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Gertz MA. Waldenström macroglobulinemia treatment algorithm 2018. Blood Cancer J 2018; 8:40. [PMID: 29712895 PMCID: PMC5928091 DOI: 10.1038/s41408-018-0076-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 03/01/2018] [Accepted: 03/08/2018] [Indexed: 12/11/2022] Open
Abstract
Waldenström macroglobulinemia is often an indolent disorder, and many patients are candidates for observation with careful monitoring. For symptomatic patients, one must distinguish between those patients whose symptoms are related to immunologic manifestations associated with the IgM monoclonal protein and those that have symptoms related to progressive marrow and nodal infiltration with lymphoplasmacytic lymphoma. In Waldenström macroglobulinemia, the driver for therapy in the majority of patients is progressive anemia, secondary to bone marrow replacement by lymphoplasmacytic lymphoma. Recent introduction of MYD88 mutational analysis has been very useful for diagnostic purposes but is unclear what effect it might have on the prognosis or response rate to therapy. An algorithm is provided on the management of asymptomatic individuals and the sequence used for chemotherapeutic intervention of symptomatic patients.
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Affiliation(s)
- Morie A Gertz
- Division of Hematology, Mayo Clinic, 200 First Street, SW, Rochester, MN, 55905, USA.
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Tashiro H, Shirasaki R, Watanabe M, Kawasugi K, Takahashi Y, Shirafuji N. Direct Factor X sequestration by systemic amyloid light-chain amyloidosis. Clin Case Rep 2018. [PMID: 29531730 PMCID: PMC5838284 DOI: 10.1002/ccr3.1398] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
We present a lymphoplasmacytic lymphoma patient with Factor X (FX) deficiency. Despite the absence of FX inhibitor, the administration of fresh frozen plasma and anti‐inhibitor coagulant complex did not increase the FX level. The autopsy showed that massive amyloid depositions to multiple organs and FX existed in union with amyloidosis.
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Affiliation(s)
- Haruko Tashiro
- Department of Hematology/OncologyTeikyo University School of MedicineItabashi‐kuTokyoJapan
| | - Ryosuke Shirasaki
- Department of Hematology/OncologyTeikyo University School of MedicineItabashi‐kuTokyoJapan
| | - Masato Watanabe
- Department of PathologyTeikyo University School of MedicineItabashi‐kuTokyoJapan
| | - Kazuo Kawasugi
- Department of Hematology/OncologyTeikyo University School of MedicineItabashi‐kuTokyoJapan
| | - Yoshihisa Takahashi
- Department of PathologyGraduate School of Medical SciencesInternational University of Health and WelfareNaritaChibaJapan
| | - Naoki Shirafuji
- Department of Hematology/OncologyTeikyo University School of MedicineItabashi‐kuTokyoJapan
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Shimazaki C, Hata H, Iida S, Ueda M, Katoh N, Sekijima Y, Ikeda S, Yazaki M, Fukushima W, Ando Y. Nationwide Survey of 741 Patients with Systemic Amyloid Light-chain Amyloidosis in Japan. Intern Med 2018; 57:181-187. [PMID: 29093404 PMCID: PMC5820034 DOI: 10.2169/internalmedicine.9206-17] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Objective To retrospectively investigate the clinical manifestations of systemic amyloid light-chain (AL) amyloidosis in Japanese patients and the treatment strategy for the condition. Methods We conducted a survey of Japanese AL amyloidosis patients, who were treated between January 1, 2012, and December 31, 2014. Results A total of 741 AL amyloidosis patients were included in this study (436 men and 305 women; median age: 65 years old, range: 31-93). The most frequently affected organ was the kidneys (n=542), followed by the heart (n=252), gastrointestinal (GI) tract (n=164), autonomic nervous system (n=131), liver (n=71), and peripheral nervous system (n=71). Diagnostic findings were most commonly detected in the GI tract (upper GI tract: 350 cases, lower GI tract: 167 cases), followed by the bone marrow and kidneys. An abdominal fat-pad biopsy was only conducted in 128 patients. Autologous stem cell transplants (ASCTs) and bortezomib were used to treat 126 and 276 patients, respectively. Conclusion The clinical features of Japanese patients with systemic AL amyloidosis are similar to those reported previously for cases in the US and Europe. Regarding treatment, a significant number of ASCTs were performed in Japan as well as in Western countries. Surprisingly, a marked number of patients received bortezomib as a treatment for AL amyloidosis.
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Affiliation(s)
- Chihiro Shimazaki
- Department of Hematology, Japan Community Health care Organization Kyoto Kuramaguchi Medical Center, Japan
| | - Hiroyuki Hata
- Department of Immunology and Hematology, Graduate School of Health Sciences, Kumamoto University, Japan
| | - Sinsuke Iida
- Department of Hematology and Oncology, Nagoya City University Graduate School of Medical Sciences, Japan
| | - Mitsuharu Ueda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Japan
| | - Nagaaki Katoh
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Japan
| | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Japan
| | - Shuichi Ikeda
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Japan
| | - Masahide Yazaki
- Department of Biological Sciences for Intractable Neurological Diseases, Institute for Biomedical Sciences, Shinshu University, Japan
| | - Wakaba Fukushima
- Department of Public Health, Osaka City University Faculty of Medicine, Japan
| | - Yukio Ando
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Japan
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Gertz MA, Lacy MQ, Dispenzieri A, Buadi FK, Dingli D, Hayman SR, Kumar SK, Leung N, Lust J, Rajkumar SV, Russell SJ, Suman VJ, Le-Rademacher JG, Hogan WJ. Stem cell transplantation compared with melphalan plus dexamethasone in the treatment of immunoglobulin light-chain amyloidosis. Cancer 2016; 122:2197-205. [PMID: 27142462 PMCID: PMC4930380 DOI: 10.1002/cncr.30051] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 03/22/2016] [Accepted: 03/28/2016] [Indexed: 01/27/2023]
Abstract
BACKGROUND Autologous stem cell transplantation (SCT) is a common management strategy for select patients with immunoglobulin light-chain amyloidosis, but no trials have documented improved overall survival. METHODS Eighty-nine patients with biopsy-proven immunoglobulin light-chain amyloidosis were allowed to select treatment with melphalan plus dexamethasone (n = 34) or SCT (n = 55); all patients were transplant eligible. Treatment preference resulted in imbalanced study arms. Patients who selected SCT were younger, more frequently had an Eastern Cooperative Oncology Group performance status score less than 2, had lower-stage amyloidosis, and had a lower incidence of cardiac amyloidosis. RESULTS Patients receiving melphalan plus dexamethasone had a 3-year progression-free survival rate of 29.1% and an overall survival rate of 58.8%. Patients undergoing SCT had a 3-year progression-free survival rate of 51.7% and an overall survival rate of 83.6%. An attempt to match patients between the 2 arms in terms of risk produced 24 matched triplet sets (2 SCT patients for each melphalan-dexamethasone patient); there was no difference in hematologic response, but there was better survival after autologous SCT. A propensity score-matched analysis of the cohorts (melphalan plus dexamethasone vs SCT) showed an overall mortality hazard ratio of 2.56 (P < .01). CONCLUSIONS Although the study had limitations, similar hematologic responses and improved survival were observed after SCT versus melphalan plus dexamethasone. Cancer 2016;122:2197-205. © 2016 American Cancer Society.
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Affiliation(s)
- Morie A Gertz
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | - Martha Q Lacy
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | | | | | - David Dingli
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | | | - Shaji K Kumar
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | - Nelson Leung
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - John Lust
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | | | - Stephen J Russell
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
- Department of Molecular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Vera J Suman
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
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Kikukawa Y, Hata H, Ueda M, Yamashita T, Nasu S, Ide K, Ueno S, Ando Y, Mitsuya H, Okuno Y. Successful Treatment of Amyloid Light-chain Amyloidosis in a Charcot-Marie-Tooth Disease Patient with Lenalidomide, Cyclophosphamide, and Dexamethasone. Intern Med 2016; 55:2707-12. [PMID: 27629972 DOI: 10.2169/internalmedicine.55.5815] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 70-year-old woman with Charcot-Marie-Tooth disease (CMT) suffered from nephrotic syndrome and a renal biopsy revealed non-AA amyloid depositions that contained immunoglobulin light chain λ. Her serum λ free LC was elevated to 80.8 mg/L and she was diagnosed with primary amyloid light-chain (AL) amyloidosis. She was subsequently treated with lenalidomide, cyclophosphamide, and dexamethasone (RCD). After 14 cycles of RCD, she achieved complete remission. Her serum albumin levels gradually normalized to 3.1 g/dL. No exacerbation of neurologic symptoms related to CMT was observed. Thus, RCD may be a well-tolerated and effective regimen for treating AL amyloidosis in patients with CMT disease.
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Affiliation(s)
- Yoshitaka Kikukawa
- Departments of Hematology, Rheumatology, and Infectious Disease, Kumamoto University Graduate School of Medicine, Japan
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Abstract
Immunoglobulin light chain amyloidosis (AL) is a rare, complex disease caused by misfolded free light chains produced by a usually small, indolent plasma cell clone. Effective treatments exist that can alter the natural history, provided that they are started before irreversible organ damage has occurred. The cornerstones of the management of AL amyloidosis are early diagnosis, accurate typing, appropriate risk-adapted therapy, tight follow-up, and effective supportive treatment. The suppression of the amyloidogenic light chains using the cardiac biomarkers as guide to choose chemotherapy is still the mainstay of therapy. There are exciting possibilities ahead, including the study of oral proteasome inhibitors, antibodies directed at plasma cell clone, and finally antibodies attacking the amyloid deposits are entering the clinic, offering unprecedented opportunities for radically improving the care of this disease.
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Affiliation(s)
- Angela Dispenzieri
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
- Division of Laboratory Medicine, Mayo Clinic, Rochester, MN, USA
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center, Foundation IRCCS Policlinico San Matteo and Department of Molecular Medicine, University of Pavia, Pavia, Italy.
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Shimazaki C, Fuchida SI, Suzuki K, Ishida T, Imai H, Sawamura M, Takamatsu H, Abe M, Miyamoto T, Hata H, Yamada M, Ando Y. Phase 1 study of bortezomib in combination with melphalan and dexamethasone in Japanese patients with relapsed AL amyloidosis. Int J Hematol 2015; 103:79-85. [PMID: 26588925 DOI: 10.1007/s12185-015-1901-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 11/04/2015] [Accepted: 11/09/2015] [Indexed: 10/22/2022]
Abstract
UNLABELLED We performed a phase 1 study to evaluate the safety and feasibility of bortezomib (BOR) with melphalan and dexamethasone (BMD) in patients with light chain amyloidosis (AL) without severe cardiac failure. Patients received BOR on a twice-weekly schedule (days 1, 4, 8, and 11 of 28-day treatment cycles) at planned doses of 1.0 (dose level 1) and 1.3 (dose level 2) mg/m(2) in combination with melphalan 8 mg/m(2) on days 1-4 and dexamethasone 20 mg on days 1, 2, 4, 5, 8, 9, 11, and 12. Dose-limiting toxicity (DLT) was evaluated at the end of cycle one, and treatment was continued for four cycles. Six patients were enrolled at dose level 1, and one showed DLT (grade 3: herpes zoster). Further 3 patients were enrolled at dose level 2, and none experienced DLT. Thus, the maximum tolerated dose was defined as BOR doses of 1.3 mg/m(2) for the twice-weekly schedule. A total of 32 cycles of BMD therapy were given, and the most common hematologic toxicity was thrombocytopenia (47%). Peripheral neuropathy was the most common non-hematologic toxicity (16%). We demonstrated that BMD is safe and tolerable for Japanese AL patients without severe cardiac damage. CLINICAL TRIAL REGISTRATION UMIN000006604.
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Affiliation(s)
- Chihiro Shimazaki
- Department of Hematology, Japan Community Healthcare Organization, Kyoto Kuramaguchi Medical Center, Kyoto, Japan.
| | - Shin-Ichi Fuchida
- Department of Hematology, Japan Community Healthcare Organization, Kyoto Kuramaguchi Medical Center, Kyoto, Japan
| | - Kenshi Suzuki
- Department of Hematology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Tadao Ishida
- Department of Gastroenterology, Rheumatology and Clinical Immunology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Hirokazu Imai
- Department of Nephrology and Rheumatology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Morio Sawamura
- Department of Hematology, National Hospital Organization Nishigunma National Hospital, Shibukawa, Japan
| | - Hiroyuki Takamatsu
- Department of Hematology, Kanazawa University School of Medicine, Kanazawa, Japan
| | - Masahiro Abe
- Department of Hematology, Endocrinology and Metabolism, Tokushima University Graduate School, Tokushima, Japan
| | - Toshihiro Miyamoto
- Medicine and Biosystemic Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hiroyuki Hata
- Department of Hematology, Kumamoto University School of Medicine, Kumamoto, Japan
| | - Masahito Yamada
- Department of Neurology and Neurobiology of Aging, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Yukio Ando
- Department of Neurology, Kumamoto University School of Medicine, Kumamoto, Japan
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Dispenzieri A, Buadi F, Kumar SK, Reeder CB, Sher T, Lacy MQ, Kyle RA, Mikhael JR, Roy V, Leung N, Grogan M, Kapoor P, Lust JA, Dingli D, Go RS, Hwa YL, Hayman SR, Fonseca R, Ailawadhi S, Bergsagel PL, Chanan-Khan A, Rajkumar SV, Russell SJ, Stewart K, Zeldenrust SR, Gertz MA. Treatment of Immunoglobulin Light Chain Amyloidosis: Mayo Stratification of Myeloma and Risk-Adapted Therapy (mSMART) Consensus Statement. Mayo Clin Proc 2015; 90:1054-81. [PMID: 26250727 DOI: 10.1016/j.mayocp.2015.06.009] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 06/10/2015] [Accepted: 06/11/2015] [Indexed: 01/19/2023]
Abstract
Immunoglobulin light chain amyloidosis (AL amyloidosis) has an incidence of approximately 1 case per 100,000 person-years in Western countries. The rarity of the condition not only poses a challenge for making a prompt diagnosis but also makes evidenced decision making about treatment even more challenging. Physicians caring for patients with AL amyloidosis have been borrowing and customizing the therapies used for patients with multiple myeloma with varying degrees of success. One of the biggest failings in the science of the treatment of AL amyloidosis is the paucity of prospective trials, especially phase 3 trials. Herein, we present an extensive review of the literature with an aim of making recommendations in the context of the best evidence and expert opinion.
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Affiliation(s)
| | | | | | - Craig B Reeder
- Division of Hematology/Oncology, Mayo Clinic, Scottsdale, AZ
| | - Tamur Sher
- Division of Hematology/Oncology, Mayo Clinic, Jacksonville, FL
| | | | | | | | - Vivek Roy
- Division of Hematology/Oncology, Mayo Clinic, Jacksonville, FL
| | - Nelson Leung
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - Martha Grogan
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | | | - John A Lust
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - David Dingli
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - Ronald S Go
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - Yi Lisa Hwa
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | - Rafael Fonseca
- Division of Hematology/Oncology, Mayo Clinic, Scottsdale, AZ
| | | | | | | | | | | | - Keith Stewart
- Division of Hematology/Oncology, Mayo Clinic, Scottsdale, AZ
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A mouse model recapitulating human monoclonal heavy chain deposition disease evidences the relevance of proteasome inhibitor therapy. Blood 2015; 126:757-65. [PMID: 26113545 DOI: 10.1182/blood-2015-03-630277] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Accepted: 06/23/2015] [Indexed: 12/11/2022] Open
Abstract
Randall-type heavy chain deposition disease (HCDD) is a rare disorder characterized by glomerular and peritubular amorphous deposits of a truncated monoclonal immunoglobulin heavy chain (HC) bearing a deletion of the first constant domain (CH1). We created a transgenic mouse model of HCDD using targeted insertion in the immunoglobulin κ locus of a human HC extracted from a HCDD patient. Our strategy allows the efficient expression of the human HC in mouse B and plasma cells, and conditional deletion of the CH1 domain reproduces the major event underlying HCDD. We show that the deletion of the CH1 domain dramatically reduced serum HC levels. Strikingly, even with very low serum level of truncated monoclonal HC, histologic studies revealed typical Randall-type renal lesions that were absent in mice expressing the complete human HC. Bortezomib-based treatment resulted in a strong decrease of renal deposits. We further demonstrated that this efficient response to proteasome inhibitors mostly relies on the presence of the isolated truncated HC that sensitizes plasma cells to bortezomib through an elevated unfolded protein response (UPR). This new transgenic model of HCDD efficiently recapitulates the pathophysiologic features of the disease and demonstrates that the renal damage in HCDD relies on the production of an isolated truncated HC, which, in the absence of a LC partner, displays a high propensity to aggregate even at very low concentration. It also brings new insights into the efficacy of proteasome inhibitor-based therapy in this pathology.
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