Successful non-myeloablative allogeneic peripheral blood stem cell transplantation (PBSCT) for Waldenström's macroglobulinemia with severe pancytopenia

Efficacy of Autologous and Allogeneic Hematopoietic Cell Transplantation in Waldenström Macroglobulinemia: A Systematic Review and Meta-analysis

INTRODUCTION

Waldenström macroglobulinemia (WM) is an IgM-producing lymphoproliferative disorder that remains incurable. Patients with high-risk disease have an overall survival (OS) of less than 3 years. Both autologous (AHCT) and allogeneic (allo-HCT) hematopoietic cell transplantation (HCT) are prescribed for treatment of WM despite a lack of randomized controlled studies.

MATERIALS AND METHODS

We performed a comprehensive literature search using PubMed/Medline and EMBASE on September 10, 2019. Data on clinical outcomes related to benefits and harms was extracted independently by 3 authors. Fifteen studies (8 AHCT [n = 278 patients], 7 allo-HCT [n = 311 patients]) were included in this systematic review/meta-analysis.

RESULTS

Pooled OS, progression-free survival (PFS), and nonrelapse mortality (NRM) rates post AHCT were 76% (95% confidence interval [CI], 65%-86%), 55% (95% CI, 42%-68%), and 4% (95% CI, 1%-7%), respectively. Pooled OS, PFS, and NRM rates post allografting were 57% (95% CI, 50%-65%), 49% (95% CI, 42%-56%), and 29% (95% CI, 23%-34%), respectively. OS and PFS rates were reported at 3 to 5 years, and NRM was reported at 1 year in most studies. Pooled ORR (at day 100) post AHCT and allo-HCT were 85% (95% CI, 72%-94%) and 81% (95% CI, 69%-91%), respectively. Pooled complete response rates post AHCT and allo-HCT were 22% (95% CI, 17%-28%) and 26% (95% CI, 7%-50%), respectively. Relapse rates post AHCT and allo-HCT were 42% (95% CI, 30%-55%) and 23% (95% CI, 18%-28%), respectively.

CONCLUSIONS

Our results show that both AHCT and allo-HCT are effective in the treatment of WM. A 2-fold lower relapse rate but a 7-fold higher NRM was noted for allo-HCT compared with AHCT. The role of transplant in WM needs to be addressed in the era of novel agents.

High-Dose Therapy and Hematopoietic Stem Cell Transplantation in Waldenström Macroglobulinemia

Waldenström macroglobulinemia (WM) is an indolent low-grade non-Hodgkin lymphoma characterized by bone marrow infiltration by lymphoplasmacytic cells and associated clonal IgM paraproteinemia. Recent insights into the biology and genomic characteristics of WM have provided a further platform for more targeted therapies. Despite the high response rates and better depth and duration of responses, the disease remains incurable. This review focuses on use of the high-dose therapy with either autologous or allogeneic hematopoietic stem cell transplantation.

The role of stem cell transplantation in Waldenstrom's macroglobulinemia

Waldenstrom's macroglobulinemia (WM) is an indolent B-cell lymphoma, which is highly chemosensitive, with an overall response rate over 90% to novel agents. However, most patients eventually relapse after response to first-line chemotherapy, necessitating further treatment. The possibility of long-lasting remission after high-dose cytotoxic chemotherapy followed by stem cell rescue is high in WM due to the chemosensitive nature of the disease and lower proliferative activity compared to multiple myeloma. In this paper, we have reviewed current evidence on autologous (auto-) and allogeneic (allo-) stem cell transplantation (SCT) in WM. Auto-SCT can be safely performed in WM and is recommended as second-line treatment or beyond in eligible patients. It is associated with extremely low transplant-related mortality. Allo-SCT is effective in WM with incremental benefit due to graft-versus-WM effect, but is associated with high non-relapse mortality of 30%, hence should be preferably considered investigational as part of clinical trials in selected patients who have exhausted other treatment options.

Waldenström macroglobulinemia at 70

SUMMARY 

Over the last seven decades, Waldenström macroglobulinemia (WM) has changed from a clinical observation by an astute clinician to an uncommon, but well-defined clinical–pathologic entity. Similarly, therapeutic advances have evolved and now parallel our increasing understanding of the biology of WM. Very recently, the discovery of a highly prevalent somatic gene mutation has provided new understanding that challenges us to further individualize management of this disease. This article is intended to chronicle the 70-year development of our knowledge, treatment options and limitations that bring us to our current approach to WM, as well as the challenge for international collaboration in order to enable us to develop the most efficient path to optimal patient care.

Advances in the treatment of Waldenström’s macroglobulinemia

Waldenström's macroglobulinemia is a distinct disorder characterized by a monoclonal immunoglobulin M paraprotein and morphological evidence of lymphoplasmacytic lymphoma. It is relatively rare, accounting for approximately 2% of all hematological malignancies. The aim of treatment for patients with Waldenström's macroglobulinemia should be to improve the quality and duration of life with minimal side effects in the most cost-effective manner. It is not yet clear if achievement of a complete remission confers clinical benefit and it is possible that prolonging therapy to maximal response may increase toxicity without extra benefit. Plasma exchange is indicated for the acute management of patients with severe problems due to a circulating paraprotein. There are no comparative data but alkylating agent-based treatments, combination therapy or purine analogs are all suitable choices for the initial therapy of patients requiring treatment. In younger patients, in whom high-dose treatment is contemplated, there is a role for the use of rituximab; however, it should be administered with caution in patients with high levels of immunoglobulin M paraprotein or signs of hyperviscosity because of the risk of 'flare' in the paraprotein level and consequent adverse clinical events.

Allogeneic hematopoietic stem cell transplantation allows long-term complete remission and curability in high-risk Waldenström’s macroglobulinemia. Results of a retrospective analysis of the Société Française de Greffe de Moelle et de Thérapie Cellulaire

BACKGROUND

Patients with poor-risk Waldenström's macroglobulinemia have suboptimal response and early post-treatment relapse with conventional therapies. Hence, new therapeutic approaches such as allogeneic stem cell transplantation should be evaluated in these patients.

DESIGN AND METHODS

We examined the long-term outcome of allogeneic stem cell transplantation in Waldenström's macroglobulinemia by studying the records of 24 patients reported in the SFGM-TC database and one transplanted in the bone marrow unit in Hamburg.

RESULTS

Median age at the time of transplant was 48 years (range, 24-64). The patients had previously received a median of 3 lines of therapy (range, 1-6) and 44% of them had refractory disease at time of transplant. Allogeneic stem cell transplantation after myeloablative (n=12) or reduced-intensity (n=13) conditioning yielded an overall response rate of 92% and immunofixation-negative complete remission in 50% of evaluable patients. With a median follow-up of 64 months among survivors (range, 11-149 months), 5-year overall survival and progression-free survival rates were respectively, 67% (95% CI: 46-81) and 58% (95% CI: 38-75). The 5-year estimated risk of progression was 25% (95% CI: 10-36%), with only one relapse among the 12 patients who entered complete remission, versus 5 in the 12 patients who did not. Only one of the 6 relapses occurred more than three years post-transplant.

CONCLUSIONS

Allogeneic stem cell transplantation yields a high rate of complete remissions and is potentially curative in poor-risk Waldenström's macroglobulinemia.

The outcome of haemopoietic stem cell transplantation in the treatment of lymphoplasmacytic lymphoma in the UK: a British Society Bone Marrow Transplantation study

Lymphoplasmacytic lymphoma (LL) is incurable by standard therapy (median survival: 60 months). UK transplant registry data 1984-2003 identified 18 cases of histologically verified LL (median age: 50 years, range: 38-58 years). Nine patients received high dose chemotherapy [plus total body irradiation (TBI) in 1/9] and autologous peripheral blood stem cells (PBSC). Disease status at transplant was complete remission (2), partial remission (5), primary refractory (1) or relapse (1). Transplant related mortality (TRM) at 12 months was 0%. Median follow-up is 44 months with 4 year disease free survival 43% and overall survival 73%. Karnofsky performance status (KPS) is 80-100%. The nine allografted patients (median age: 49 years, range: 39-56 years) were conditioned with standard TBI (2), BEAM (2) or FLU-MEL (5) and received PBSC from HLA-matched sibling (8) or unrelated (1) donors. Disease status at transplant was partial remission (7) or primary refractory (2). TRM at 12 months was 44%. Complications included graft failure (2), grades I-II acute graft versus host disease (aGVHD) (2), grades III-IV aGVHD (3) and chronic GVHD (4). Median follow-up is 32 months with 4 year disease free survival 44% and overall survival 56%. KPS is 70-100%.

Waldenström macroglobulinaemia

Over time, Waldenström macroglobulinaemia (WM) has evolved conceptually from a clinical syndrome to a distinct clinicopathological entity. Progress is being made in standardization of the disease definition and treatment response criteria, although nosologic controversies persist. According to the Second International Workshop on WM, the disease is defined as a B-cell neoplasm characterized by a lymphoplasmacytic infiltrate in the bone marrow, with an associated immunoglobulin (Ig) M paraprotein. Disease symptoms are often divided into those related to tumour infiltration and those related to the rheological effects of the monoclonal IgM. As with other low-grade lymphomas, asymptomatic patients are observed only, with treatment reserved for symptomatic patients. There is no standard treatment for WM and choices include rituximab, alkylating agents, purine nucleoside analogues, alone or in combination, as well as autologous peripheral blood stem cell transplant in eligible patients. Novel treatments, such as bortezomib, oblimersen sodium, perifosine and others are being evaluated.

Evidence of graft-versus-Waldenstrom's macroglobulinaemia effect after allogeneic stem cell transplantation: a single centre experience

The role of allogeneic stem cell transplantation (SCT) in Waldenstrom's macroglobulinaemia (WM) is not yet clear, as published data on allogeneic SCT in WM are limited. We present a retrospective study of allogeneic SCT in five patients with WM. Median age was 56 years (range 40-60 years). All patients were heavily pretreated. Conditioning therapy with busulphan and cyclophosphamide was used for all patients and all were given cyclosporine and methotrexate for graft-versus-host disease prophylaxis. With a median follow-up of 32 months (range 2-43), all except one are alive and disease free. Progressive, delayed decline in serum IgM levels were noted in all the patients, suggesting an active graft-versus-Waldenstrom's effect. With the limited available data, it appears that allogeneic SCT is a useful treatment option for advanced WM.

Waldenström macroglobulinemia

In the past 36 months, new developments have occurred both in the understanding of the biology of Waldenström macroglobulinemia (WM) and in therapeutic options for WM. Here, we review the classification, clinical features, and diagnostic criteria of the disease. WM is a B-cell neoplasm characterized by lymphoplasmacytic infiltration of the bone marrow and a monoclonal immunoglobulin M (IgM) protein. The symptoms of WM are attributable to the extent of tumor infiltration and to elevated IgM levels. The most common symptom is fatigue attributable to anemia. The prognostic factors predictive of survival include the patient's age, β2-microglobulin level, monoclonal protein level, hemoglobin concentration, and platelet count. Therapy is postponed for asymptomatic patients, and progressive anemia is the most common indication for initiation of treatment. The main therapeutic options include alkylating agents, nucleoside analogues, and rituximab. Studies involving combination chemotherapy are ongoing, and preliminary results are encouraging. No specific agent or regimen has been shown to be superior to another for treatment of WM. Novel agents such as bortezomib, perifosine, atacicept, oblimersen sodium, and tositumomab show promise as rational targeted therapy for WM.

Autologous or allogeneic stem cell transplantation in patients with Waldenstrom's macroglobulinemia

The role of hematopoietic stem cell transplantation (SCT) in Waldenstrom's macroglobulinemia (WM) has not been extensively studied. To determine the potential for long-term disease control using SCT in WM, we performed a retrospective review of 36 patients with WM who received autologous (n = 10) or allogeneic (n = 26) SCT and were reported to the Center for International Blood and Marrow Transplant Research between 1986 and 2002. The following outcomes were described: nonrelapse mortality (NRM), relapse, progression-free survival (PFS), and overall survival (OS). Median age at the time of SCT was 51 years (range, 30-76 years), and median time from initial treatment to SCT was 29 months (range, 2-198 months). A total of 78% of the patients had 2 or more previous chemotherapy regimens, and 52% had disease resistant to salvage chemotherapy. In the allogeneic SCT group, 58% of the patients received myeloablative conditioning regimens containing total body irradiation (TBI), and of the allograft recipients, 19% received nonmyeloablative/reduced-intensity conditioning. After a median follow-up of 65 months, 15 of the 36 patients (42%) are alive. Primary disease accounted for 29% of the deaths in the allogeneic SCT group and 25% of the deaths in the autologous SCT group. The relapse rate at 3 years was 29% (95% confidence interval [CI], 14%-48%) in the allogeneic group and 24% (95% CI, 4%-54%) in the autologous group. PFS at 3 years was 31% (95% CI, 14%-50%) in the allogeneic group and 65% (95% CI, 32%-91%) in the autologous group; OS was 46% (95% CI, 27%-65%) in the allogeneic group and 70% (95% CI, 40%-93%) in the autologous group. NRM at 3 years was 40% (95% CI, 23%-59%) in the allogeneic group and 11% (95% CI, 0-36%) in the autologous group. Autologous SCT is a safe and feasible treatment option for patients with WM, especially for those who present with adverse prognostic factors. Allogeneic SCT carries a much higher (40%) risk of NRM and should not be considered outside the context of a clinical trial.

Waldenström macroglobulinemia: a review of therapy

Waldenström macroglobulinemia is a rare monoclonal gammopathy-associated lymphoplasmacytic lymphoma. Its incidence is only 4 per million per year. This review contains the known published literature specifically on the available management tools for Waldenström macroglobulinemia and is designed to assist clinicians in making management decisions for patients with this uncommon disorder.

Treatment Options in Waldenstrom's Macroglobulinemia

Waldenstrom's macroglobulinemia (WM) is a rare chronic B-cell lymphoproliferative disorder characterized by macroglobulin (immunoglobulin M; IgM) paraproteinemia. The clinical manifestations associated with WM can be related to those of direct organ tumor infiltration, hyperviscosity and tissue deposition of IgM. Treatment must be individualized according to the nature of the clinical manifestations. Plasmapheresis has a role in patients whose symptoms are caused by increased serum viscosity. Chlorambucil was first used with response rates varying between 31% and 72% and is now probably the most commonly used oral agent. Melphalan and cyclophosphamide may have similar clinical efficacy. The addition of corticosteroids does not seem to increase response rates and the use of combination chemotherapy in the first-line setting is not recommended. Fludarabine and cladribine are cross-resistant and induce a response in 30%-60% of patients who have had prior therapy with alkylating agents and as many as 100% of previously untreated patients. Thirty-five percent to 50% of patients respond to single rituximab therapy, with limited toxicity. There are no data from prospective randomized studies to guide the choice between alkylating agents, nucleoside analogues, and rituximab for first-line therapy of WM. Autologous and allogeneic stem cell transplantation may be considered for patients with primary refractory/relapsing disease, especially in the younger age groups. Thalidomide alone or in combination with steroids/clarithromycin may be a useful salvage regimen for some heavily pretreated patients with cytopenia, even though toxicity is considerable. Splenectomy is rarely indicated.

Treatment for Waldenstrom’s macroglobulinemia

Waldenstrom's macroglobulinemia is a rare form of indolent lymphoma characterized by the production of a monoclonal immunoglobulin M protein, and complications such as hyperviscosity, cytopenias and peripheral neuropathy. Conventional treatment approaches are based on alkylators or nucleoside analogs, but in the absence of a clearly superior regimen, a broad array of alternative therapies exists. Choices range from biological agents to combination chemotherapy to stem-cell transplantation. A rational approach therefore must be based on careful patient assessment and individualization of therapy.

Waldenström macroglobulinaemia

Waldenström macroglobulinemia (WM) is a lymphoid neoplasm characterised by a monoclonal lymphoplasmacytic expansion accompanied by a serum monoclonal immunoglobulin M (IgM). In some patients, the monoclonal protein will lead to a characteristic hyperviscosity syndrome. Although indolent, WM is incurable and most patients eventually succumb to disease progression. Thus, we need to better understand the natural history and biology of the disease. Recent work has shown that half of patients with WM harbour deletions in the long arm of chromosome 6. Increasing evidence suggests the disease is a defined pathological entity and not purely a clinical syndrome. Current therapeutic modalities include alkylator agents, purine nucleoside analogues, and rituximab. The optimum initial therapeutic strategy is not yet defined, and current clinical trials are addressing the role of combination therapy. In this review, we summarise the current understanding of the pathogenesis, clinical and laboratory features, prognostic factors, and therapeutic options for patients with WM. We also discuss current knowledge of WM and available therapies.

Transplantation in Waldenstrom's macroglobulinemia--the French experience

Published data on transplantation in Waldenstrom's macroglobulinemia (WM) are still limited. We present a retrospective multicentric study of 27 WM patients who underwent 19 autologous (median age, 54 years) and 10 allogeneic (median age, 46 years) transplantations. Median time between diagnosis and transplantation was 36 months; 66% of patients had received three or more treatment lines and 72 % had chemosensitive disease. High-dose therapy (HDT) and autologous transplantation induced a 95% response rate (RR), including 10 major responses. With a median follow-up of 18 months, 12 patients are alive at 10 to 81 months and eight are free of disease progression at 10 to 34 months. The toxic mortality rate (TRM) was 6%. Allogeneic transplantation was preceded by HDT in nine patients and by a nonmyeloablative regimen in one patient. The RR was 80%, including seven major responses. With a median follow-up of 20.5 months, six patients are alive and free of progression at 3 to 76 months. Four patients died, all from toxicity, resulting in a TRM of 40%. HDT followed by autologous transplantation is feasible in WM, even in heavily pretreated patients, with some prolonged responses but a high relapse rate. Conversely, allogeneic transplantation is more toxic, but likely induces a graft-versus-WM effect and may, for some patients, result in long-term disease control.

Treatment recommendations in Waldenstrom's macroglobulinemia: consensus panel recommendations from the Second International Workshop on Waldenstrom's Macroglobulinemia

This presentation represents consensus recommendations for the treatment of patients with Waldenstrom's macroglobulinemia (WM), which were prepared in conjunction with the second International Workshop held in Athens, Greece during September 2002. The faculty adopted the following statements for the management of patients with Waldenstrom's macroglobulinemia: (1) Alkylating agents, nucleoside analogues, and rituximab are reasonable choices for first line therapy of WM. (2) Both cladribine and fludarabine are reasonable choices for the therapy of WM. (3) Combinations of alkylating agents, nucleoside analogues, or rituximab should at this time be encouraged in the context of a clinical trial. (4) In WM, rituximab can cause a sudden rise in serum IgM and viscosity levels in certain patients, which may lead to complications, therefore close monitoring of these parameters and symptoms of hyperviscosity is recommended for WM patients undergoing rituximab therapy. (5) For relapsed disease, it is reasonable to use an alternate first line agent or re-use of the same agent; however, since autologous stem cell transplantation may have a role in treating patients with relapsed disease it is recommended that for patients in whom autologous transplantation is seriously being considered, exposure to alkylator or nucleoside analogue drugs should be limited. (6) Combination chemotherapy for patients who can tolerate myelotoxic therapy, thalidomide alone or with dexamethasone, can reasonably be considered to have relapsed. (7) Autologous stem cell transplantation may be considered for patients with refractory or relapsing disease. (8) Allogeneic transplantation should only be undertaken in the context of a clinical trial. (9) Plasmapheresis should be considered as interim therapy until definitive therapy can be initiated. (10) Rituximab should be considered for patients with IgM-related neuropathies. (11) Corticosteroids may be useful in the treatment of symptomatic mixed cryoglobulinemia. (12) Splenectomy is rarely indicated but has been used to manage painful splenomegaly and hypersplenism.

Autologous and allogeneic stem cell transplantation in Waldenstrom's macroglobulinemia: review of the literature and future directions

Waldenstrom's macroglobulinemia (WM) is a chronic lymphoproliferative disorder characterized by lymphoplasmacytic infiltrate and a monoclonal IgM serum peak. Treatment includes cytotoxic chemotherapy with alkylators, or purine nucleoside analogues and monoclonal anti-CD20 antibody. The role of stem cell transplantation (SCT) in WM has not been established. We identified 24 published cases of WM treated with high-dose chemotherapy (HDC) followed by autologous SCT (ASCT). The median age was 50 years; half of the patients had refractory disease and received a variety of preparative regimens. Nine complete and 14 partial responses were observed, with one early death. Fifteen patients were alive and well at follow-ups ranging from 1 to 132 months. Six additional patients, with a median age of 45 years (range, 30 to 62), who received allogeneic SCT have been reported. All were heavily pretreated with refractory or relapsed disease. Median time from diagnosis to transplant was 3.1 years (range, 1.3 to 7). Two patients died of complications of the procedure while one died of disease progression. Three patients were alive and well between 5 and 112 months post-transplant. The small number of reported patients precludes any significant conclusion except that SCT is feasible in WM and long-term disease control can be achieved in selected patients with autologous or allogeneic SCT, even in those with refractory disease.

Waldenström's macroglobulinaemia

Waldenström's macroglobulinaemia (WM) is most usefully defined as a distinct chronic lymphoproliferative disorder with characteristic marrow morphology and phenotype; although nodal morphology if available will reveal a lymphoplasmacytoid lymphoma, the presence of a significant IgM paraprotein defines the clinical features of the disease. The clonal cell is a B-cell expressing IgM, CD19, and CD20 but not IgD, CD5, CD10 or CD23 and has somatic hypermutation of immunoglobulin heavy chain variable regions consistent with a post-germinal centre origin. Treatment of WM has been dependent on alkylating agents with or without coriticosteroids for many years, supplemented by the use of therapeutic plasmapheresis in the initial stages for patients at risk from the clinical consequences of hyperviscosity. This approach to treatment results in response rates of approximately 60% with a median survival of about 60 months. There is increasing evidence to show that the purine analogues fludarabine and cladribine which are active in the treatment of patients who are resistant to alkylating agents such as chlorambucil may be able to achieve higher response rates when used as initial therapy. A prospective trial is being undertaken to compare fludarabine and chlorambucil as initial treatment; because of the effect of subsequent active treatment on patients who do not respond to the first treatment choice, the long-term outcome may be similar for both groups. Recent advances in therapy include the use of therapeutic monoclonal antibodies such as rituximab and the use of autologous or allogeneic transplant procedures for selected patients.

Stem cell transplantation (SCT) for Waldenstrom's macroglobulinemia (WM)

Waldenstrom's macroglobulinemia (WM) is a low-grade lymphoplasmacytoid malignancy of unknown etiology. It primarily affects elderly patients and is characterized by a monoclonal IgM component, varying degrees of cytopenias, lymphadenopathy and manifestations related to hyperviscosity syndromes. WM is usually treated with single agent nucleoside analogues or alkylating agents that often provide high response rates and durable remissions. Recurrence of the disease after primary therapy is not uncommon, and resistance to both alkylating agents and nucleoside analogs eventually emerges. Small numbers of patients have undergone high-dose chemotherapy (HDC) with either autologous (n = 24) or allogeneic (n = 6) stem cell transplantation (SCT) as treatment for this disease. Most patients in both groups achieved remission. Results are promising and a more in-depth analysis of possible applications of this treatment modality is attempted with this mini-review.