Immunoglobulin abnormalities in families of patients with Waldenström's macroglobulinemia

Waldenström Macroglobulinemia - A State-of-the-Art Review: Part 1: Epidemiology, Pathogenesis, Clinicopathologic Characteristics, Differential Diagnosis, Risk Stratification, and Clinical Problems

Waldenström macroglobulinemia (WM) is an infrequent variant of lymphoma, classified as a B-cell malignancy identified by the presence of IgM paraprotein, infiltration of clonal, small lymphoplasmacytic B cells in the bone marrow, and the MYD88 L265P mutation, which is observed in over 90% of cases. The direct invasion of the malignant cells into tissues like lymph nodes and spleen, along with the immune response related to IgM, can also lead to various health complications, such as cytopenias, hyperviscosity, peripheral neuropathy, amyloidosis, and Bing-Neel syndrome. Chemoimmunotherapy has historically been considered the preferred treatment for WM, wherein the combination of rituximab and nucleoside analogs, alkylating drugs, or proteasome inhibitors has exhibited notable efficacy in inhibiting tumor growth. Recent studies have provided evidence that Bruton Tyrosine Kinase inhibitors (BTKI), either used independently or in conjunction with other drugs, have been shown to be effective and safe in the treatment of WM. The disease is considered to be non-curable, with a median life expectancy of 10 to 12 years.

Macroglobulinaemia in an Icelandic family

Macroglobulinaemia in an Icelandic family is presented. A woman had Waldenström's macroglobulinaemia, and two of her brothers had monoclonal macroglobulinaemia of the benign form. One was asymptomatic, but the other had polyneuropathy and IgM deposits in peripheral nerves. A third brother of these siblings died of a lymphoreticular disease, which presented with a widespread neuropathy. A second sister had polyclonal increase in serum IgA and two other brothers of this sibship had IgM slightly elevated. A study of all descendants (45 in all and 19 spouses) revealed seven individuals with elevated IgM levels. No other immunoglobulin abnormalities were detected.

Waldenström's macroglobulinemia in monozygotic twins

This paper reports a unique familial occurrence of Waldenström's macroglobulinemia (WM) in monozygotic twins. The determination of twin monozygosity has been performed by electrophoretic and immunological typing of genetic systems (erythrocyte blood groups, leucocyte antigens and serum protein polymorphism). The two monoclonal IgM differ one from the other by their light chain type and their idiotypic determinants. Although a genetic predisposition to WM exists in these twins, the gene recombination leading to idiotypic specificity and light chain assortment occurs independently of the monoclonal malignant involvement.

Risk of lymphoproliferative disorders among first-degree relatives of lymphoplasmacytic lymphoma/Waldenstrom macroglobulinemia patients: a population-based study in Sweden

A role for genetic factors in the etiology of lymphoplasmacytic lymphoma/Waldenström macroglobulinemia (LPL/WM) is implicated based on prior findings from multiply affected families and small case-control and cohort studies. We identified 2144 LPL/WM patients (1539 WM [72%] and 605 LPL [28%]) diagnosed in Sweden, 8279 population-based matched controls, and linkable first-degree relatives of patients (n = 6177) and controls (n = 24 609). Using a marginal survival model, we calculated relative risks and 95% confidence intervals as measures of familial aggregation. We found first-degree relatives of LPL/WM patients to have 20-fold (4.1-98.4), 3.0-fold (2.0-4.4), 3.4-fold (1.7-6.6), and 5.0-fold (1.3-18.9) increased risks of developing LPL/WM, non-Hodgkin lymphoma (NHL), chronic lymphocytic leukemia (CLL), and monoclonal gammopathy of undetermined significance (MGUS), respectively. However, there was no evidence of an increased risk of developing multiple myeloma or Hodgkin lymphoma. In analyses stratified by type of first-degree relative (parent, sibling, offspring), age at diagnosis of the probands (greater or less than 70 years), and sex of the first-degree relative, we did not observe the risk estimates to be significantly different compared with the overall analyses. Our findings of highly increased risks of developing LPL/WM, NHL, CLL, and MGUS support the operation of shared susceptibility genes that predispose to LPL/WM and other lymphoproliferative disorders.

Long-term Evaluation of Three Multiple-Case Waldenström Macroglobulinemia Families

PURPOSE

Because the clinical significance of immunoglobulin abnormalities reported in relatives of familial Waldenström macroglobulinemia (WM) patients is unknown, we initiated a follow-up study of three WM families originally evaluated 27 years previously.

EXPERIMENTAL DESIGN

Of 29 eligible first-degree relatives of WM patients, 27 (93%) had originally participated in clinical and electrophoretic evaluations. We re-contacted all participants for prospective follow-up electrophoretic analysis and other studies.

RESULTS

Initially, five relatives had IgM monoclonal gammopathy (IgM MG), and four had IgM polyclonal gammopathy (PG). Twenty-two relatives (81%) were re-evaluated. Median follow-up was 17 years (range, 7-27). At re-contact, all IgM MG persisted or progressed, including three that evolved to WM. Among the four with PG, two new IgM MG cases developed. Overall, seven relatives (26%) had IgM MG, and five (18%) had IgM PG.

CONCLUSIONS

Although based on small numbers, this study provides the longest comprehensive follow-up of WM families to date. IgM MG seems to be a phenotypic marker of WM susceptibility in some families and may have a high risk of progression to WM. IgM PG may also be important in WM families. These observations require validation in larger studies and, if confirmed, may be used to identify a cohort (relatives with IgM MG) for future prevention strategies.

Genomewide linkage screen for Waldenstrom macroglobulinemia susceptibility loci in high-risk families

Waldenstrom macroglobulinemia (WM), a distinctive subtype of non-Hodgkin lymphoma that features overproduction of immunoglobulin M (IgM), clearly has a familial component; however, no susceptibility genes have yet been identified. We performed a genomewide linkage analysis in 11 high-risk families with WM that were informative for linkage, for a total of 122 individuals with DNA samples, including 34 patients with WM and 10 patients with IgM monoclonal gammopathy of undetermined significance (IgM MGUS). We genotyped 1,058 microsatellite markers (average spacing 3.5 cM), performed both nonparametric and parametric linkage analysis, and computed both two-point and multipoint linkage statistics. The strongest evidence of linkage was found on chromosomes 1q and 4q when patients with WM and with IgM MGUS were both considered affected; nonparametric linkage scores were 2.5 (P=.0089) and 3.1 (P=.004), respectively. Other locations suggestive of linkage were found on chromosomes 3 and 6. Results of two-locus linkage analysis were consistent with independent effects. The findings from this first linkage analysis of families at high risk for WM represent important progress toward identifying gene(s) that modulate susceptibility to WM and toward understanding its complex etiology.

Familial Waldenstrom's macroglobulinemia

The etiology of Waldenstrom's macroglobulinemia (WM) is unknown. A possible role for genetic factors has been suggested by reports of familial clustering of WM. However, it is not yet possible to define the proportion of all WM that occurs in the familial setting. Review of the data on the 12 families published since 1962 suggests that familial WM may differ from sporadic disease in certain respects. Among these families, there is a pronounced occurrence of a variety of immunologic abnormalities in the relatives of WM cases. Notably, the prevalence of IgM monoclonal gammopathy (IgM MG) in first-degree relatives of WM cases was reported to be as high as 6.3%, representing a 10-fold increase relative to general population estimates. IgM MG has been shown to progress to WM at a rate of approximately 1.5% per year in a large case series; whether this rate of progression is altered in familial WM is unknown. Although limited by small numbers and a lack of systematic ascertainment and evaluation, these data are intriguing and provide a compelling basis for further study and systematic investigation of WM in families.

Human CD5-positive B cells in lymphoid malignancy and connective tissue diseases

The current literature on human CD5-positive B cells (CD5 + B cells) has been analysed, with a special emphasis on non organ-specific auto-immune diseases. Malignant cells of most of the chronic lymphoid leukaemias of the B cell lineage express the CD5 molecule. Antibodies of the IgM class produced by leukaemic B cells are multispecific auto-antibodies. The CD5 + B cell subset may be expanded in non organ-specific autoimmune diseases, such as rheumatoid arthritis, primary Sjögren's syndrome, systemic lupus erythematosus. This holds true for various conditions, including organ-specific auto-immune diseases. Since auto-immune features are common in lymphoproliferative disorders, and the latter be a complication in non organ-specific auto-immune diseases, CD5 + B cells may represent an intermediary between these auto-immune diseases and B cell lymphoproliferations. Studies on the regulation of CD5 + B cell production and function are likely to shed light on the aetiology of, and pathogenetic mechanisms operating in the different disease states.

Familial macroglobulinemia in a Lebanese family with two sisters presenting Waldenström's disease

We report a non-consanguineous family with ten children, in which two sisters were found to have Waldenström's disease with light chain IgM monoclonal components. Immunoglobulins were examined in four siblings and revealed high serum IgM concentrations with no monoclonal component. This additional case of familial Waldenström's macroglobulinemia stresses the usefulness of screening family members of patients with monoclonal gammopathy since they may be at high risk of developing the disease.

Four brothers with Waldenstrom's macroglobulinemia

An exceptional family including four brothers with Waldenstrom's macroglobulinemia was studied. The four patients had different light chain IgM monoclonal components: two of the kappa type and two of the lambda type. Anti-idiotypic rabbit antisera, prepared for each monoclonal component, revealed no cross-reactivity. The four brothers did not share a common HLA A B DR haplotype and a genetic linkage to the HLA complex cannot be ascertained. Five of the 12 relatives had high serum immunoglobulin concentration (four IgG, three IgA, and two IgM) without monoclonal components. Two relatives showed auto-antibodies at low titer. Some of the youngest relatives exhibited immunological abnormalities and they may be high-risk subjects with regard to Waldenstrom's macroglobulinemia.

IgM monoclonal gammopathy and neuropathy in two siblings

A sister and a brother with a progressive mixed axonal and demyelinating polyneuropathy were found to have a monoclonal IgM gammopathy of kappa and lambda type, respectively. Sural nerve and cutaneous nerve specimens obtained by biopsy showed deposits of IgM on myelin sheets. Sera from both patients contained antibodies directed to bovine peripheral nerve myelin as determined by ELISA technique and to normal human peripheral nerve myelin as demonstrated by indirect immunofluorescence histochemistry. These siblings may have a genetic predisposition to the formation of autoantibodies with peripheral nerve myelin as the target for the immune attack.

[Familial myeloma. Apropos of a case]

2 cases of multiple myeloma, both with IgG kappa, are reported in a man and his daughter. 33 other cases of myeloma involving two or more first degree relatives have been reported in the literature. Reported cases showed no major specific characteristics of the myelomas involved. Monoclonal protein family members were rarely identical. Our observation of identical monoclonal protein in two family members has only been found in 4 other reports. Occurrence of several cases of myeloma in one family is unlikely to be due to chance alone and the possibility of familial myeloma must be considered. Reports of benign monoclonal gammapathy in other members of the family of a patient with myeloma is also in favor of genetic factors. HLA-typing has shown an increase in frequency of the 4c complex and HLA-A9 in myeloma, and the latter was present in our patients. A genetic predisposition is further supported by experimental observations in mice. Finally, the short delay between onsets of myeloma in family members, less than 5 years in 20 families out of 27, and 4 years in our case, suggests a possible role of environmental factors.

Altered immunoregulation in Waldenström's macroglobulinemia. I. The absence of Con A-induced and spontaneous T suppressor cell activity in a patient and his kindred

In vitro lymphocyte functions in a patient with Waldenström's macroglobulinemia and his kindred were examined. The percentage and number of total peripheral blood T cells and the absolute number of FC gamma bearing T cells were decreased in the patient and family members compared to controls but the B cells and monocytes were normal. In addition, PHA and PWM stimulated proliferation were decreased. Decreased responsiveness to PWM was abrogated by preculturing PBMC in media alone before PWM stimulation. Decreased responsiveness to PHA was not reversed by a similar period of preculture. To further define the above abnormalities in immunoregulation we examined mononuclear subpopulations. In controls, adding purified T cells or Con A activated lymphocytes to autologous cultures which had been stimulated with PHA and PWM significantly decreased proliferative activity. No such suppressive activity of T cells or Con A activated cells from the patient or family members was noted. These data demonstrate an absent or functionally inactive spontaneous and Con A activated T suppressor cells in the family of a patient with Waldenström's macroglobulinemia.

Bilateral middle ear carcinomas associated with Waldenström's macroglobulinemia

A case of bilateral middle ear squamous cell carcinomas with concurrent Waldenström's macroglobulinemia is described. An increased incidence of malignant tumors occurring in patients with this potentially fatal, chronic lymphoproliferative disorder is well recognized, but the association with an otological tumor has not previously been reported. The relationship between the two conditions is discussed.

Lymphomas and leukemias in the relatives of patients with mycosis fungoides

Of 526 consecutive patients with cutaneous T-cell lymphomas, 21 had first-degree relatives with lymphoproliferative or hematopoietic malignancies. Twenty-nine such tumors occurred in the 21 kindreds. Hodgkin's disease accounted for one-third of this total, with various leukemias (11 cases), non-Hodgkin's lymphoma (five cases), and multiple myeloma (three cases) comprising the remainder. These data suggest that genetically-determined immunoregulatory abnormalities may represent a shared pathway of oncogenesis in diverse lymphoproliferative and hematopoietic malignancies.

Monoclonal gammopathies in the adult population of Finistère, France

Three hundred and thirty-four monoclonal gammopathies were detected in the sera of 30 279 adults from Finistère. Monoclonal gammopathies (MG) are more common in Finistère than in Paris and their distribution is not homogeneous. IgG paraproteins are particularly common in the northeast of Finistère whereas IgM paraproteins are more common in the southwest. Family studies and the high degree of inbreeding would support the hypothesis that there is a genetic predisposition to develop MG but the occurrence of paraproteins among three non-consanguineous couples seems to favour the existence of an environmental factor.

An inherited restriction in the idiotypic variability as a possible explanation of a genetic predisposition for a monoclonal component

Genetic factors have been proposed to play a role in the aetiology of a monoclonal proliferation of B lymphocytes. As an additional genetic factor we postulate that a restriction in the idiotypic variability of an individual contributes to a genetic predisposition to monoclonal gammopathy. To support our hypothesis, we have examined three families with multiple occurrence of M-components for sharing of idiotypic antigenicity between the related M-components and between the M-components and the sera of unaffected relatives. Idiotypic antisera against five isolated M-components were raised in guinea-pigs and used in a radiobinding inhibition assay. In none of the three families was idiotypic cross-reactivity observed between the familial M-components. However, in a family with three members with an M-component, sera of first-degree relatives showed a higher inhibitory capacity than sera of non-related individuals when an idiotypic antiserum, raised against the M-component of proposita, was employed. Within this particular family the observed restriction in the idiotypic variability could have contributed to the multiple occurrence of M-components.

Familial non-Hodgkin lymphoma: histologic diversity and relation to other cancers

Familial non-Hodgkin lymphoma (NHL) cases were classified according to the histologic criteria (modified) of Rappaport, to determine the extent of morphologic similarities of the tumors. In four families affected members had different tumor histologies that may be observed in an individual patient as the lymphoma progresses. In two families, the affected relatives had tumors of seemingly discordant histology. These tumors may nonetheless be etiologically related as indicated by the pattern of laboratory abnormalities, especially immunologic, in affected as well as unaffected members. The 20 cases had a reversal of the sex ratio (M/F) usually seen in NHL: 0.5 instead of 1.3. Other tumors observed in these families included primary hepatocellular carcinoma, pulmonary adenocarcinoma, Hodgkin disease, and acute lymphocytic leukemia - all of which have been associated with inborn or acquired immunodeficiency states.

Familial immunopathies: report of nine families and survey of literature

Nineteen individuals are reported who represent nine familial instances of various immunopathies. Multiple myeloma was diagnosed in 10 members of five families, lanthanic (idiopathic) paraproteinemia in five members of two families and either myeloma or lanthanic paraproteinemia in four members of the remaining two families. The parent-child relationship occurred in three instances, siblings were affected in three, and first cousins in three families. Immunochemical studies revealed IgG paraprotein in nine cases; IgA in three; IgMl type in three subjects belonging to the same family; Bence-Jones protein in one case and biclonal paraproteinemia, IgGk plus IgAl in one. Three individual cases of lanthanic paraproteinemia, discovered in a prospective study of 76 relatives of subjects with immunopathies, suggest that there may be a higher frequency of immunopathies among family members than observed in the general population of comparable age. The published reports on familial paraproteinemias are reviewed..

Varied manifestations of a familial lymphoproliferative disorder

In a sibship of nine adults, four died of lymphocytic or histiocytic lymphomas, and one of Waldenström's macroglobulinemia (immunoglobulin M [IgM], kappa type) complicated by adenocarcinoma of the lung. In the next generation, one member died of Hodgkin's disease; four of nine healthy persons had impaired lymphocyte transformation in vitro in response to phytohemagglutinin-P (PHA-P), and three of these had polyclonal elevations in IgM levels. Subsequent to these observations, adenocarcinoma of the lung developed in one woman with immune defects, and lymphocytic leukemia developed in her 3 year old grandson. The findings in this family point to a genetically regulated defect of immunity expressed as diverse lymphoproliferative disorders, including polyclonal and monoclonal IgM gammopathies. The occurrence of pulmonary adenocarcinoma in two members suggests genetic and immunologic determinants in these instances.

IgM paraproteins

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Immunoglobulins in NZB-BL mice. I. Serum immunoglobulin levels and immunoglobulin class of erythrocyte autoantibody

Determination of serum immunoglobulin levels in NZB and normal mice has indicated that an elevation of the gammaM-globulin level occurs in NZB mice. This can be demonstrated in young NZB mice well before other autoimmune manifestations are observed. A slight elevation of gammaM-globulin was also observed in NZB hybrid mice. Erythrocyte autoantibodies were analyzed by the direct Coombs' test with specific antiimmunoglobulin reagents. Autoantibodies in NZB mice can be of all immunoglobulin classes, although predominantly of gammaG(1)-class. In (NZB x NZC)F(1) hybrid mice, although Coombs' positivity develops around the same age as in NZB mice, there is a greater restriction of the autoantibodies into gammaM- and gammaG(1)-classes. Preliminary attempts to quantitate immunoglobulins coating NZB red cells have shown that there are approximately 400 molecules of gammaM and 5000 molecules of gammaG-globulin per NZB mouse red cell.