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Lopedote P, Evans B, Marchetti A, Chen T, Moscvin M, Boullt S, Bolli N, Bianchi G. Clonal hematopoiesis of indeterminate potential in patients with immunoglobulin light-chain AL amyloidosis. Blood Adv 2024; 8:3427-3436. [PMID: 38652890 PMCID: PMC11259929 DOI: 10.1182/bloodadvances.2024012840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 04/18/2024] [Accepted: 04/18/2024] [Indexed: 04/25/2024] Open
Abstract
ABSTRACT Immunoglobulin light-chain (AL) amyloidosis is characterized by the deposition of misfolded monoclonal free light chains, with cardiac complications accounting for patient mortality. Clonal hematopoiesis of indeterminate potential (CHIP) has been associated with worse cardiovascular outcomes in the general population. Its significance in AL amyloidosis remains unclear. We collected clinical information and outcome data on 76 patients with a diagnosis of AL amyloidosis who underwent deep targeted sequencing for myeloid neoplasia-associated mutations between April 2018 and August 2023. Variant allele frequency was set at 2% to call CHIP-associated mutations. CHIP mutations were present in patients with AL amyloidosis at a higher frequency compared with age-matched control individuals. Sixteen patients (21%) had at least 1 CHIP mutation. DNMT3A was the most frequent mutation (7/16; 44%). Compared with patients without CHIP, patients with CHIP had a higher prevalence of t(11;14) translocation (69% vs 25%, respectively; P = .004). Furthermore, among patients with renal involvement, those with CHIP had a lower Palladini renal stage (P = .001). At a median follow-up of 32.5 months, the presence of CHIP was not associated with worse overall survival or major organ dysfunction progression-free survival. Larger studies and longer follow-up are needed to better define the impact of CHIP in patients with AL amyloidosis.
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Affiliation(s)
- Paolo Lopedote
- Department of Medicine, St. Elizabeth's Medical Center, Boston University, Boston, MA
| | - Benjamin Evans
- Amyloidosis Program, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston, MA
- Division of Hematology, Brigham and Women's Hospital, Boston, MA
| | - Alfredo Marchetti
- Department of Oncology and Onco-Hematology, University of Milan, Milan, Italy
| | - Tianzeng Chen
- Amyloidosis Program, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston, MA
- Division of Hematology, Brigham and Women's Hospital, Boston, MA
| | - Maria Moscvin
- Amyloidosis Program, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston, MA
- Division of Hematology, Brigham and Women's Hospital, Boston, MA
| | - Samuel Boullt
- Amyloidosis Program, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston, MA
- Division of Hematology, Brigham and Women's Hospital, Boston, MA
| | - Niccolò Bolli
- Department of Oncology and Onco-Hematology, University of Milan, Milan, Italy
- Hematology Division, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giada Bianchi
- Amyloidosis Program, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston, MA
- Division of Hematology, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
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Delrue C, Dendooven A, Vandendriessche A, Speeckaert R, De Bruyne S, Speeckaert MM. Advancing Renal Amyloidosis Care: The Role of Modern Diagnostic Techniques with the Potential of Enhancing Patient Outcomes. Int J Mol Sci 2024; 25:5875. [PMID: 38892061 PMCID: PMC11172584 DOI: 10.3390/ijms25115875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 05/24/2024] [Accepted: 05/28/2024] [Indexed: 06/21/2024] Open
Abstract
Renal amyloidosis is a set of complex disorders characterized by the deposition of amyloid proteins in the kidneys, which causes gradual organ damage and potential kidney failure. Recent developments in diagnostic methods, particularly mass spectrometry and proteome profiling, have greatly improved the accuracy of amyloid typing, which is critical for disease management. These technologies provide extensive insights into the specific proteins involved, allowing for more targeted treatment approaches and better patient results. Despite these advances, problems remain, owing to the heterogeneous composition of amyloid proteins and the varying efficacy of treatments based on amyloid type. Access to sophisticated diagnostics and therapy varies greatly, highlighting the global difference in renal amyloidosis management. Future research is needed to investigate next-generation sequencing and gene-editing technologies, like clustered regularly interspaced short palindromic repeats (CRISPR), which promise more profound insights into the genetic basis of amyloidosis.
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Affiliation(s)
- Charlotte Delrue
- Department of Nephrology, Ghent University Hospital, 9000 Ghent, Belgium;
| | - Amélie Dendooven
- Department of Pathology, Ghent University Hospital, 9000 Ghent, Belgium; (A.D.); (A.V.)
- Faculty of Medicine, University of Antwerp, 2610 Wilrijk, Belgium
| | | | | | - Sander De Bruyne
- Department of Laboratory Medicine, Ghent University Hospital, 9000 Ghent, Belgium;
| | - Marijn M. Speeckaert
- Department of Nephrology, Ghent University Hospital, 9000 Ghent, Belgium;
- Research Foundation-Flanders (FWO), 1000 Brussels, Belgium
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Baljevic M, Sengsayadeth S. Relapsed systemic light chain amyloidosis - in search of a higher bar. Bone Marrow Transplant 2024; 59:441-443. [PMID: 38263391 DOI: 10.1038/s41409-024-02203-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 01/02/2024] [Accepted: 01/09/2024] [Indexed: 01/25/2024]
Affiliation(s)
- Muhamed Baljevic
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Salyka Sengsayadeth
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
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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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Li X, Pan XH, Fang Q, Liang Y. Pomolidomide for relapsed/refractory light chain amyloidosis after resistance to both bortezomib and daratumumab: A case report. World J Clin Cases 2022; 10:12703-12710. [PMID: 36579116 PMCID: PMC9791522 DOI: 10.12998/wjcc.v10.i34.12703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 10/13/2022] [Accepted: 11/04/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Immunoglobulin light chain (AL) amyloidosis is a rare disease characterized by deposition of ALs essentially in any organ or tissue, with cardiac involvement being very frequent (61%). Early diagnosis is of high importance because early initiation of treatment in AL amyloidosis may improve outcomes. Despite the administration of immunotherapeutic agents, in particular bortezomib and daratumumab, which have improved the outcomes of AL amyloidosis, anti-plasma cell therapy remains suboptimal for some patients.
CASE SUMMARY We report the case of a 55-year-old man presenting with heart failure who was diagnosed with cardiac AL amyloidosis by an endomyocardial biopsy. He experienced a short-term hematological remission with no organ response after being administered a bortezomib-daratumumab containing regimen. The treatment was switched to pomolidomide due to pulmonary involvement and progressive pleural effusion, in which flow cytometry analysis showed abnormal plasma cells. After two cycles of this regimen, the pleural effusion was controlled effectively with no recurrence.
CONCLUSION This case emphasizes the crucial role of endomyocardial biopsy in early diagnosis of cardiac amyloidosis and suggests that pomolidomide may be an effective treatment for patients with AL amyloidosis that is relapsed/refractory to both bortezomib and daratumumab.
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Affiliation(s)
- Xian Li
- Department of Hematology, The Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
| | - Xiao-Hong Pan
- Department of Cardiology, The Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
| | - Qiu Fang
- Department of Hematology, Huzhou Central Hospital, Affiliated Huzhou Hospital, Zhejiang University School of Medicine, Huzhou 313099, Zhejiang Province, China
| | - Yun Liang
- Department of Hematology, The Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
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Anbalagan LC, Pannu AK. Multiple Myeloma or AL amyloidosis? QJM 2022; 116:403-404. [PMID: 35792862 DOI: 10.1093/qjmed/hcac165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- L C Anbalagan
- Department of Internal Medicine, Postgraduate Institute of Medical, Education and Research, Nehru Hospital, Sector 12, Chandigarh (India) (160012)
| | - A K Pannu
- Department of Internal Medicine, Postgraduate Institute of Medical, Education and Research, Nehru Hospital, Sector 12, Chandigarh (India) (160012)
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Bianchi G, Zhang Y, Comenzo RL. AL Amyloidosis: Current Chemotherapy and Immune Therapy Treatment Strategies: JACC: CardioOncology State-of-the-Art Review. JACC: CARDIOONCOLOGY 2021; 3:467-487. [PMID: 34729520 PMCID: PMC8543128 DOI: 10.1016/j.jaccao.2021.09.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/10/2021] [Accepted: 09/12/2021] [Indexed: 12/19/2022]
Abstract
Immunoglobulin light chain (AL) amyloidosis is an incurable plasma cell disorder characterized by deposition of fibrils of misfolded immunoglobulin free light chains (FLC) in target organs, leading to failure. Cardiac involvement is common in AL amyloidosis and represents the single most adverse prognostic feature. A high index of clinical suspicion with rapid tissue diagnosis and commencement of combinatorial, highly effective cytoreductive therapy is crucial to arrest the process of amyloid deposition and preserve organ function. The clinical use of molecularly targeted drugs, such as proteasome inhibitors and immunomodulatory agents, monoclonal antibodies such as daratumumab, and risk-adjusted autologous stem cell transplant in eligible patients, has radically changed the natural history of AL amyloidosis. Here, we review the state-of-the-art treatment landscape in AL amyloidosis with an eye toward future therapeutic venues to impact the outcome of this devastating illness.
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Affiliation(s)
- Giada Bianchi
- Amyloidosis Program, Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yifei Zhang
- John C Davis Myeloma and Amyloid Program, Tufts Medical Center, Division of Hematology-Oncology, Division of Cardiovascular Diseases, Boston, Massachusetts, USA
| | - Raymond L Comenzo
- John C Davis Myeloma and Amyloid Program, Tufts Medical Center, Division of Hematology-Oncology, Division of Cardiovascular Diseases, Boston, Massachusetts, USA
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