London, UK
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7
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Mehta P, Chapel DB, Goyal N, Yu DB, Mor-Avi V, Narang A, Addetia K, Sarswat N, Lang RM, Husain AN, Patel AR. A histopathologic schema to quantify the burden of cardiac amyloidosis: Relationship with survival and echocardiographic parameters. Echocardiography 2018; 36:285-291. [PMID: 30592782 DOI: 10.1111/echo.14245] [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: 09/06/2018] [Revised: 11/16/2018] [Accepted: 12/04/2018] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Despite routine use of echocardiographic parameters to evaluate the severity of cardiac amyloidosis (CA), this methodology has not been well validated. We developed a histopathologic schema for quantifying CA burden and evaluated its relationship with clinical outcomes. Additionally, echocardiographic parameters were tested as potential noninvasive indices of CA burden. METHODS We retrospectively studied 59 patients with CA (17 light chain, 42 transthyretin) who underwent endomyocardial biopsies. Light microscopy with staining was used to categorize CA burden as mild-to-moderate (<50%) or high (≥50%). Kaplan-Meier survival analysis was performed for the two groups. In 34 patients with good-quality echocardiograms, we measured left ventricular volumes, ejection fraction (EF), interventricular septal thickness (IVSt), posterior wall thickness (PWt), LV mass, lateral e'-velocity, and global longitudinal strain (GLS). These parameters were compared between the two groups. RESULTS Thirty-five patients had mild-to-moderate and 24 severe amyloid burden. Kaplan-Meier curves demonstrated a trend toward worse mortality with high CA burden, which was more common and associated with higher mortality specifically in transthyretin-type patients. Echocardiography-derived IVSt, PWt, and LV mass were directly related to CA burden, while LV EF, e'-velocity, and GLS magnitude were inversely related to CA burden. CONCLUSIONS Our findings provided a signal that CA burden is a clinically important entity with potentially valuable prognostic information. Echocardiographic parameters of LV anatomy and function correlate with histopathologic burden of CA, which is inversely related to survival. Further studies are needed to determine whether these parameters could be used as imaging biomarkers of treatment-related changes in CA burden.
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Affiliation(s)
- Priya Mehta
- Departments of Medicine, University of Chicago, Chicago, Illinois
| | - David B Chapel
- Departments of Medicine, University of Chicago, Chicago, Illinois
| | - Neha Goyal
- Departments of Medicine, University of Chicago, Chicago, Illinois
| | - Dong Bo Yu
- Departments of Medicine, University of Chicago, Chicago, Illinois
| | - Victor Mor-Avi
- Departments of Medicine, University of Chicago, Chicago, Illinois
| | - Akhil Narang
- Departments of Medicine, University of Chicago, Chicago, Illinois
| | - Karima Addetia
- Departments of Medicine, University of Chicago, Chicago, Illinois
| | - Nitasha Sarswat
- Departments of Medicine, University of Chicago, Chicago, Illinois
| | - Roberto M Lang
- Departments of Medicine, University of Chicago, Chicago, Illinois
| | - Aliya N Husain
- Departments of Pathology, University of Chicago, Chicago, Illinois
| | - Amit R Patel
- Departments of Medicine, University of Chicago, Chicago, Illinois.,Departments of Radiology, University of Chicago, Chicago, Illinois
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