1
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Leung N, Nasr SH. 2024 Update on Classification, Etiology, and Typing of Renal Amyloidosis: A Review. Am J Kidney Dis 2024; 84:361-373. [PMID: 38514011 DOI: 10.1053/j.ajkd.2024.01.530] [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: 07/25/2023] [Revised: 12/20/2023] [Accepted: 01/29/2024] [Indexed: 03/23/2024]
Abstract
Amyloidosis is a protein folding disease that causes organ injuries and even death. In humans, 42 proteins are now known to cause amyloidosis. Some proteins become amyloidogenic as a result of a pathogenic variant as seen in hereditary amyloidoses. In acquired forms of amyloidosis, the proteins form amyloid in their wild-type state. Four types (serum amyloid A, transthyretin, apolipoprotein A-IV, and β2-macroglobulin) of amyloid can occur either as acquired or as a mutant. Iatrogenic amyloid from injected protein medications have also been reported and AIL1RAP (anakinra) has been recently found to involve the kidney. Finally, the mechanism of how leukocyte cell-derived chemotaxin 2 (ALECT2) forms amyloid remains unknown. This article reviews the amyloids that involve the kidney and how they are typed.
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Affiliation(s)
- Nelson Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota; Division of Hematology, Mayo Clinic, Rochester, Minnesota.
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
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2
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Leung N, Chapman JA, Bhatia S. First report of teclistamab in a patient with relapsed AL amyloidosis and multiple myeloma. EJHAEM 2023; 4:1157-1159. [PMID: 38024617 PMCID: PMC10660095 DOI: 10.1002/jha2.772] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 08/09/2023] [Indexed: 11/29/2023]
Affiliation(s)
- Nelson Leung
- Division of Nephrology and HypertensionMayo ClinicRochesterMinnesotaUSA
- Division of HematologyMayo ClinicRochesterMinnesotaUSA
| | | | - Sumeet Bhatia
- Community Health Network MD AndersonIndianapolisIndianaUSA
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3
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Fuchida SI, Ogura M, Ishida T, Hata H, Handa H, Katoh N, Nakaseko C, Sunami K, Katayama Y, Nobata H, Oshiro K, Iida S, Sekijima Y, Naiki H, Shimazaki C. A retrospective analysis of clinical features and treatment outcome in 21 patients with immunoglobulin M-related light-chain amyloidosis in Japan: a study from the Amyloidosis Research Committee. Int J Hematol 2023; 118:443-449. [PMID: 37515656 DOI: 10.1007/s12185-023-03647-2] [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: 03/10/2023] [Revised: 07/14/2023] [Accepted: 07/19/2023] [Indexed: 07/31/2023]
Abstract
We retrospectively gathered data of 21 patients (13 male and 8 female; median age 65 years) diagnosed with immunoglobulin M (IgM)-related light-chain (AL) amyloidosis in Japan to investigate characteristics of IgM-AL amyloidosis and its optimal treatment strategy. Median IgM and difference free light chain (FLC) at diagnosis were 1257 mg/dl and 34.3 mg/l, respectively. Organ involvement was observed in the heart in 7 patients (33%), kidneys in 15 (71%), and lymph nodes in 5 (24%). Initial treatments were melphalan/dexamethasone in 7 patients, bortezomib/cyclophosphamide/dexamethasone in 3, autologous stem cell transplantation in 3, rituximab/bendamustine in 1, other in 3, and none in 4. Hematological responses among 15 evaluable patients were as follows: 3 reached complete response (CR), 4 partial response (PR), and 1 very good PR (VGPR), making the overall response rate of PR or better 40%. Median overall survival (OS) was 14.0 months and 1-year OS was 71.4%. Prognosis was significantly poorer in patients with cardiac involvement than those with non-cardiac involvement (1-year OS 27.8% vs. 85.7%, p = 0.0468). The involved FLC value was low in several patients and therapeutic response was difficult to assess. Further study is necessary to determine the optimal treatment for IgM-AL amyloidosis.
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Affiliation(s)
- Shin-Ichi Fuchida
- Department of Hematology, Japan Community Health care Organization, Kyoto Kuramaguchi Medical Center, 27 Shimofusa-cho, Kita-ku, Kyoto, 603-8151, Japan.
| | - Mizuki Ogura
- Department of Hematology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Tadao Ishida
- Department of Hematology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Hiroyuki Hata
- Department of Informative Clinical Sciences, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Hiroshi Handa
- Department of Hematology, Graduate School of Medicine, Gunma University, Maebashi, Japan
| | - Nagaaki Katoh
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Chiaki Nakaseko
- Department of Hematology, Faculty of Medicine, International University of Health and Welfare, Otawara, Japan
| | - Kazutaka Sunami
- Department of Hematology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Yuta Katayama
- Department of Hematology, Hiroshima Red Cross and Atomic Bomb Hospital, Hiroshima, Japan
| | - Hironobu Nobata
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan
| | - Kazuiku Oshiro
- Department of Hematology and Oncology, Okinawa Prefectural Nanbu Medical Center and Children's Medical Center, Okinawa, Japan
| | - Shinsuke Iida
- Department of Hematology and Oncology, Nagoya City University Institute of Medical and Pharmaceutical Sciences, Nagoya, Japan
| | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Hironobu Naiki
- Department of Molecular Pathology, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Chihiro Shimazaki
- Department of Hematology, Japan Community Health care Organization, Kyoto Kuramaguchi Medical Center, 27 Shimofusa-cho, Kita-ku, Kyoto, 603-8151, Japan
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4
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Gustine JN, Szalat RE, Staron A, Joshi T, Mendelson L, Sloan JM, Sanchorawala V. Light chain amyloidosis associated with Waldenström macroglobulinemia: treatment and survival outcomes. Haematologica 2023; 108:1680-1684. [PMID: 36546447 PMCID: PMC10230421 DOI: 10.3324/haematol.2022.282264] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 12/12/2022] [Indexed: 03/29/2024] Open
Affiliation(s)
- Joshua N Gustine
- Amyloidosis Center and Section of Hematology and Medical Oncology, Boston University School of Medicine and Boston Medical Center, Boston, MA
| | - Raphael E Szalat
- Amyloidosis Center and Section of Hematology and Medical Oncology, Boston University School of Medicine and Boston Medical Center, Boston, MA
| | - Andrew Staron
- Amyloidosis Center and Section of Hematology and Medical Oncology, Boston University School of Medicine and Boston Medical Center, Boston, MA
| | - Tracy Joshi
- Amyloidosis Center and Section of Hematology and Medical Oncology, Boston University School of Medicine and Boston Medical Center, Boston, MA
| | - Lisa Mendelson
- Amyloidosis Center and Section of Hematology and Medical Oncology, Boston University School of Medicine and Boston Medical Center, Boston, MA
| | - J Mark Sloan
- Amyloidosis Center and Section of Hematology and Medical Oncology, Boston University School of Medicine and Boston Medical Center, Boston, MA
| | - Vaishali Sanchorawala
- Amyloidosis Center and Section of Hematology and Medical Oncology, Boston University School of Medicine and Boston Medical Center, Boston, MA.
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5
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Merlini G, Sarosiek S, Benevolo G, Cao X, Dimopoulos M, Garcia-Sanz R, Gatt ME, Fernandez de Larrea C, San-Miguel J, Treon SP, Minnema MC. Report of Consensus Panel 6 from the 11 th International Workshop on Waldenström's Macroglobulinemia on Management of Waldenström's Macroglobulinemia Related Amyloidosis. Semin Hematol 2023; 60:113-117. [PMID: 37099030 DOI: 10.1053/j.seminhematol.2023.03.002] [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: 03/08/2023] [Accepted: 03/09/2023] [Indexed: 03/31/2023]
Abstract
Consensus Panel 6 (CP6) of the 11th International Workshop on Waldenström's Macroglobulinemia (IWWM-11) was tasked with reviewing the state of the art for diagnosis, prognosis, and therapy of AL amyloidosis associated with Waldenström macroglobulinemia (WM). Since significant advances have been made in the management of AL amyloidosis an update for this rare disease associated with WM was necessary. The key recommendations from IWWM-11 CP6 included: (1) The need to improve the diagnostic process by recognizing red flags and using biomarkers and imaging; (2) The essential tests for appropriate workup; (3) The diagnostic flowchart, including mandatory amyloid typing, that improves the differential diagnosis with transthyretin amyloidosis; (4) Criteria for therapy response assessment; (5) State of the art of the treatment including therapy of wild type transthyretin amyloidosis associated with WM.
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Affiliation(s)
- Giampaolo Merlini
- Amyloidosis Research and Treatment Center, IRCCS Policlinico San Matteo, and University of Pavia, Pavia, Italy.
| | - Shayna Sarosiek
- Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Giulia Benevolo
- SSD Mieloma Unit e Clinical Trial e S.C. Hematology U, Turin, Turin, Italy
| | - Xinxin Cao
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, Beijing, China
| | - Meletios Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Ramon Garcia-Sanz
- Hematology Department, University Hospital of Salamanca, Research Biomedical Institute of Salamanca, CIBERONC and Center for Cancer Research-IBMCC (University of Salamanca-CSIC), Salamanca, Salamanca, Spain
| | - Moshe E Gatt
- Department of Hematology, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - Jesus San-Miguel
- Clínica Universidad de Navarra, Centro de Investigación Médica Aplicada, Instituto de Investigación Sanitaria de Navarra, Centro de Investigación Biomédica en Red Cáncer, Pamplona, Navarra, Spain
| | - Steven P Treon
- Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Monique C Minnema
- Department of Hematology, University Medical Center Utrecht, Utrecht, Utrecht, the Netherlands
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6
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Treon SP, Tedeschi A, San-Miguel J, Garcia-Sanz R, Anderson KC, Kimby E, Minnema MC, Benevolo G, Qiu L, Yi S, Terpos E, Tam CS, Castillo JJ, Morel P, Dimopoulos M, Owen RG. Report of consensus Panel 4 from the 11th International Workshop on Waldenstrom's macroglobulinemia on diagnostic and response criteria. Semin Hematol 2023; 60:97-106. [PMID: 37173155 DOI: 10.1053/j.seminhematol.2023.03.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 03/28/2023] [Indexed: 05/15/2023]
Abstract
Consensus Panel 4 (CP4) of the 11th International Workshop on Waldenstrom's Macroglobulinemia (IWWM-11) was tasked with reviewing the current criteria for diagnosis and response assessment. Since the initial consensus reports of the 2nd International Workshop, there have been updates in the understanding of the mutational landscape of IgM related diseases, including the discovery and prevalence of MYD88 and CXCR4 mutations; an improved recognition of disease related morbidities attributed to monoclonal IgM and tumor infiltration; and a better understanding of response assessment based on multiple, prospective trials that have evaluated diverse agents in Waldenstrom's macroglobulinemia. The key recommendations from IWWM-11 CP4 included: (1) reaffirmation of IWWM-2 consensus panel recommendations that arbitrary values for laboratory parameters such as minimal IgM level or bone marrow infiltration should not be used to distinguish Waldenstrom's macroglobulinemia from IgM MGUS; (2) delineation of IgM MGUS into 2 subclasses including a subtype characterized by clonal plasma cells and MYD88 wild-type, and the other by presence of monotypic or monoclonal B cells which may carry the MYD88 mutation; and (3) recognition of "simplified" response assessments that use serum IgM only for determining partial and very good partial responses (simplified IWWM-6/new IWWM-11 response criteria). Guidance on response determination for suspected IgM flare and IgM rebound related to treatment, as well as extramedullary disease assessment was also updated and included in this report.
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Affiliation(s)
- Steven P Treon
- Bing Center for Waldenstrom's Macroglobulinemia, Dana Farber Cancer Institute, Boston, MA.
| | | | - Jesus San-Miguel
- Clinica Universidad de Navarra, CCUN, CIMA, IDISNA, CIBERONC, Navarra, Spain
| | | | | | - Eva Kimby
- Division of Hematology, Department of Medicine Huddinge, Karolinska Institute, Stockholm Sweden
| | | | - Giulia Benevolo
- SSD Mieloma Unit e Clinical Trial e S.C. Hematology Univ., Turin Italy
| | - Lugui Qiu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China; Tianjin Institutes of Health Science...Tianjin 301600, China
| | - Shuhui Yi
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China; Tianjin Institutes of Health Science...Tianjin 301600, China
| | | | | | - Jorge J Castillo
- Bing Center for Waldenstrom's Macroglobulinemia, Dana Farber Cancer Institute, Boston, MA
| | - Pierre Morel
- Hematology Department, University Hospital Amiens- Picardie, Amiens, France
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Wechalekar AD, Cibeira MT, Gibbs SD, Jaccard A, Kumar S, Merlini G, Palladini G, Sanchorawala V, Schönland S, Venner C, Boccadoro M, Kastritis E. Guidelines for non-transplant chemotherapy for treatment of systemic AL amyloidosis: EHA-ISA working group. Amyloid 2023; 30:3-17. [PMID: 35838162 DOI: 10.1080/13506129.2022.2093635] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND This guideline has been developed jointly by the European Society of Haematology and International Society of Amyloidosis recommending non-transplant chemotherapy treatment for patients with AL amyloidosis. METHODS A review of literature and grading of evidence as well as expert recommendations by the ESH and ISA guideline committees. RESULTS AND CONCLUSIONS The recommendations of this committee suggest that treatment follows the clinical presentation which determines treatment tolerance tempered by potential side effects to select and modify use of drugs in AL amyloidosis. All patients with AL amyloidosis should be considered for clinical trials where available. Daratumumab-VCD is recommended from most untreated patients (VCD or VMDex if daratumumab is unavailable). At relapse, the two guiding principles are the depth and duration of initial response, use of a class of agents not previously exposed as well as the limitation imposed by patients' fitness/frailty and end organ damage. Targeted agents like venetoclax need urgent prospective evaluation. Future prospective trials should include advanced stage patients to allow for evidence-based treatment decisions. Therapies targeting amyloid fibrils or those reducing the proteotoxicity of amyloidogenic light chains/oligomers are urgently needed.
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Affiliation(s)
- Ashutosh D Wechalekar
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
| | - M Teresa Cibeira
- Amyloidosis and Myeloma Unit, Hospital Clinic of Barcelona, IDIBAPS, Barcelona, Spain
| | - Simon D Gibbs
- Victorian and Tasmanian Amyloidosis Service, Eastern Health Monash University Clinical School, Box Hill, VIC, Australia
| | - Arnaud Jaccard
- Hematology Department, French Reference Center for AL Amyloidosis (Limoges-Poitiers), CHU Limoges, Limoges, France
| | - Shaji Kumar
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center, Foundation "Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo" and Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Giovanni Palladini
- Amyloidosis Research and Treatment Center, Foundation "Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo" and Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Vaishali Sanchorawala
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Stefan Schönland
- Medical Department V, Amyloidosis Center, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Mario Boccadoro
- Department of Molecular Biotechnology and Health Sciences, University of Turin, Turin, Italy
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
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Bouclet F, Krzisch D, Leblond V, Tomowiak C, Laribi K, Ysebaert L, Tournilhac O, Dartigeas C, Leprêtre S, Jondreville L. [Waldenström disease: News and perspectives in 2022]. Bull Cancer 2023; 110:88-100. [PMID: 36229266 DOI: 10.1016/j.bulcan.2022.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 08/25/2022] [Accepted: 08/26/2022] [Indexed: 11/05/2022]
Abstract
Waldenström's disease is a B-cell neoplasm characterized by the accumulation of lymphoplasmacytic cells (LPCs) in the bone marrow, and more rarely in the lymph nodes and the spleen, which produce a monoclonal immunoglobulin M (IgM) protein. The diagnosis requires the identification of LPCs in the bone marrow, using specific markers in flow cytometry. The MYD88L265P mutation is found in 95% of cases and the CXCR4 mutation in 30-40% of cases. These markers must be sought because they have a diagnostic and prognostic role, and they might become predictive in the future. The clinical presentation is very variable, and includes anomalies related to the bone marrow infiltration of the LPCs (such as anemia), but also anomalies of the physico-chemical and/or immunological activity of the overproduced IgM (hyperviscosity, AL amyloidosis, cryoglobulinemia, anti-MAG neuropathies, etc.). Prognostic scores (IPSSWM) now make it possible to understand the prognosis of symptomatic WM requiring appropriate treatment. The therapeutic management depends on many parameters, such as the specific clinical presentation, the speed of evolution and of course the age and comorbidities. Immuno-chemotherapy is often the 1st line treatment (rituximab-cyclophosphamide-dexamethasone (RCD) or bendamustine-rituximab (BR)) but the role of targeted therapies is becoming preponderant. Bruton tyrosine kinase inhibitors (BTKi) are used today in first relapse. Other therapeutic perspectives will certainly allow us tomorrow to better understand this incurable chronic disease, such as new generations of BTKi, BCL2 inhibitors, anti-CXCR4, bi-specific antibodies, and CAR-T cells.
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Affiliation(s)
- Florian Bouclet
- Centre Henri Becquerel, department of clinical haematology, 76038 Rouen, France
| | - Daphné Krzisch
- AP-HP, Sorbonne université, hôpital Pitié-Salpêtrière, Paris, France
| | - Véronique Leblond
- AP-HP, Sorbonne université, hôpital Pitié-Salpêtrière, Paris, France
| | | | | | - Loïc Ysebaert
- Institut universitaire du cancer de toulouse (IUCT) - Oncopole, Toulouse, France
| | | | | | - Stéphane Leprêtre
- Centre Henri Becquerel, department of clinical haematology, 76038 Rouen, France; Centre Henri Becquerel and Normandie university UNIROUEN, Inserm U1245 and department of hematology, Rouen, France.
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9
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Berkowitz C, Dittus C. Diagnosis and management of AL amyloidosis due to B-cell non-Hodgkin lymphoma. Front Oncol 2022; 12:915420. [PMID: 36591532 PMCID: PMC9797846 DOI: 10.3389/fonc.2022.915420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 11/18/2022] [Indexed: 12/23/2022] Open
Abstract
Immunoglobulin light chain (AL) amyloidosis may be caused by a B-cell non-Hodgkin lymphoma (NHL) rather than a plasma cell neoplasm in rare cases, which presents unique diagnostic and management considerations. NHL associated with AL will often have an IgM paraprotein; thus, this disease is termed IgM-related AL amyloidosis (IgM AL). The clinical presentation of IgM AL is more likely to involve the lungs, peripheral nerves, and soft tissue; cardiac involvement is less common. Patients with IgM AL amyloidosis should undergo a lymphoma-directed work-up including evaluation for nodal and extranodal disease. Additionally, patients with an IgM paraproteinemia should be screened for AL amyloidosis through history and physical examination. Treatment regimens active against underlying lymphoma, rather than plasma cell-directed regimens, are recommended. Historical response rates in IgM AL have been poor; prospective studies of novel antineoplastic regimens may improve treatment outcomes.
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10
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IgM-Related Immunoglobulin Light Chain (AL) Amyloidosis. HEMATO 2022. [DOI: 10.3390/hemato3040049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Waldenström macroglobulinemia (WM) is a rare lymphoplasmacytic disorder characterized by an IgM paraprotein. The clinical presentation of WM varies and can include common manifestations such as anemia and hyperviscosity, in addition to less common features such as cryoglobulinemia, IgM-related neuropathy, and immunoglobulin light chain (AL) amyloidosis. Amyloidosis is a protein-folding disorder in which vital organ damage occurs due to the accumulation of misfolded protein aggregates. The most common type of amyloidosis in patients with an IgM paraprotein is AL amyloidosis, although other types of amyloidosis may occur. IgM-related amyloidosis has distinct clinical features when compared with other subtypes of AL amyloidosis. This review highlights the diagnostic criteria of IgM-related AL amyloidosis, as well as the clinical characteristics and treatment options for this disorder.
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11
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Palladini G, Milani P. Advances in the treatment of light chain amyloidosis. Curr Opin Oncol 2022; 34:748-756. [PMID: 35943427 DOI: 10.1097/cco.0000000000000881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW After many years, the management of systemic light chain (AL) amyloidosis is entering the era of evidence-based medicine, with three recently published randomized clinical trials, a regimen (daratumumab, cyclophosphamide, bortezomib, and dexamethasone, daratumumab-CyBorD) labeled for upfront therapy, more clinical trials ongoing, and published guidelines. In this review, we discuss how current practice is changing based on this data. RECENT FINDINGS Daratumumab-CyBorD grants unprecedentedly high rates of hematologic and organ response and became the novel standard-of-care in AL amyloidosis. The International Society of Amyloidosis and the European Hematology Association issued common guidelines for autologous stem cell transplant (ASCT) in this disease. Improved patient selection and effective induction regimens greatly reduced ASCT-related mortality. Venetoclax is emerging as a very effective option in patients harboring the common t(11;14) abnormality. Rapid and profound reduction of the amyloid free light chain can improve survival also at advanced stages. SUMMARY Daratumumab-CyBorD is being integrated into the treatment flow-chart whereas the role of ASCT is being redefined. New approaches are being tested in clinical trials. Treatment of daratumumab-refractory patients and validation of criteria of hematologic progression to be used in clinical trials and in individual patient management are current areas of research.
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Affiliation(s)
| | - Paolo Milani
- Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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12
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Intérêt du daratumumab dans l’amylose AL réfractaire chez une patiente de 96 ans. Rev Med Interne 2022; 43:673-676. [DOI: 10.1016/j.revmed.2022.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 06/26/2022] [Accepted: 07/18/2022] [Indexed: 01/15/2023]
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13
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Girard LP, Soekojo CY, Ooi M, Chng WJ, de Mel S. Immunoglobulin M Monoclonal Gammopathies of Clinical Significance. Front Oncol 2022; 12:905484. [PMID: 35756635 PMCID: PMC9219578 DOI: 10.3389/fonc.2022.905484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 05/05/2022] [Indexed: 01/07/2023] Open
Abstract
Immunoglobulin M monoclonal gammopathy of undetermined significance (MGUS) comprises 15-20% of all cases of MGUS. IgM MGUS is distinct from other forms of MGUS in that the typical primary progression events include Waldenstrom macroglobulinaemia and light chain amyloidosis. Owing to its large pentameric structure, IgM molecules have high intrinsic viscosity and precipitate more readily than other immunoglobulin subtypes. They are also more commonly associated with autoimmune phenomena, resulting in unique clinical manifestations. Organ damage attributable to the paraprotein, not fulfilling criteria for a lymphoid or plasma cell malignancy has recently been termed monoclonal gammopathy of clinical significance (MGCS) and encompasses an important family of disorders for which diagnostic and treatment algorithms are evolving. IgM related MGCS include unique entities such as cold haemagglutinin disease, IgM related neuropathies, renal manifestations and Schnitzler's syndrome. The diagnostic approach to, and management of these disorders differs significantly from other categories of MGCS. We describe a practical approach to the evaluation of these patients and our approach to their treatment. We will also elaborate on the key unmet needs in IgM MGCS and highlight potential areas for future research.
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Affiliation(s)
- Louis-Pierre Girard
- Aberdeen Royal Infirmary, National Health Service Grampian, Scotland, United Kingdom
| | - Cinnie Yentia Soekojo
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore, Singapore
| | - Melissa Ooi
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore, Singapore
| | - Wee Joo Chng
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore, Singapore.,Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Sanjay de Mel
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore, Singapore
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14
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Steinhardt M, Kortüm M, Einsele H, Rasche L. [Monoclonal gammopathy of (un)known significance]. Dtsch Med Wochenschr 2022; 147:675-682. [PMID: 35636418 DOI: 10.1055/a-1664-7353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Monoclonal gammopathies are a frequently diagnosed entity. However, the diagnosis is not always clinically relevant. The diagnosis of a monoclonal gammopathy requires serum electrophoresis, immunofixation and free light chain measurement. Sometimes, monoclonal gammopathies occur in the course of transient or autoimmune inflammation. Further diagnostics should only be performed after risk assessment according to Mayo criteria. In non-low risk patients, a symptomatic myeloma has to be ruled out via SLiM-CRAB criteria. The diagnostic work-up should include whole-body MRI and a bone marrow puncture as well as a 24 h urine sample. If it does not imply myeloma, the diagnosis of MGUS is confirmed and a follow-up after 6 months is recommended. After that, low-risk patients only need SLiM-CRAB screening at clinical signs of progression. All other patients should receive serologic follow-ups once a year. Importantly, MGUS patients show higher morbidity. Amongst a higher prevalence of osteoporosis and immunodeficiency, a wide array of MGUS-associated diseases such as AL amyloidosis, deposition diseases and Fc binding-dependent effects can occur. This article gives an overview over the work-up, observation and caveats of monoclonal gammopathy of (un)known significance.
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Affiliation(s)
| | - Martin Kortüm
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg
| | - Hermann Einsele
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg
| | - Leo Rasche
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg
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15
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Utility of Bruton’s Tyrosine Kinase Inhibitors in Light Chain Amyloidosis Caused by Lymphoplasmacytic Lymphoma (Waldenström’s Macroglobulinemia). Adv Hematol 2022; 2022:1182384. [PMID: 35096069 PMCID: PMC8791721 DOI: 10.1155/2022/1182384] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 11/21/2021] [Accepted: 01/07/2022] [Indexed: 11/18/2022] Open
Abstract
Of the variety of immunoglobulin related amyloidosis (AL), immunoglobulin M (IgM) related AL represents only 6 to 10% of affected patients, and the majority of these cases are associated with underlying non-Hodgkin's Lymphoma including Waldenström's macroglobulinemia (WM). Ibrutinib, acalabrutinib, and zanubrutinib are Bruton tyrosine kinase (BTK) inhibitors approved for certain indolent B cell non-Hodgkin's lymphoma (NHL). BTK is a nonreceptor kinase involved in B-cell survival, proliferation, and interaction with the microenvironment. We retrospectively evaluated the tolerability and effectiveness of BTK inhibitors ibrutinib and acalabrutinib therapy in (n = 4) patients with IgM-related AL amyloidosis with underlying WM. Treatment was well tolerated with both hematologic and organ response in patients with AL amyloidosis in the setting of WM. Atrial fibrillation led to the discontinuation of ibrutinib in one patient, and acalabrutinib caused significant thumb hematoma needing dose reduction in another patient. All patients evaluated had the MYD88 mutation. This may explain the good response to BTK inhibitors therapy in our series. BTK inhibitors should be further investigated in larger prospective studies for treatment of AL amyloidosis in patients with lymphoplasmacytic lymphoma/WM.
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16
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Cingam S, Sidana S. Differential Diagnosis of Waldenström's Macroglobulinemia and Early Management: Perspectives from Clinical Practice. Blood Lymphat Cancer 2022; 12:107-117. [PMID: 36003901 PMCID: PMC9394652 DOI: 10.2147/blctt.s259860] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 07/28/2022] [Indexed: 11/23/2022]
Abstract
Waldenström's Macroglobulinemia (WM) is a clonal B-lymphocyte neoplasm characterized by the presence of IgM monoclonal protein and ≥10% bone marrow involvement with lymphoplasmacytic cells. Several mature B-cell and plasma cell disorders can potentially produce monoclonal IgM immunoglobulin and hence, careful consideration of the differential diagnosis is vital. Clinico-pathological features, immunophenotype, and MYD88 mutation status help distinguish WM from other plasma cell and lymphoproliferative disorders. Treatment is only indicated in patients symptomatic from adenopathy or organomegaly, neuropathy, hyper viscosity, cryoglobulinemia, cold agglutinin disease, cytopenia's or amyloidosis. Alkylators (cyclophosphamide, bendamustine) in combination with anti-CD20 antibodies and novel targeted agents including Bruton tyrosine kinase (BTK) inhibitors like ibrutinib are the mainstay of frontline treatment in symptomatic WM.
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Affiliation(s)
- Shashank Cingam
- Division of Hematology and Oncology, University of New Mexico Comprehensive Cancer Center, Albuquerque, NM, 87102, USA
| | - Surbhi Sidana
- Division of BMT and Cell Therapy, Stanford University School of Medicine, Stanford, CA, 94305, USA
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17
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Abstract
The treatment of patients with systemic light chain (AL) amyloidosis is a challenge to hematologists. Despite its generally small size, the underlying clone causes a rapidly progressing, often devastating multiorgan dysfunction through the toxic light chains that form amyloid deposits. Clinical manifestations are deceitful and too often recognized at an irreversible stage. However, hematologists are in the unique position to diagnose AL amyloidosis at a pre-symptomatic stage checking biomarkers of amyloid organ involvement in patients with monoclonal gammopathies at higher risk to develop the disease. Adequate technology and expertise are needed for a prompt and correct diagnosis, particularly for ruling out non-AL amyloidoses that are now also treatable. Therapy should be carefully tailored based on severity of organ involvement and clonal characteristics, and early and continual monitoring of response is critical. Three recent randomized clinical trials moved AL amyloidosis to evidence-based era. Above all, the daratumumab-bortezomib combination is a new standard-of-care for newly diagnosed patients inducing rapid and deep responses that translate into high rates of organ response. The availability of new effective drugs allows to better personalize the therapy, reduce toxicity, and improve outcomes. Patients should be treated within clinical trials whenever possible.
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18
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Askari E, Rodriguez S, Garcia-Sanz R. Waldenström's Macroglobulinemia: An Exploration into the Pathology and Diagnosis of a Complex B-Cell Malignancy. J Blood Med 2021; 12:795-807. [PMID: 34512060 PMCID: PMC8416181 DOI: 10.2147/jbm.s267938] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 07/19/2021] [Indexed: 12/22/2022] Open
Abstract
After 77 years since the initial description, Waldenström macroglobulinemia (WM) remains as a bone marrow neoplastic disorder with lymphoplasmacytic differentiation oversecreting a monoclonal immunoglobulin M (IgM). However, many biological and genetic aspects of this entity have been unraveled and it is now easy to correctly diagnose patients with this illness. The diagnosis requires the presence of a monoclonal IgM component and bone marrow lymphoid infiltration must be demonstrated. In addition, other small B-cell lymphoid neoplasms with plasma cell differentiation must be discarded. Although the clinical picture is highly heterogeneous, the diagnosis is much easier today compared to the past, since now we can demonstrate the presence of somatic mutations, especially the L265P mutation in the MYD88 gene, highly characteristic of WM (>90% of the patients), followed by the WHIM-like mutations in the CXCR4 gene (~35%). The identification of these mutations is very important, because they can modulate the response to new treatments with Bruton's tyrosine kinase (BTK) inhibitors. Thus, the conventional prognostic factors that predict the outcome of these patients (anemia, thrombopenia, high M component, high B2M, and advanced age), must be complemented with the genetic evaluation of the patient, that can help us in the prediction of the risk of transformation from asymptomatic to symptomatic forms (Del6q) and/or from indolent forms of the disease to aggressive lymphomas (CD79b mutations).
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Affiliation(s)
- Elham Askari
- Hematology Department, Fundación Jiménez Díaz, Centro de Investigación Biomédica en Red-Cáncer (CIBERONC) CB16/12/00369, Madrid, Spain
| | - Sara Rodriguez
- Clinica Universidad de Navarra, Centro de Investigación Medica Aplicada (CIMA), Instituto de Investigación Sanitaria de Navarra (IDISNA), Accelerator project, Centro de Investigación Biomédica en Red-Cáncer (CIBERONC) CB16/12/00369, Pamplona, Spain
| | - Ramon Garcia-Sanz
- Haematology Department, University Hospital of Salamanca, Research Biomedical Institute of Salamanca (IBSAL), Accelerator project, Centro de Investigación Biomédica en Red-Cáncer (CIBERONC) CB16/12/00369 and Center for Cancer Research-IBMCC (USAL-CSIC), Salamanca, Spain
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19
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Staron A, Zheng L, Doros G, Connors LH, Mendelson LM, Joshi T, Sanchorawala V. Marked progress in AL amyloidosis survival: a 40-year longitudinal natural history study. Blood Cancer J 2021; 11:139. [PMID: 34349108 PMCID: PMC8338947 DOI: 10.1038/s41408-021-00529-w] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 12/15/2022] Open
Abstract
The recent decades have ushered in considerable advancements in the diagnosis and treatment of systemic light chain (AL) amyloidosis. As disease outcomes improve, AL amyloidosis-unrelated factors may impact mortality. In this study, we evaluated survival trends and primary causes of death among 2337 individuals with AL amyloidosis referred to the Boston University Amyloidosis Center. Outcomes were analyzed according to date of diagnosis: 1980-1989 (era 1), 1990-1999 (era 2), 2000-2009 (era 3), and 2010-2019 (era 4). Overall survival increased steadily with median values of 1.4, 2.6, 3.3, and 4.6 years for eras 1–4, respectively (P < 0.001). Six-month mortality decreased over time from 23% to 13%. Wide gaps in survival persisted amid patient subgroups; those with age at diagnosis ≥70 years had marginal improvements over time. Most deaths were attributable to disease-related factors, with cardiac failure (32%) and sudden unexpected death (23%) being the leading causes. AL amyloidosis-unrelated mortality increased across eras (from 3% to 16% of deaths) and with longer-term survival (29% of deaths occurring >10 years after diagnosis). Under changing standards of care, survival improved and early mortality declined over the last 40 years. These findings support a more optimistic outlook for patients with AL amyloidosis.
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Affiliation(s)
- Andrew Staron
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Section of Hematology and Oncology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Luke Zheng
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Gheorghe Doros
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Lawreen H Connors
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Department of Pathology and Laboratory Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Lisa M Mendelson
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Tracy Joshi
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Vaishali Sanchorawala
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA. .,Section of Hematology and Oncology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.
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20
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Pessach I, Dimopoulos MA, Kastritis E. Managing complications secondary to Waldenström's macroglobulinemia. Expert Rev Hematol 2021; 14:621-632. [PMID: 34170207 DOI: 10.1080/17474086.2021.1947236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Waldenström's macroglobulinemia (WM) is a rare lymphoma characterized by the accumulation of IgM-secreting lymphoplasmacytic cells in the bone marrow and other organs. Clinical sequelae relate to direct tissue infiltration by malignant cells but also to the physicochemical and immunological properties of the monoclonal IgM, resulting in a variety of disease-related complications.Areas covered: This narrative review, following a thorough Pubmed search of pertinent published literature, discusses complications secondary to WM, related to direct tumor infiltration, monoclonal IgM circulation, and deposition, as well as other less common ones. The description and pathophysiology of these complications were described together with their specific management strategies and in the context of available treatment options for WM (anti-CD20 monoclonal antibody-based combinations, proteasome inhibitors, BTK inhibitors, and other emerging ones).Expert opinion: The availability of many novel, active and less toxic regimens for the treatment of WM allows the management of the disease with strategies that depend on clinical presentation and disease-related complications, age, toxicity considerations, and presence of comorbidities.
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Affiliation(s)
- Ilias Pessach
- Division of Hematology, Athens Medical Center, Athens, Greece
| | - Meletios A Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
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21
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Muchtar E, Dispenzieri A, Gertz MA, Kumar SK, Buadi FK, Leung N, Lacy MQ, Dingli D, Ailawadhi S, Bergsagel PL, Fonseca R, Hayman SR, Kapoor P, Grogan M, Abou Ezzeddine OF, Rosenthal JL, Mauermann M, Siddiqui M, Gonsalves WI, Kourelis TV, Larsen JT, Reeder CB, Warsame R, Go RS, Murray DL, McPhail ED, Dasari S, Jevremovic D, Kyle RA, Lin Y, Lust JA, Russell SJ, Hwa YL, Fonder AL, Hobbs MA, Rajkumar SV, Roy V, Sher T. Treatment of AL Amyloidosis: Mayo Stratification of Myeloma and Risk-Adapted Therapy (mSMART) Consensus Statement 2020 Update. Mayo Clin Proc 2021; 96:1546-1577. [PMID: 34088417 DOI: 10.1016/j.mayocp.2021.03.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/31/2021] [Accepted: 03/03/2021] [Indexed: 12/17/2022]
Abstract
Immunoglobulin light chain (AL) amyloidosis is a clonal plasma cell disorder leading to progressive and life-threatening organ failure. The heart and the kidneys are the most commonly involved organs, but almost any organ can be involved. Because of the nonspecific presentation, diagnosis delay is common, and many patients are diagnosed with advanced organ failure. In the era of effective therapies and improved outcomes for patients with AL amyloidosis, the importance of early recognition is further enhanced as the ability to reverse organ dysfunction is limited in those with a profound organ failure. As AL amyloidosis is an uncommon disorder and given patients' frailty and high early death rate, management of this complex condition is challenging. The treatment of AL amyloidosis is based on various anti-plasma cell therapies. These therapies are borrowed and customized from the treatment of multiple myeloma, a more common disorder. However, a growing number of phase 2/3 studies dedicated to the AL amyloidosis population are being performed, making treatment decisions more evidence-based. Supportive care is an integral part of management of AL amyloidosis because of the inherent organ dysfunction, limiting the delivery of effective therapy. This extensive review brings an updated summary on the management of AL amyloidosis, sectioned into the 3 pillars for survival improvement: early disease recognition, anti-plasma cell therapy, and supportive care.
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Affiliation(s)
- Eli Muchtar
- Division of Hematology, Mayo Clinic, Rochester, MN.
| | | | | | | | | | - Nelson Leung
- Division of Hematology, Mayo Clinic, Rochester, MN; Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | | | - David Dingli
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | | | - Rafael Fonseca
- Division of Hematology/Oncology, Mayo Clinic, Scottsdale, AZ
| | | | | | - Martha Grogan
- Division of Hematology, Mayo Clinic, Rochester, MN; Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | | | | | | | | | | | | | - Jeremy T Larsen
- Division of Hematology/Oncology, Mayo Clinic, Scottsdale, AZ
| | - Craig B Reeder
- Division of Hematology/Oncology, Mayo Clinic, Scottsdale, AZ
| | | | - Ronald S Go
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - David L Murray
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Ellen D McPhail
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Surendra Dasari
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Dragan Jevremovic
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | - Yi Lin
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - John A Lust
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | - Yi Lisa Hwa
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | | | - S Vincent Rajkumar
- Division of Hematology, Mayo Clinic, Rochester, MN; Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Vivek Roy
- Division of Hematology/Oncology, Mayo Clinic, Jacksonville, FL
| | - Taimur Sher
- Division of Hematology/Oncology, Mayo Clinic, Jacksonville, FL
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22
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IGVL gene region usage correlates with distinct clinical presentation in IgM vs non-IgM light chain amyloidosis. Blood Adv 2021; 5:2101-2105. [PMID: 33877297 DOI: 10.1182/bloodadvances.2020003671] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 03/03/2021] [Indexed: 12/11/2022] Open
Abstract
Patients with immunoglobulin M (IgM) light chain (AL) amyloidosis have a distinct clinical presentation compared with those with non-IgM amyloidosis. We hypothesized that differential immunoglobulin light-chain variable region (IGVL) gene usage may explain the differences in organ involvement, because IGVL usage correlates with organ tropism. IGVL usage was evaluated by mass spectrometry of amyloid deposits (IgM, n = 45; non-IgM, n = 391) and differed across the 2 groups. In the λ family, LV2-08 (13% vs 2%; P < .001) and LV2-14 (36% vs 10%; P < .001) usage was more common in IgM vs non-IgM amyloidosis, whereas LV1-44 (0% vs 10%; P = .02) and LV6-57 (2% vs 18%; P = .004) usage was less common. In the κ family, there was a trend toward higher KV4-01 (11% vs 4%; P = .06) usage in IgM amyloidosis. IGVL usage correlated with disease characteristics/organ tropism. LV2-14 (more common in IgM amyloidosis) has historically been associated with peripheral nerve involvement and lower light chain burden, which were more frequent in IgM amyloidosis. LV1-44 (less common in IgM), associated with cardiac involvement, was less frequent in IgM patients. LV6-57 (less common in IgM) is associated with t(11;14), which was less frequent in IgM patients. In conclusion, IGVL gene usage differs in patients with IgM vs non-IgM amyloidosis and may explain the distinct clinical presentation.
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23
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Leguit RJ, Vink A, de Jonge N, Minnema MC, Oerlemans MIF. Endomyocardial biopsy with co-localization of a lymphoplasmacytic lymphoma and AL amyloidosis. Cardiovasc Pathol 2021; 53:107348. [PMID: 34038803 DOI: 10.1016/j.carpath.2021.107348] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/30/2021] [Accepted: 05/15/2021] [Indexed: 10/21/2022] Open
Abstract
In about 4% of cases, amyloid light chain (AL) amyloidosis is due to an underlying lymphoplasmacytic lymphoma (LPL) or other monoclonal protein forming low-grade B-cell lymphoma, instead of a plasma cell neoplasm. We report an unusual case of a 55-year-old male with co-localization of an IgG positive LPL and AL amyloidosis in his endomyocardial biopsy (EMB). The patient was diagnosed 4 years earlier with a low grade B-cell non Hodgkin lymphoma stage IV, at the time classified as marginal zone lymphoma. He received several lines of treatment for his lymphoma, which had shown progressive disease. Four years after initial diagnosis, he developed increasing dyspnea on exertion. Echocardiography demonstrated left and right ventricular hypertrophy with classical apical sparing, suspicious for cardiac amyloidosis. Bone marrow biopsy revealed massive infiltration by his low grade B-cell lymphoma, which was now reclassified as LPL based on the demonstration of a MYD88 L265P mutation. An EMB confirmed the presence of amyloid, which was typed as AL amyloidosis by the use of immunoelectron microscopy. In addition, mild B-cell infiltrates were present in the EMB, which were shown to be part of his LPL by the demonstration of the MYD88 L265P mutation using the highly sensitive droplet digital polymerase chain reaction technique. This is a rare case of cardiac AL amyloidosis based on an IgG kappa positive LPL, in which not only the amyloid but also the lymphoma itself were present in the EMB. In addition, this case nicely illustrates the use of 2 highly sensitive techniques (immunoelectron microscopy and droplet digital polymerase chain reaction), which both can be performed on small, formalin-fixed paraffin-embedded biopsies.
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Affiliation(s)
- Roos J Leguit
- Department of Pathology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
| | - Aryan Vink
- Department of Pathology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Nicolaas de Jonge
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Monique C Minnema
- Department of Hematology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Marish I F Oerlemans
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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24
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Bridoux F, Cockwell P, Glezerman I, Gutgarts V, Hogan JJ, Jhaveri KD, Joly F, Nasr SH, Sawinski D, Leung N. Kidney injury and disease in patients with haematological malignancies. Nat Rev Nephrol 2021; 17:386-401. [PMID: 33785910 DOI: 10.1038/s41581-021-00405-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2021] [Indexed: 02/07/2023]
Abstract
Acute kidney injury (AKI) is common in patients with cancer, especially in those with haematological malignancies. Kidney injury might be a direct consequence of the underlying haematological condition. For example, in the case of lymphoma infiltration or extramedullary haematopoiesis, it might be caused by a tumour product; in the case of cast nephropathy it might be due to the presence of monoclonal immunoglobulin; or it might result from tumour complications, such as hypercalcaemia. Kidney injury might also be caused by cancer treatment, as many chemotherapeutic agents are nephrotoxic. High-intensity treatments, such as high-dose chemotherapy followed by haematopoietic stem cell transplantation, not only increase the risk of infection but can also cause AKI through various mechanisms, including viral nephropathies, engraftment syndrome and sinusoidal obstruction syndrome. Some conditions, such as thrombotic microangiopathy, might also result directly from the haematological condition or the treatment. Novel immunotherapies, such as immune checkpoint inhibitors and chimeric antigen receptor T cell therapy, can also be nephrotoxic. As new therapies for haematological malignancies with increased anti-tumour efficacy and reduced toxicity are developed, the number of patients receiving these treatments will increase. Clinicians must gain a good understanding of the different mechanisms of kidney injury associated with cancer to better care for these patients.
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Affiliation(s)
- Frank Bridoux
- Department of Nephrology, and Centre d'Investigation Clinique (CIC INSERM 1402), Centre Hospitalier Universitaire et Université de Poitiers, Poitiers, France.,CNRS, UMR7276, Limoges, France.,Centre de référence Amylose AL et autres maladies par dépôt d'immunoglobulines monoclonales, Poitiers, France
| | - Paul Cockwell
- Department of Nephrology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Ilya Glezerman
- Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
| | - Victoria Gutgarts
- Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
| | - Jonathan J Hogan
- Renal, Electrolyte and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Kenar D Jhaveri
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Great Neck, NY, USA
| | - Florent Joly
- Department of Nephrology, and Centre d'Investigation Clinique (CIC INSERM 1402), Centre Hospitalier Universitaire et Université de Poitiers, Poitiers, France
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Deirdre Sawinski
- Renal, Electrolyte and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Nelson Leung
- Division of Nephrology and Hypertension, Division of Hematology, Mayo Clinic, Rochester, MN, USA.
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25
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Palladini G, Milani P, Malavasi F, Merlini G. Daratumumab in the Treatment of Light-Chain (AL) Amyloidosis. Cells 2021; 10:cells10030545. [PMID: 33806310 PMCID: PMC7998921 DOI: 10.3390/cells10030545] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 02/25/2021] [Accepted: 02/27/2021] [Indexed: 02/07/2023] Open
Abstract
Systemic light-chain (AL) amyloidosis is caused by a small B cell, most commonly a plasma cell (PC), clone that produces toxic light chains (LC) that cause organ dysfunction and deposits in tissues. Due to the production of amyloidogenic, misfolded LC, AL PCs display peculiar biologic features. The small, indolent plasma cell clone is an ideal target for anti-CD38 immunotherapy. A recent phase III randomized study showed that in newly diagnosed patients, the addition of daratumumab to the standard of care increased the rate and depth of the hematologic response and granted more frequent organ responses. In the relapsed/refractory setting, daratumumab alone or as part of combination regimens gave very promising results. It is likely that daratumumab-based regimens will become new standards of care in AL amyloidosis. Another anti-CD38 monoclonal antibody, isatuximab, is at an earlier stage of development as a treatment for AL amyloidosis. The ability to target CD38 on the amyloid PC offers new powerful tools to treat AL amyloidosis. Future studies should define the preferable agents to combine with daratumumab upfront and in the rescue setting and assess the role of maintenance. In this review, we summarize the rationale for using anti-CD38 antibodies in the treatment of AL amyloidosis.
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Affiliation(s)
- Giovanni Palladini
- Amyloidosis Research and Treatment Center, Foundation “Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo”, 27100 Pavia, Italy; (G.P.); (P.M.)
- Department of Molecular Medicine, University of Pavia, 10121 Pavia, Italy
| | - Paolo Milani
- Amyloidosis Research and Treatment Center, Foundation “Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo”, 27100 Pavia, Italy; (G.P.); (P.M.)
- Department of Molecular Medicine, University of Pavia, 10121 Pavia, Italy
| | - Fabio Malavasi
- Laboratory of Immunogenetics, Department of Medical Sciences, Center for Experimental Research and Medical Studies (CeRMS), University of Turin, Fondazione Ricerca Molinette, 10121 Turin, Italy;
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center, Foundation “Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo”, 27100 Pavia, Italy; (G.P.); (P.M.)
- Department of Molecular Medicine, University of Pavia, 10121 Pavia, Italy
- Correspondence:
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Palladini G, Paiva B, Wechalekar A, Massa M, Milani P, Lasa M, Ravichandran S, Krsnik I, Basset M, Burgos L, Nuvolone M, Lecumberri R, Foli A, Puig N, Sesta MA, Bozzola M, Cascino P, Nevone A, Ripepi J, Berti P, Casarini S, Annibali O, Orfao A, San-Miguel J, Merlini G. Minimal residual disease negativity by next-generation flow cytometry is associated with improved organ response in AL amyloidosis. Blood Cancer J 2021; 11:34. [PMID: 33594045 PMCID: PMC7887224 DOI: 10.1038/s41408-021-00428-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 10/17/2020] [Accepted: 11/02/2020] [Indexed: 12/30/2022] Open
Abstract
Light chain (AL) amyloidosis is caused by a small B-cell clone producing light chains that form amyloid deposits and cause organ dysfunction. Chemotherapy aims at suppressing the production of the toxic light chain (LC) and restore organ function. However, even complete hematologic response (CR), defined as negative serum and urine immunofixation and normalized free LC ratio, does not always translate into organ response. Next-generation flow (NGF) cytometry is used to detect minimal residual disease (MRD) in multiple myeloma. We evaluated MRD by NGF in 92 AL amyloidosis patients in CR. Fifty-four percent had persistent MRD (median 0.03% abnormal plasma cells). There were no differences in baseline clinical variables in patients with or without detectable MRD. Undetectable MRD was associated with higher rates of renal (90% vs 62%, p = 0.006) and cardiac response (95% vs 75%, p = 0.023). Hematologic progression was more frequent in MRD positive (0 vs 25% at 1 year, p = 0.001). Altogether, NGF can detect MRD in approximately half the AL amyloidosis patients in CR, and persistent MRD can explain persistent organ dysfunction. Thus, this study supports testing MRD in CR patients, especially if not accompanied by organ response. In case MRD persists, further treatment could be considered, carefully balancing residual organ damage, patient frailty, and possible toxicity.
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Affiliation(s)
- Giovanni Palladini
- Amyloidosis Research and Treatment Center, "Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo", Pavia, Italy. .,Biochemistry, Biotechnology and Advanced Diagnostics Laboratory, "Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo", Pavia, Italy. .,Department of Molecular Medicine, University of Pavia, Pavia, Italy.
| | - Bruno Paiva
- Clinica Universidad de Navarra, Centro de Investigacion Medica Aplicada (CIMA), IDISNA, CIBERONC CB16/12/00369 Pamplona, Pamplona, Spain
| | - Ashutosh Wechalekar
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK.,Department of Haematology, University College London Hospitals, London, UK
| | - Margherita Massa
- Biochemistry, Biotechnology and Advanced Diagnostics Laboratory, "Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo", Pavia, Italy
| | - Paolo Milani
- Amyloidosis Research and Treatment Center, "Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo", Pavia, Italy.,Biochemistry, Biotechnology and Advanced Diagnostics Laboratory, "Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo", Pavia, Italy
| | - Marta Lasa
- Clinica Universidad de Navarra, Centro de Investigacion Medica Aplicada (CIMA), IDISNA, CIBERONC CB16/12/00369 Pamplona, Pamplona, Spain
| | - Sriram Ravichandran
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
| | - Isabel Krsnik
- Hospital Universitario Puerta del Hierro, Madrid, Spain
| | - Marco Basset
- Amyloidosis Research and Treatment Center, "Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo", Pavia, Italy.,Biochemistry, Biotechnology and Advanced Diagnostics Laboratory, "Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo", Pavia, Italy.,Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Leire Burgos
- Clinica Universidad de Navarra, Centro de Investigacion Medica Aplicada (CIMA), IDISNA, CIBERONC CB16/12/00369 Pamplona, Pamplona, Spain
| | - Mario Nuvolone
- Amyloidosis Research and Treatment Center, "Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo", Pavia, Italy.,Biochemistry, Biotechnology and Advanced Diagnostics Laboratory, "Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo", Pavia, Italy.,Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Ramón Lecumberri
- Clinica Universidad de Navarra, Centro de Investigacion Medica Aplicada (CIMA), IDISNA, CIBERONC CB16/12/00369 Pamplona, Pamplona, Spain
| | - Andrea Foli
- Amyloidosis Research and Treatment Center, "Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo", Pavia, Italy.,Biochemistry, Biotechnology and Advanced Diagnostics Laboratory, "Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo", Pavia, Italy
| | - Noemi Puig
- Servicio General de Citometría, Universidad de Salamanca, IBSAL, and IBMCC CSIC-USAL, CIBERONC, Salamanca, Spain
| | - Melania Antonietta Sesta
- Amyloidosis Research and Treatment Center, "Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo", Pavia, Italy.,Biochemistry, Biotechnology and Advanced Diagnostics Laboratory, "Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo", Pavia, Italy.,Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Margherita Bozzola
- Amyloidosis Research and Treatment Center, "Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo", Pavia, Italy.,Biochemistry, Biotechnology and Advanced Diagnostics Laboratory, "Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo", Pavia, Italy.,Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Pasquale Cascino
- Amyloidosis Research and Treatment Center, "Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo", Pavia, Italy.,Biochemistry, Biotechnology and Advanced Diagnostics Laboratory, "Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo", Pavia, Italy.,Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Alice Nevone
- Amyloidosis Research and Treatment Center, "Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo", Pavia, Italy.,Biochemistry, Biotechnology and Advanced Diagnostics Laboratory, "Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo", Pavia, Italy.,Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Jessica Ripepi
- Amyloidosis Research and Treatment Center, "Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo", Pavia, Italy.,Biochemistry, Biotechnology and Advanced Diagnostics Laboratory, "Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo", Pavia, Italy.,Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Pierpaolo Berti
- Immunohematology and Transfusion Medicine Unit, Department of Laboratories, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Simona Casarini
- Amyloidosis Research and Treatment Center, "Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo", Pavia, Italy.,Biochemistry, Biotechnology and Advanced Diagnostics Laboratory, "Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo", Pavia, Italy
| | - Ombretta Annibali
- Hematology and Stem Cell Transplantation Unit, University Campus Bio-medico, Rome, Italy
| | - Alberto Orfao
- Servicio General de Citometría, Universidad de Salamanca, IBSAL, and IBMCC CSIC-USAL, CIBERONC, Salamanca, Spain
| | - Jesus San-Miguel
- Clinica Universidad de Navarra, Centro de Investigacion Medica Aplicada (CIMA), IDISNA, CIBERONC CB16/12/00369 Pamplona, Pamplona, Spain
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center, "Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo", Pavia, Italy.,Biochemistry, Biotechnology and Advanced Diagnostics Laboratory, "Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo", Pavia, Italy.,Department of Molecular Medicine, University of Pavia, Pavia, Italy
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Vaxman I, Visram A, Pasvolsky O, Kumar S, Dispenzieri A, Buadi F, Dingli D, Lacy M, Hayman S, Kyle R, Kapoor P, Leung N, Gonsalves W, Kourelis T, Warsame R, Gertz M. Retroperitoneal involvement with light chain amyloidosis- case series and literature review. Leuk Lymphoma 2020; 62:316-322. [DOI: 10.1080/10428194.2020.1832670] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Iuliana Vaxman
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center Petah-Tikva, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Alissa Visram
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Oren Pasvolsky
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center Petah-Tikva, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Shaji Kumar
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | | | - Francis Buadi
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - David Dingli
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Martha Lacy
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | | | - Robert Kyle
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | | | - Nelson Leung
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Rahma Warsame
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Morie Gertz
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
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28
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Godara A, Palladini G. Monoclonal Antibody Therapies in Systemic Light-Chain Amyloidosis. Hematol Oncol Clin North Am 2020; 34:1145-1159. [PMID: 33099430 DOI: 10.1016/j.hoc.2020.08.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
In systemic light-chain amyloidosis, monoclonal antibodies target antigens that are either membrane-bound or circulating or deposited in the organs. CD38 holds high promise as a target against clonal plasma cells. Multiple anti-CD38 antibodies are either approved for use or being investigated in clinical trials. Daratumumab has been investigated and has clinical efficacy in upfront or refractory settings. High rates of hematologic response are seen with daratumumab, which translates to high organ response rates. Rituximab is usually integrated into the treatment regimen for IgM amyloidosis. Anti-amyloid therapies have shown preclinical proof of principle, but lack confirmation of improvement.
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Affiliation(s)
- Amandeep Godara
- Divsion of Hematology-Oncology, Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA
| | - Giovanni Palladini
- Department of Molecular Medicine, Amyloidosis Research and Treatment Center Foundations, "Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo", University of Pavia, Viale Golgi, 19 IT, Pavia 27100, Italy.
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29
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Abstract
Lymphoma-related amyloidosis is a rare entity. Systemic AL amyloidosis is generally caused by an underlying plasma cell clone in the bone marrow with an intact monoclonal immunoglobulin G (IgG) or IgA protein. The rarity of the lymphoma-related amyloidosis makes the generation of data in randomized trials and the determination of the optimal treatment almost impossible. Therefore, treatment recommendations discussed here are based on either retrospective or small prospective trials of single centers.
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30
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Chakraborty R, Lentzsch S. Emerging drugs for the treatment of light chain amyloidosis. Expert Opin Emerg Drugs 2020; 25:299-317. [PMID: 32731778 DOI: 10.1080/14728214.2020.1803829] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Systemic AL amyloidosis is a protein-misfolding disorder that is characterized by the deposition of insoluble amyloid fibrils derived from kinetically unstable light chains. Achieving a rapid and deep hematologic response is critical for long-term survival. AREAS COVERED This review covers the existing and emerging treatment options for systemic AL, divided into anti-plasma cell and fibril-directed therapies. The anti-CD38 monoclonal antibody daratumumab has demonstrated an unprecedented hematologic response rate and will become the new standard-of-care in newly diagnosed patients in combination with CyBorD/VCD. Other plasma cell-directed drugs that have prospective data on safety and efficacy in AL include proteasome inhibitors [bortezomib and ixazomib], immunomodulatory drugs [lenalidomide and pomalidomide], and alkylating agents [melphalan and bendamustine]. A major unmet need is the development of fibril-directed therapies with the goal of eliminating amyloid fibrils that are already deposited in vital organs. EXPERT OPINION The treatment of newly diagnosed AL in the future will likely include daratumumab-based therapy in conjunction with fibril-directed therapy. The most promising second line drugs are venetoclax [for t(11;14)] and pomalidomide, with several others in the pipeline, including antibody-drug conjugates. Minimal residual disease will emerge as a new endpoint for drug development and will potentially guide treatment duration.
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Affiliation(s)
- Rajshekhar Chakraborty
- Department of Medicine, Division of Hematology and Oncology, Columbia University Medical Center , New York, USA
| | - Suzanne Lentzsch
- Department of Medicine, Division of Hematology and Oncology, Columbia University Medical Center , New York, USA
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31
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Basset M, Nuvolone M, Palladini G, Merlini G. Novel challenges in the management of immunoglobulin light chain amyloidosis: from the bench to the bedside. Expert Rev Hematol 2020; 13:1003-1015. [PMID: 32721177 DOI: 10.1080/17474086.2020.1803060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Immunoglobulin light chain (AL) amyloidosis is one of the most frequent systemic amyloidosis in Western countries. It is caused by a B-cell clone producing a misfolded light chain (LC) that deposits in organs. AREAS COVERED The review examines recent findings on pathophysiology and clinical management of AL amyloidosis. It contains an update on the recent hot topics as novel therapeutic approaches, definition of relapse, and hematologic response assessment. To review literature on AL amyloidosis, a bibliographic search was performed using PubMed. EXPERT OPINION Due to the proteotoxicity of amyloidogenic LCs, the therapeutic goal is a rapid and profound decrease in their concentration. The standard treatment is a risk-adapted chemotherapy targeting the B-cell clone. Novel, promising drugs, as daratumumab, are currently under evaluation in newly-diagnosed and relapsed/refractory patients. New sensitive techniques, as mass spectrometry approach and bone marrow minimal residual disease assessment, are available to evaluate depth of response. After first-line therapy, increase in LC concentration may precede worsening of organ dysfunction and should be considered carefully. Further clarification of molecular mechanisms of the disease are shedding light on new possible therapeutic targets. Innovative treatment strategies and novel technologies will improve our ability to treat AL amyloidosis, preventing organ deterioration.
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Affiliation(s)
- Marco Basset
- Amyloidosis Research and Treatment Center, Foundation IRCCS Policlinico San Matteo, and Department of Molecular Medicine, University of Pavia , Pavia, Italy
| | - Mario Nuvolone
- Amyloidosis Research and Treatment Center, Foundation IRCCS Policlinico San Matteo, and Department of Molecular Medicine, University of Pavia , Pavia, Italy
| | - Giovanni Palladini
- Amyloidosis Research and Treatment Center, Foundation IRCCS Policlinico San Matteo, and Department of Molecular Medicine, University of Pavia , Pavia, Italy
| | - 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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32
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Immunoglobulin M Paraproteinaemias. Cancers (Basel) 2020; 12:cancers12061688. [PMID: 32630470 PMCID: PMC7352433 DOI: 10.3390/cancers12061688] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/14/2020] [Accepted: 06/23/2020] [Indexed: 12/11/2022] Open
Abstract
Monoclonal paraproteinaemia is an increasingly common reason for referral to haematology services. Paraproteinaemias may be associated with life-threatening haematologic malignancies but can also be an incidental finding requiring only observation. Immunoglobulin M (IgM) paraproteinaemias comprise 15–20% of monoclonal proteins but pose unique clinical challenges. IgM paraproteins are more commonly associated with lymphoplasmacytic lymphoma than multiple myeloma and can occur in a variety of other mature B-cell neoplasms. The large molecular weight of the IgM multimer leads to a spectrum of clinical manifestations more commonly seen with IgM paraproteins than others. The differential diagnosis of B-cell and plasma cell dyscrasias associated with IgM gammopathies can be challenging. Although the discovery of MYD88 L265P and other mutations has shed light on the molecular biology of IgM paraproteinaemias, clinical and histopathologic findings still play a vital role in the diagnostic process. IgM secreting clones are also associated with a number of “monoclonal gammopathy of clinical significance” entities. These disorders pose a novel challenge from both a diagnostic and therapeutic perspective. In this review we provide a clinical overview of IgM paraproteinaemias while discussing the key advances which may affect how we manage these patients in the future.
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Dittrich T, Kimmich C, Hegenbart U, Schönland SO. Prognosis and Staging of AL Amyloidosis. Acta Haematol 2020; 143:388-400. [PMID: 32570242 DOI: 10.1159/000508287] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 04/28/2020] [Indexed: 12/11/2022]
Abstract
The treatment options for systemic light chain amyloidosis (AL) are currently widening in an unprecedented way, brought about by an expanding arsenal of anti-myeloma therapy as well as by novel approaches to target toxic light chains and, most recently, deposited amyloid directly. In this context, accurate estimates of prognosis in AL, which allow for reliable patient advice and for example comparison of different therapies, are particularly important to clinicians. Some biomarkers and especially the genetic background of the underlying clonal disease as evaluated by interphase fluorescence in situ hybridization even have predictive value, enabling an appropriate treatment selection. Derived from the most frequently involved organs in AL, heart and kidney, this review focuses on overall survival and renal survival. A comprehensive overview and summary of reported prognostic factors and biomarkers in AL is given and the most important and validated factors are highlighted. Finally, established staging systems in AL as well as validated and perspective response criteria are presented.
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Affiliation(s)
- Tobias Dittrich
- Department of Internal Medicine V, Division of Hematology/Oncology, Heidelberg University Hospital, Heidelberg, Germany
- Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Christoph Kimmich
- Department of Internal Medicine V, Division of Hematology/Oncology, Heidelberg University Hospital, Heidelberg, Germany
- Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Ute Hegenbart
- Department of Internal Medicine V, Division of Hematology/Oncology, Heidelberg University Hospital, Heidelberg, Germany
- Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Stefan O Schönland
- Department of Internal Medicine V, Division of Hematology/Oncology, Heidelberg University Hospital, Heidelberg, Germany,
- Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany,
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Oishi N, Inoue T, Odate T, Mochizuki K, Ohashi K, Kirito K, Kondo T. Composite monoclonal B-cell lymphocytosis and MYD88 L265P-positive lymphoplasmacytic lymphoma in a patient with IgM light chain amyloidosis: Case report. Pathol Int 2020; 70:458-462. [PMID: 32323419 DOI: 10.1111/pin.12937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 03/23/2020] [Accepted: 04/06/2020] [Indexed: 11/29/2022]
Abstract
Monoclonal B-cell lymphocytosis (MBL) is an early or precursor asymptomatic proliferation of chronic lymphocytic lymphoma (CLL)-like B-cells. Lymphoplasmacytic lymphoma (LPL), often clinically associated with Waldenström macroglobulinemia, is a B-cell neoplasm characterized by frequent MYD88 L265P mutation. Here, we report a rare composite MBL and LPL in a patient with IgM light chain (AL) amyloidosis. A 74-year-old male with a known IgM monoclonal protein developed proteinuria. No lymphocytosis was detected. Renal biopsy showed deposition of AL λ amyloid in the glomeruli and vessels. Subsequent bone marrow biopsy revealed nodular atypical CLL-like small B-cell proliferation and scattered peripheral LPL. Immunohistochemistry and/or flow cytometry revealed that the atypical CLL-like population expressed CD19, CD20, CD5, weak CD23, LEF-1 and diminished surface Igκ. The LPL was positive for CD19, CD20 and surface Igλ. Using laser-capture microdissection and allele-specific polymerase chain reaction, we confirmed that MYD88 L265P was detectable in the LPL but not in the atypical CLL-like population. Thus, we demonstrated that these two populations were clonally independent, and made the diagnosis of composite MBL and LPL. An integrated clinical, pathological, immunophenotypic and genetic assessment is essential in such complicated cases, and especially 'clone-specific' MYD88 genotyping may facilitate the differential diagnoses of low-grade B-cell lymphomas.
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Affiliation(s)
- Naoki Oishi
- Department of Pathology, University of Yamanashi, Yamanashi, Japan
| | - Tomohiro Inoue
- Department of Pathology, University of Yamanashi, Yamanashi, Japan
| | - Toru Odate
- Department of Pathology, University of Yamanashi, Yamanashi, Japan
| | - Kunio Mochizuki
- Department of Pathology, University of Yamanashi, Yamanashi, Japan
| | - Kenichi Ohashi
- Department of Pathology, Yokohama City University, Kanagawa, Japan
| | - Keita Kirito
- Department of Hematology, University of Yamanashi, Yamanashi, Japan
| | - Tetsuo Kondo
- Department of Pathology, University of Yamanashi, Yamanashi, Japan
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