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Tan M, Chen Y, Ooi M, de Mel S, Tan D, Soekojo C, Tso A, Khoo CY, Tan HZ, Choo J, Lee LK, Diong CP, Goh YT, Hwang W, Linn YC, Ho A, Chng WJ, Nagarajan C. AL amyloidosis: Singapore Myeloma Study Group consensus guidelines on diagnosis, treatment and management. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2023; 52:601-624. [PMID: 38920149 DOI: 10.47102/annals-acadmedsg.2023101] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
AL amyloidosis is the most common form of systemic amyloidosis. However, the non-specific nature of presenting symptoms requires the need for a heightened clinical suspicion to detect unexplained manifestations in the appropriate clinical setting. Early detection and treatment are crucial as the degree of cardiac involvement emerges as a primary prognostic predictor of survival in a patient with AL amyloidosis. Following the diagnosis of AL amyloidosis with appropriate tissue biopsies, prompt treatment with a bortezomib, cyclophosphamide and dexamethasone-based first-line induction with or without daratumumab should be initiated. The goal of treatment is to achieve the best haematologic response possible, ideally with involved free light chain <20 mg/L, as it offers the best chance of organ function improvement. Treatment should be changed if patients do not achieve a partial response within 2 cycles of treatment or very good partial response after 4 cycles or after autologous stem cell transplant, as achievement of profound and prolonged clonal responses translates to better organ response and long-term outcomes. Early involvement of multidisciplinary subspecialists such as renal physicians, cardiologists, neurologists, and gastroenterologists for optimal maintenance and support of involved organs is recommended for optimal management of patients with AL amyloidosis.
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Affiliation(s)
- Melinda Tan
- Department of Haematology, Singapore General Hospital, Singapore
- Department of Haematology, National Cancer Centre Singapore, Singapore
| | - Yunxin Chen
- Department of Haematology, Singapore General Hospital, Singapore
- Department of Haematology, National Cancer Centre Singapore, Singapore
| | - Melissa Ooi
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore
| | - Sanjay de Mel
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore
| | - Daryl Tan
- Clinic for Lymphoma, Myeloma and Blood Disorders, Singapore
| | - Cinnie Soekojo
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore
| | - Allison Tso
- Department of Haematology, Tan Tock Seng Hospital, Singapore
| | - Chun Yuan Khoo
- Department of Cardiology, National Heart Centre, Singapore
| | - Hui Zhuan Tan
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Jason Choo
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Lian King Lee
- Department of Haematology, Tan Tock Seng Hospital, Singapore
| | | | - Yeow Tee Goh
- Department of Haematology, Singapore General Hospital, Singapore
- Department of Haematology, National Cancer Centre Singapore, Singapore
| | - William Hwang
- Department of Haematology, Singapore General Hospital, Singapore
- Department of Haematology, National Cancer Centre Singapore, Singapore
| | - Yeh Ching Linn
- Department of Haematology, Singapore General Hospital, Singapore
- Department of Haematology, National Cancer Centre Singapore, Singapore
| | - Aloysius Ho
- Department of Haematology, Singapore General Hospital, Singapore
- Department of Haematology, National Cancer Centre Singapore, Singapore
| | - Wee Joo Chng
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore
| | - Chandramouli Nagarajan
- Department of Haematology, Singapore General Hospital, Singapore
- Department of Haematology, National Cancer Centre Singapore, Singapore
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2
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Hubben A, Dima D, Atieh T, Chaulagain C, Faiman B, Ferraro C, Mazzoni S, Williams L, Samaras C, Valent J, Sauter C, Anwer F, Khouri J. On demand plerixafor is safe and effective for hematopoietic progenitor cell mobilization in patients with light chain amyloidosis at risk for mobilization failure with G-CSF alone. Bone Marrow Transplant 2023; 58:610-612. [PMID: 36828957 PMCID: PMC10164067 DOI: 10.1038/s41409-023-01938-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 02/07/2023] [Accepted: 02/14/2023] [Indexed: 02/26/2023]
Affiliation(s)
- Anne Hubben
- Cleveland Clinic, Department of Hematology and Medical Oncology, Cleveland, OH, USA.
| | - Danai Dima
- Cleveland Clinic, Department of Hematology and Medical Oncology, Cleveland, OH, USA
| | - Tahani Atieh
- University of Kansas, Department of Hematology and Medical Oncology, Kansas City, KS, USA
| | - Chakra Chaulagain
- Cleveland Clinic Florida, Department of Hematology and Medical Oncology, Maroone Cancer Center, Weston, FL, USA
| | - Beth Faiman
- Cleveland Clinic, Department of Hematology and Medical Oncology, Cleveland, OH, USA
| | - Christina Ferraro
- Cleveland Clinic, Department of Hematology and Medical Oncology, Cleveland, OH, USA
| | - Sandra Mazzoni
- Cleveland Clinic, Department of Hematology and Medical Oncology, Cleveland, OH, USA
| | - Louis Williams
- Cleveland Clinic, Department of Hematology and Medical Oncology, Cleveland, OH, USA
| | - Christy Samaras
- Cleveland Clinic, Department of Hematology and Medical Oncology, Cleveland, OH, USA
| | - Jason Valent
- Cleveland Clinic, Department of Hematology and Medical Oncology, Cleveland, OH, USA
| | - Craig Sauter
- Cleveland Clinic, Department of Hematology and Medical Oncology, Cleveland, OH, USA
| | - Faiz Anwer
- Cleveland Clinic, Department of Hematology and Medical Oncology, Cleveland, OH, USA
| | - Jack Khouri
- Cleveland Clinic, Department of Hematology and Medical Oncology, Cleveland, OH, USA
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3
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Sanchorawala V, Boccadoro M, Gertz M, Hegenbart U, Kastritis E, Landau H, Mollee P, Wechalekar A, Palladini G. Guidelines for high dose chemotherapy and stem cell transplantation for systemic AL amyloidosis: EHA-ISA working group guidelines. Amyloid 2022; 29:1-7. [PMID: 34783272 DOI: 10.1080/13506129.2021.2002841] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AL amyloidosis is a systemic amyloidosis and is associated with an underlying plasma cell dyscrasia. High dose intravenous melphalan and autologous stem cell transplantation was developed for the treatment of AL amyloidosis in the early 1990s and was prompted by its success in multiple myeloma. This application has evolved significantly over the past three decades. These guidelines provide a comprehensive assessment of eligibility criteria, stem cell collection and mobilisation strategies and regimens, risk-adapted melphalan dosing, role for induction and consolidation therapies, specific supportive care management, long-term outcome with respect to survival, haematologic response and relapse and organ responses following stem cell transplantation. These guidelines are developed by the experts in the field on behalf of the stem cell transplant working group of the International Society of Amyloidosis (ISA) and European Haematology Association (EHA).
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Affiliation(s)
- Vaishali Sanchorawala
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Mario Boccadoro
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Citta della Salute e della Scienza di Torino, Torino, Italy
| | - Morie Gertz
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Ute Hegenbart
- Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Alexandra General Hospital, Athens, Greece
| | - Heather Landau
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Peter Mollee
- Princess Alexandra Hospital and University of Queensland, Brisbane, Queensland, Australia
| | - Ashutosh Wechalekar
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Giovanni Palladini
- Amyloidosis Research and Treatment Center, University of Pavia, Pavia, Italy
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4
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Gertz MA, Schonland S. Stem Cell Mobilization and Autologous Transplant for Immunoglobulin Light-Chain Amyloidosis. Hematol Oncol Clin North Am 2020; 34:1133-1144. [PMID: 33099429 DOI: 10.1016/j.hoc.2020.07.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Stem cell transplantation was one of the first proven effective regimens for the management of immunoglobulin light-chain amyloidosis. Criteria for patient selection and the mobilization regimen become important features in ensuring a safe outcome. The technique of stem cell transplantation has evolved considerably in parallel with the development of new chemotherapeutic agents for the management of amyloidosis. Optimal outcomes require both the use of effective novel agent induction and appropriate application of high-dose chemotherapy with subsequent stem cell reconstitution.
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Affiliation(s)
- Morie A Gertz
- Division of Hematology, Mayo Clinic, 200 Southwest First Street, W10, Rochester, MN 55905, USA.
| | - Stefan Schonland
- Department of Internal Medicine V, Division of Hematology/Oncology, Amyloidosis Center, Heidelberg University Hospital, Im Neuenheimer Feld 450, Heidelberg 69120, Germany
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Gertz MA. Immunoglobulin light chain amyloidosis: 2020 update on diagnosis, prognosis, and treatment. Am J Hematol 2020; 95:848-860. [PMID: 32267020 DOI: 10.1002/ajh.25819] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 04/02/2020] [Indexed: 01/10/2023]
Abstract
DISEASE OVERVIEW Immunoglobulin light chain amyloidosis is a clonal, nonproliferative plasma cell disorder in which fragments of immunoglobulin light or heavy chain are deposited in tissues. Clinical features depend on organs involved but can include heart failure with preserved ejection fraction, nephrotic syndrome, hepatic dysfunction, peripheral/autonomic neuropathy, and "atypical smoldering multiple myeloma or monoclonal gammopathy undetermined significance (MGUS)." DIAGNOSIS Tissue biopsy stained with Congo red demonstrating amyloid deposits with apple-green birefringence is required for diagnosis. Invasive organ biopsy is not required in 85% of patients. Verification that amyloid is composed of immunoglobulin light chains is mandatory. The gold standard is laser capture mass spectroscopy. PROGNOSIS N-terminal pro-brain natriuretic peptide (NT-proBNP), serum troponin T, and difference between involved and uninvolved immunoglobulin free light chain (FLC) values are used to classify patients into four groups of similar size; median survivals are 94.1, 40.3, 14.0, and 5.8 months. THERAPY All patients with a systemic amyloid syndrome require therapy to prevent deposition of amyloid in other organs and prevent progressive organ failure. Stem cell transplant (SCT) is preferred, but only 20% of patients are eligible. Requirements for safe SCT include systolic blood pressure >90 mmHg, troponin T < 0.06 ng/mL and serum creatinine ≤1.7 mg/dL. Nontransplant candidates can be offered cyclophosphamide-bortezomib-dexamethasone or daratumumab-containing regimens as it appears to be highly active in AL amyloidosis. FUTURE CHALLENGES Delayed diagnosis remains a major obstacle to initiating effective therapy prior to the development of end-stage organ failure.
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Affiliation(s)
- Morie A. Gertz
- Division of HematologyMayo Clinic Rochester Minnesota USA
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Sanchorawala V. High-Dose Melphalan and Autologous Peripheral Blood Stem Cell Transplantation in AL Amyloidosis. Acta Haematol 2020; 143:381-387. [PMID: 32248194 DOI: 10.1159/000506498] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 02/11/2020] [Indexed: 12/17/2022]
Abstract
AL amyloidosis is a systemic amyloidosis and is associated with an underlying plasma cell dyscrasia. High-dose intravenous melphalan and autologous stem cell transplantation was developed for the treatment of AL amyloidosis in the early 1990s and was prompted by its success in myeloma. This application has evolved significantly over the past three decades. This review provides a comprehensive assessment of eligibility criteria, stem cell collection, and mobilization strategies and regimens, risk-adapted melphalan dosing, role for induction and consolidation therapies as well as long-term outcome with respect to survival, hematologic response and relapse as well as organ responses following stem cell transplantation. Continued efforts to refine patient selection and management, and incorporate novel anti-plasma cell agents in combination or sequentially to further improve outcomes in AL amyloidosis are also discussed.
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Affiliation(s)
- Vaishali Sanchorawala
- Amyloidosis Center, Boston University School of Medicine and Stem Cell Transplantation Program of Section of Hematology and Oncology, Boston Medical Center, Boston, Massachusetts, USA,
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7
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Badar T, Dhakal B, Szabo A, Padmanabhan A, Johnson BD, Heidtke S, Esselmann J, Chhabra S, Hamadani M, Hari P, D'Souza A. An updated single center experience with plerixafor and granulocyte colony-stimulating factor for stem cell mobilization in light chain amyloidosis. J Clin Apher 2019; 34:686-691. [PMID: 31566813 DOI: 10.1002/jca.21747] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 08/09/2019] [Accepted: 09/02/2019] [Indexed: 01/21/2023]
Abstract
The use of granulocyte-colony stimulating factor (G-CSF) with or without chemotherapy to mobilize hematopoietic progenitor cells (HPCs) can result in significant morbidity in light chain (AL) amyloidosis patients. Plerixafor, a strong inducer and mobilizer of HPCs, can be used as an adjunct to G-CSF to improve mobilization efficiency. We describe the outcomes for combined G-CSF/plerixafor mobilized patients with AL amyloidosis. We reviewed data of 53 consecutive AL amyloidosis patients who underwent combined G-CSF/plerixafor HPC mobilization between May 2011 and October 2017 at our institution. We evaluated patients for HPC collection efficiency, perimobilization toxicity and postautologous hematopoietic cell transplantation (autoHCT) outcomes. Median CD34+ cell collection was 12.4 × 106 cells/kg (range 2.5 × 106 to 34.1 × 106 cells/kg) and 45 (85%) patients had collections of ≥5.0 × 106 CD34+ cells/kg. There were no mobilization failures or perimobilization mortality. During mobilization, 37 (70%) patients had weight gain (median 1.3 kg, range 0.1-4) but none >10% body weight, 5 (10%) patients had diarrhea, and one patient each had hypotension and cardiac arrhythmia. Among the 31 patients analyzed for CD34 collection efficiency (CE), the median CD34 CE was 47% (range 36-62). At 5 years follow-up 82% and 84% of patients were progression-free and alive, respectively. Our results suggest that G-CSF/plerixafor mobilization is safe, well tolerated, and effective in AL amyloidosis.
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Affiliation(s)
- Talha Badar
- BMT and Cellular Therapy Program, Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Binod Dhakal
- BMT and Cellular Therapy Program, Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Aniko Szabo
- Institute for Health and Equity, Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Anand Padmanabhan
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, Wisconsin
| | - Bryon D Johnson
- Department of Microbiology and Molecular Genetics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Sarah Heidtke
- Department of Microbiology and Molecular Genetics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jean Esselmann
- BMT and Cellular Therapy Program, Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Saurabh Chhabra
- BMT and Cellular Therapy Program, Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mehdi Hamadani
- BMT and Cellular Therapy Program, Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Parameswaran Hari
- BMT and Cellular Therapy Program, Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Anita D'Souza
- BMT and Cellular Therapy Program, Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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Varga C, Comenzo RL. High-dose melphalan and stem cell transplantation in systemic AL amyloidosis in the era of novel anti-plasma cell therapy: a comprehensive review. Bone Marrow Transplant 2019; 54:508-518. [PMID: 30089901 DOI: 10.1038/s41409-018-0284-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 05/25/2018] [Accepted: 06/08/2018] [Indexed: 11/08/2022]
Abstract
The application of high-dose melphalan and autologous stem cell transplant (SCT) to systemic AL amyloidosis (AL) has evolved over the past two decades and remains an important component of therapy for patients with AL. The era of novel agents created the opportunity to provide well -tolerated induction and post-SCT consolidation to AL patients eligible for SCT and the current availability of new monoclonal antibody therapies will likely provide additional opportunities to enhance the outcomes with SCT. In this review, we touch on the history of SCT for AL and examine the data on eligibility, mobilization, induction, risk-adapted melphalan dosing, engraftment, consolidation and maintenance, and long-term outcomes with SCT. We note that induction therapy may deprive some patients of the opportunity to proceed to SCT but is likely needed if the marrow plasmacytosis is > 10%, that risk-adapted melphalan dosing continues to be relevant, and that post-SCT consolidation improves the complete response rate as well as long-term overall survival. The importance of baseline cytogenetics is also highlighted, particularly for patients whose clonal plasma cells are ≤ 10% but harbor the t(11;14), because they may have improved survival with SCT.
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Affiliation(s)
- Cindy Varga
- The Division of Hematology-Oncology, Department of Medicine, Tufts Medical Center, Boston, MA, USA.
- The John Conant Davis Myeloma and Amyloid Program, Tufts Medical Center, Boston, MA, USA.
| | - Raymond L Comenzo
- The Division of Hematology-Oncology, Department of Medicine, Tufts Medical Center, Boston, MA, USA
- The John Conant Davis Myeloma and Amyloid Program, Tufts Medical Center, Boston, MA, USA
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Gertz MA. Immunoglobulin light chain amyloidosis: 2018 Update on diagnosis, prognosis, and treatment. Am J Hematol 2018; 93:1169-1180. [PMID: 30040145 DOI: 10.1002/ajh.25149] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 05/11/2018] [Accepted: 05/11/2018] [Indexed: 11/10/2022]
Abstract
DISEASE OVERVIEW Immunoglobulin light chain amyloidosis is a clonal, nonproliferative plasma cell disorder in which fragments of immunoglobulin light or heavy chain are deposited in tissues. Clinical features depend on organs involved but can include restrictive cardiomyopathy, nephrotic syndrome, hepatic dysfunction, peripheral/autonomic neuropathy, and "atypical multiple myeloma." DIAGNOSIS Tissue biopsy stained with Congo red demonstrating amyloid deposits with apple-green birefringence is required for diagnosis. Invasive organ biopsy is not required because amyloid deposits can be found in bone marrow, salivary gland, or subcutaneous fat aspirate in 85% of patients. Verification that amyloid is composed of immunoglobulin light chains is mandatory. The gold standard is laser capture mass spectroscopy. PROGNOSIS N-terminal pro-brain natriuretic peptide (NT-proBNP), serum troponin T, and difference between involved and uninvolved immunoglobulin free light chain values are used to classify patients into four groups of similar size; median survivals are 94.1, 40.3, 14.0, and 5.8 months. THERAPY All patients with a systemic amyloid syndrome require therapy to prevent deposition of amyloid in other organs and prevent progressive organ failure. Stem cell transplant (SCT) is preferred, but only 20% of patients are eligible. Requirements for safe SCT include systolic blood pressure >90 mm Hg, troponin T < 0.06 ng/mL, age < 70 years, and serum creatinine ≤1.7 mg/dL. Nontransplant candidates can be offered melphalan-dexamethasone or cyclophosphamide-bortezomib-dexamethasone. Daratumumab appears to be highly active in AL amyloidosis. Antibodies designed to dissolve existing amyloid deposits are under study. FUTURE CHALLENGES Delayed diagnosis remains a major obstacle to initiating effective therapy. EDUCATIONAL OBJECTIVES Upon completion of this educational activity, participants will be better able to: Master recognition of clinical presentations that should raise suspicion of amyloidosis. Understand simple techniques for confirming the diagnosis and providing material to classify the protein subunit. Recognize that a tissue diagnosis of amyloidosis does not indicate whether the amyloid is systemic or of immunoglobulin light chain origin. Understand the roles of the newly introduced chemotherapeutic and investigational antibody regimens for the therapy of light chain amyloidosis.
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Affiliation(s)
- Morie A. Gertz
- Division of Hematology; Mayo Clinic; Rochester Minnesota
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Impact of prior melphalan exposure on stem cell collection in light chain amyloidosis. Bone Marrow Transplant 2017; 53:326-333. [DOI: 10.1038/s41409-017-0020-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 10/19/2017] [Accepted: 10/22/2017] [Indexed: 11/08/2022]
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Adverse Prognostic Factors for Morbidity and Mortality During Peripheral Blood Stem Cell Mobilization in Patients with Light Chain Amyloidosis. Biol Blood Marrow Transplant 2017; 24:815-819. [PMID: 29223373 DOI: 10.1016/j.bbmt.2017.11.040] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 11/28/2017] [Indexed: 11/24/2022]
Abstract
Patients with immunoglobulin light chain (AL) amyloidosis undergoing peripheral blood hematopoietic stem cell (PBSC) mobilization for autologous hematopoietic stem cell transplantation (auto-HCT) can experience significant morbidity and mortality. The purpose of this study was to characterize the adverse events and identify prognostic factors associated with the development of morbidity and mortality in patients with AL amyloidosis who had begun PBSC mobilization for auto-HCT. A retrospective study was performed in 101 consecutive patients with AL amyloidosis who underwent PBSC mobilization for auto-HCT between January 2006 and December 2013. A composite primary endpoint of morbidity and mortality during PBSC mobilization was used. Forty-one patients (41%) experienced at least 1 adverse event, including 4 deaths during PBSC mobilization. Adverse events included in this composite endpoint were cardiac events, thromboembolic events, bleeding events, unplanned hospitalization, weight gain >2% necessitating diuretic intervention, and death. Low serum albumin levels, elevated N-terminal pro-brain natriuretic peptide, and increased interventricular septal thickness were significantly associated with the composite primary endpoint (P = .024, .001, and .006, respectively). The median progression-free survival from the start of PBSC mobilization was 4.7 years, and the median overall survival was 6.5 years. In general, PBSC mobilization is associated with minimal complications, but patients with AL amyloidosis can experience more frequent and severe complications, such as volume overload and weight gain. Careful patient selection is warranted in patients with AL amyloidosis before proceeding to PBSC mobilization and auto-HCT.
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12
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Outcomes from Autologous Hematopoietic Cell Transplantation versus Chemotherapy Alone for the Management of Light Chain Amyloidosis. Biol Blood Marrow Transplant 2017; 23:1473-1477. [DOI: 10.1016/j.bbmt.2017.05.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 05/17/2017] [Indexed: 11/21/2022]
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13
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Gertz MA. Immunoglobulin light chain amyloidosis: 2016 update on diagnosis, prognosis, and treatment. Am J Hematol 2016; 91:947-56. [PMID: 27527836 DOI: 10.1002/ajh.24433] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 05/22/2016] [Indexed: 02/01/2023]
Abstract
DISEASE OVERVIEW Immunoglobulin light chain amyloidosis is a clonal, nonproliferative plasma cell disorder in which fragments of immunoglobulin light chain are deposited in tissues. Clinical features depend on organs involved but can include restrictive cardiomyopathy, nephrotic syndrome, hepatic failure, peripheral/autonomic neuropathy, and atypical multiple myeloma. DIAGNOSIS Tissue biopsy stained with Congo red demonstrating amyloid deposits with applegreen birefringence is required for diagnosis. Invasive organ biopsy is not required because amyloid deposits can be found in bone marrow biopsy or subcutaneous fat aspirate in 85% of patients. Verification that amyloid is composed of immunoglobulin light chains is mandatory. PROGNOSIS N-terminal pro-brain natriuretic peptide (NTproBNP), serum troponin T, and difference between involved and uninvolved immunoglobulin free light chain values are used to classify patients into four groups of similar size; median survivals are 94.1, 40.3, 14.0, and 5.8 months. THERAPY All patients with a systemic amyloid syndrome require therapy to prevent deposition of amyloid in other organs and prevent progressive organ failure of involved sites. Stem cell transplant (SCT) is preferred, but only 20% of patients are eligible. Requirements for safe SCT include systolic blood pressure >90 mmHg, troponin T <0.06 ng mL21, age <70 years, and serum creatinine 1.7 mg dL21. Nontransplant candidates can be offered melphalan-dexamethasone or cyclophosphamide-bortezomib-dexamethasone. Other combinations of chemotherapy with agents such as cyclophosphamide-thalidomide (or lenalidomide)-dexamethasone, bortezomib-dexamethasone, and melphalan-prednisone-lenalidomide have documented activity. Antibodies designed to dissolve existing amyloid deposits are under study for previously treated and untreated patients. Late diagnosis remains a major obstacle to initiating effective therapy. Am. J. Hematol., 2016. © 2016 Wiley Periodicals, Inc. Am. J. Hematol. 91:948-956, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Morie A. Gertz
- Division of Hematology; Mayo Clinic; Rochester Minnesota
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14
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Muchtar E, Buadi FK, Dispenzieri A, Gertz MA. Immunoglobulin Light-Chain Amyloidosis: From Basics to New Developments in Diagnosis, Prognosis and Therapy. Acta Haematol 2016; 135:172-90. [PMID: 26771835 DOI: 10.1159/000443200] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 12/03/2015] [Indexed: 11/19/2022]
Abstract
Immunoglobulin amyloid light-chain (AL) amyloidosis is the most common form of systemic amyloidosis, where the culprit amyloidogenic protein is immunoglobulin light chains produced by marrow clonal plasma cells. AL amyloidosis is an infrequent disease, and since presentation is variable and often nonspecific, diagnosis is often delayed. This results in cumulative organ damage and has a negative prognostic effect. AL amyloidosis can also be challenging on the diagnostic level, especially when demonstration of Congo red-positive tissue is not readily obtained. Since as many as 31 known amyloidogenic proteins have been identified to date, determination of the amyloid type is required. While several typing methods are available, mass spectrometry has become the gold standard for amyloid typing. Upon confirming the diagnosis of amyloidosis, a pursuit for organ involvement is essential, with a focus on heart involvement, even in the absence of suggestive symptoms for involvement, as this has both prognostic and treatment implications. Details regarding initial treatment options, including stem cell transplantation, are provided in this review. AL amyloidosis management requires a multidisciplinary approach with careful patient monitoring, as organ impairment has a major effect on morbidity and treatment tolerability until a response to treatment is achieved and recovery emerges.
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Affiliation(s)
- Eli Muchtar
- Division of Hematology, Mayo Clinic, Rochester, Minn., USA
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Lessi F, Marson P, Colpo A, Marino F, Branca A, Tison T, Adami F. Spontaneous splenic rupture following stem cell mobilization with G-CSF and plerixafor in AL amyloidosis. Transfus Apher Sci 2015; 54:256-8. [PMID: 26458962 DOI: 10.1016/j.transci.2015.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 09/18/2015] [Accepted: 09/22/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND AL amyloidosis is a rare plasma cell dyscrasia with multiorgan involvement. Good risk patients are candidate to high dose chemotherapy and autologous stem cell transplantation. However both transplantation and stem cell collection entail significant risk in such patients. Plerixafor is a novel mobilizing agent approved for use in "poor mobilizer" patients with lymphoma and multiple myeloma; experience in systemic amyloidosis patients is limited. CASE REPORT We describe a case of spontaneous splenic rupture following administration of G-CSF and plerixafor in a patient with AL amyloidosis who previously underwent heart transplantation due to amyloid heart involvement. RESULTS AND CONCLUSION This is the first report of spontaneous splenic rupture following stem cell mobilization with G-CSF and plerixafor in AL amyloidosis. The role of plerixafor has to be established. AL amyloidosis patients undergoing stem cell mobilization need careful monitoring of signs and symptoms of spontaneous splenic rupture.
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Affiliation(s)
- Federica Lessi
- Hematology and Clinical Immunology, Department of Medicine, University of Padova, Padova, Italy.
| | - Piero Marson
- Blood Transfusion Unit, Padova University Hospital, Padova, Italy
| | - Anna Colpo
- Blood Transfusion Unit, Padova University Hospital, Padova, Italy
| | - Filippo Marino
- Pathology Unit, Department of Laboratory Medicine, University of Padova, Padova, Italy
| | - Antonio Branca
- Hematology and Clinical Immunology, Department of Medicine, University of Padova, Padova, Italy
| | - Tiziana Tison
- Blood Transfusion Unit, Padova University Hospital, Padova, Italy
| | - Fausto Adami
- Hematology and Clinical Immunology, Department of Medicine, University of Padova, Padova, Italy
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Cornell RF, Zhong X, Arce-Lara C, Atallah E, Blust L, Drobyski WR, Fenske TS, Pasquini MC, Rizzo JD, Saber W, Hari PN. Bortezomib-based induction for transplant ineligible AL amyloidosis and feasibility of later transplantation. Bone Marrow Transplant 2015; 50:914-7. [DOI: 10.1038/bmt.2015.73] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 02/13/2015] [Accepted: 02/24/2015] [Indexed: 01/12/2023]
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Sanchorawala V, Brauneis D, Shelton AC, Lo S, Sun F, Sloan JM, Quillen K, Seldin DC. Induction Therapy with Bortezomib Followed by Bortezomib-High Dose Melphalan and Stem Cell Transplantation for Light Chain Amyloidosis: Results of a Prospective Clinical Trial. Biol Blood Marrow Transplant 2015; 21:1445-51. [PMID: 25858810 DOI: 10.1016/j.bbmt.2015.04.001] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 04/01/2015] [Indexed: 12/20/2022]
Abstract
The depth of hematologic response has been shown to correlate with survival and organ responses for patients with light chain (AL) amyloidosis. We conducted a prospective trial of 2 cycles of induction with bortezomib and dexamethasone on a twice a week schedule followed by conditioning with bortezomib and high-dose melphalan (HDM) and autologous stem cell transplantation (SCT). The objectives were hematologic responses, tolerability, and survival. Thirty-five patients were enrolled from 2010 to 2013. Of these, 30 proceeded with SCT, whereas 5 did not because of clinical deterioration during induction (n = 3) or complications after stem cell collection (n = 2). Two patients developed features of an autologous graft-versus-host disease-like syndrome post-SCT, which responded to steroids; no other unusual complications were seen. Treatment-related mortality occurred in 8.5% (3/35). Hematologic responses were achieved by 100% of the 27 assessable patients (63% complete response, 37% very good partial response [VGPR]) who completed the planned treatment. By intention-to-treat, hematologic responses occurred in 77% of patients (49% complete response, 29% VGPR). With a median follow-up of 36 months, the median overall survival and progression-free survival were not reached. In conclusion, incorporating bortezomib into induction and conditioning yielded a high rate of hematologic responses after HDM/SCT in patients with AL amyloidosis.
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Affiliation(s)
- Vaishali Sanchorawala
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts.
| | - Dina Brauneis
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Anthony C Shelton
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Stephen Lo
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Fangui Sun
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - J Mark Sloan
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Karen Quillen
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - David C Seldin
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
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Superior efficacy but higher cost of plerixafor and abbreviated-course G-CSF for mobilizing hematopoietic progenitor cells (HPC) in AL amyloidosis. Bone Marrow Transplant 2015; 50:610-2. [PMID: 25621807 DOI: 10.1038/bmt.2014.318] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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20
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Galli M, Lessi F, Rambaldi A, Fedrigo M, Rosa GD, Adami F. Mobilization of peripheral blood hematopoietic stem cells by granulocyte-colony stimulating factor and plerixafor in patients with cardiac AL amyloidosis. Amyloid 2015; 22:259-60. [PMID: 26587896 DOI: 10.3109/13506129.2015.1104295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Monica Galli
- a Department of Oncology and Hematology , Hematology Unit , Ospedale Papa Giovanni XXIII, Bergamo , Italy
| | - Federica Lessi
- b Department of Medicine , Hematology & Clinical Immunology Unit, University of Padua , Padua , Italy
| | - Alessandro Rambaldi
- a Department of Oncology and Hematology , Hematology Unit , Ospedale Papa Giovanni XXIII, Bergamo , Italy
| | - Marny Fedrigo
- d Department of Cardiac , Thoracic and Vascular Sciences, University of Padua , Padua , Italy
| | - Gennaro De Rosa
- c Division of Hematology , University of Naples , Naples , Italy , and
| | - Fausto Adami
- b Department of Medicine , Hematology & Clinical Immunology Unit, University of Padua , Padua , Italy
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